经侧后方椎体次全切除减压支撑植骨治疗胸腰椎爆裂骨折

Treatment of thoracolumbar burst fracture with subtotal vertebrectomy,decompression and strut grafting through posterolateral approach

目的:探讨后正中入路经侧后方椎体次全切除减压支撑植骨治疗胸腰椎爆裂骨折的临床疗效。方法:2005年5月至2008年7月手术治疗胸腰椎爆裂骨折患者14例,男9例,女5例;年龄24～68岁,平均42.3岁。均为单椎体爆裂骨折,T111例,T125例,L15例,L23例。按AO脊柱骨折分类:A3型5例,B1型3例,B2型3例,C1型2例,C2型1例。采用ASIA分级:A级3例,B级3例,C级5例,D级2例,E级1例。均行半椎板和椎弓根切除、经硬膜侧后方进行椎体次全切除减压、支撑植骨重建椎体前中柱,辅以未减压侧后外侧植骨,全部采用椎弓根钉内固定。通过术前、术后即刻及末次随访时的X线、CT片和ASIA神经功能分级标准评定和比较伤椎前缘高度、椎管容积、Cobb角、神经功能等变化,对后凸畸形的矫正、伤椎压缩高度的恢复、脊髓神经功能的康复进行评估,并观察融合情况。结果:手术时间3.5～5.5h,平均4.0h。出血量800～2600ml,平均1300ml。神经根损伤2例,未经特别处理,3～6个月自行恢复。脑脊液漏1例,经腰大池引流治愈。胸膜损伤1例,行胸腔闭式引流治愈。无血管操作性损伤、感染等并发症发生。随访8～36个月,平均16.5个月。脊髓功能除3例A级无恢复外,其他均有不同程度的恢复。椎体前缘高度术前为相邻正常椎体的(42.25±11.87)%,术后即刻为(94.38±3.08)%,末次随访时为(92.87±3.32)%,与术前比较明显改善(P<0.05)。椎管容积(CT测量实际椎管容积占正常椎管容积的百分比)术前为(45.63±6.88)%,术后即刻为(95.26±3.31)%,末次随访时为(96.13±2.56)%,与术前比较明显改善(P<0.05)。Cobb角术前为(25.64±4.40)°,术后为(5.80±1.14)°;末次随访时Cobb角丢失0°～6°,平均为(8.10±2.65)°,较术前有明显矫正(P<0.05)。末次随访时植骨全部融合,无假关节形成。结论:后正中入路经侧后方椎体次全切除减压支撑植骨治疗胸腰椎爆裂骨折可有效恢复椎体高度、椎管容积、脊柱生理屈度和持久的稳定性,是安全有效的手术方式。

Objective：To explore the clinical effect of subtotal vertebrectomy,decompression and strut grafting in treating thoracolumbar burst fractures through posterolateral approach via posterior midline incision.Methods：From May 2005 to July 2008,14 patients with thoracolumbar burst fractures were treated with subtotal vertebrectomy,decompression and strut grafting through posterolateral approach via posterior midline incision.There were 9 males and 5 females,ranging in age from 24 to 68 years,with an average of 42.3 years.All patients were single segment fractures,of them,T11 was in 1 case,T12 in 5,L1 in 5 and L2 in 3.According to AO classification in spinal fracture,type A3 was in 5 cases,B1 in 3,B2 in 3,C1 in 2,C2 in 1.According to the ASIA classification in neurological function,grade A was in 3 cases,B in 3,C in 5,D in 2,E in 1.The height of anterior border vertebral body,volume of spinal canal and neurological function were analyzed by X-ray films,CT scanning and ASIA classification preoperative,postoperative and at final follow-up.Results：Operative time was from 3.5 to 5.5 hours with the mean of 4.0 hours;bleeding during operation was from 800 to 2 600 ml with the mean of 1 300 ml.Two cases with nerve root injury recovered without special handling after 3-6 months;1 case with leakage of cerebrospinal fluid restored through lumbar cerebrospinal fluid drainage;1 case with pleura tear healed through closed thoracic drainage.No iatrogenic vascular injury or infection was found.The follow-up time was from 8 to 36 months with the mean of 16.5 months.All patients had neurofunctional recovery at different degree,except that 3 patients in grade A.The height of anterior border vetebral body restored from（42.25±11.87）% preoperatively to（94.38±3.08）% postoperatively,and（92.87±3.32）% at final follow-up（P〈0.05）;volume of spinal canal（the actual volume of spinal canal/normal volume of spine canal）increased from（45.63±6.88）% preoperatively to（95.26±3.31）% postoperatively,and（96.13±2.56）% at final follow-up（P〈0.05）.Cobb angle were corrected from（25.64±4.40）° preoperatively to（5.80±1.14）° postoperatively;Cobb angle lost from 0°to 6° at final follow-up with（8.10±2.65）°.All patients obtained complete bony fusion without pseudarthrosis formation at final follow-up.Conclusion：Subtotal vertebrectomy,decompression and strut grafting through posterolateral approach via posterior midline incision is an effective and safe method in treating thoracolumbar burst fracture,which can restored height of intervertebral body,volume of spinal canal and physiological flexion of spinal column,and retain spinal permanent stability.