胸腰段骨折并脊髓损伤再手术疗效分析

Reoperation for thoracolumbar fracture combined with spinal cord injury

目的探讨胸腰段骨折合并脊髓损伤患者Ⅰ期前路／后路手术后Ⅱ期再手术的疗效。方法回顾性分析2005年1月－2009年3月胸腰段骨折合并脊髓损伤单纯前／后路手术后残存后凸畸形伴神经功能恢复不全或未做Ⅱ期手术疗效患者12例。男9例，女3例；年龄19～57岁，平均34．6岁。根据Denis分型，爆裂型5例，压缩型5例，骨折脱位2例。Ⅰ期前路手术5例，Ⅰ期后路手术7例。Ⅰ期手术后均存在不同程度的神经症状，对Ⅰ期前路手术5例患者行Ⅱ期后路手术。Ⅰ期后路手术7例者行Ⅱ期前路手术。Ⅰ期手术至Ⅱ期手术最长18个月，最短12个月，平均时间13．4个月。通过影像学、神经功能及社会功能综合评估疗效，包括测量Cobb角、Frankel分级和日本骨科学会（JOA）评分。结果术后切口均Ⅰ期愈合。所有患者均获得随访，随访时间12～48个月，平均25个月。伤椎前、后缘高度压缩率术前平均42．6％、70．5％，术后平均恢复至92．5％、95．7％，至末次随访时为87．3％、92．2％；脊髓不完全损伤的患者神经功能均有Frankel 2级以上的改善。所有患者Ⅱ期术后胸腰椎生理弧度良好。Cobb角术前平均36．3°，术后矫正至5．8°，末次随访时为5．9°。JOA评分标准术后改善率，本组优9例，良2例，可1例，差0例。结论对胸腰段骨折合并脊髓损伤患者Ⅰ期前路／后路手术1年后残存神经或马尾临床症状患者行Ⅱ期手术减压后取得理想疗效，可获得满意的后凸畸形矫正和神经减压，神经功能均有不同程度恢复。

Objective To evaluate the outcome of reoperation （ after I stage anterior/posterior operation） for thoracolumbar fractures combined with kyphosis and spinal cord injury. Methods A retrospective study was done on the medical records of 12 patients who underwent two-stage decompression with kyphosis and neurologic deficit due to single-stage approach （ anterior or posterior） operation of tho-racolumbar fractures combined with spinal cord injury between January 2005 and April 2009. There were 9 males and 3 females, at mean age of 34.6 years （range, 19-57 years）. According to the Denis classification, there were five patients with burst fractures, five with compression fractures and two with fracture dislocation. All the patients had couns medullaris injury. Of all the patients, five underwent one stage anterior approach surgery and the others underwent posterior approach operation. All the patients had various degrees of neurological symptoms. The patients treated with one stage anterior surgery were treated with two stage posterior surgery and the patients treated with one stage posterior surgery were treated with the two stage anterior operation. The mean interval from one stage operation to two stage decompression was 13.4 months （range, 12-18 months）. The radiologic, neurologic and functional outcomes were assessed through observation of the Cobb angle, Frankel spinal cord injury grading and Japanese Orthopaedic Association Scores （JOA）. Results All the patients were followed up for mean 25 months （ 12-48 months） , which showed primary healing of the incisions in all the patients. The average anterior and posterior height of the vertebrae were corrected from preoperative 42.6% and 70.5% to postoperative 92.5% and 95.7% and to 87.3% and 92.2% at the final follow-up respectively. Neurologic status was improved at least one Frankel grade in the patients who had preoperative incomplete paraplegia. The Cobb angle was corrected from preoperative 36.3° to postoperative 5.8° and to 5.9°at the final follow-up （P 〈 0.05）. No patient had any notable loss of correction between discharge and final follow-up. According to JOA coring, the results were excellent in nine patients, good in two and fair in one, with excellence rate of 92%. Conclusions Two stage decompression for epiconus and cauda equina syndrome resulted from one stage approach （ anterior or posterior） operation of thoracolumbar fractures combined with spinal cord injury can attain satisfactory correction of the kyphosis and nerve decompression as well as various degrees of nerve function recovery.