经肌间隙入路单节段固定治疗胸腰椎骨折的临床研究

Single-segment pedicle screw fixation for the treatment of thoracolumbar fractures through the gap of paravertebral muscles

目的:比较经椎旁肌肌间隙入路单节段椎弓根钉固定术与椎旁肌剥离双节段椎弓根钉固定术治疗胸腰椎骨折的疗效。方法:2008年9月至2010年1月,65例符合纳入标准的胸腰椎非完全压缩性或爆裂性单侧终板损伤患者根据随机原则分组,30例采用经肌间隙入路椎弓根钉单节段固定术治疗(治疗组),35例行椎旁肌剥离入路椎弓根钉双节段固定术治疗(对照组),术后10～12个月均取出内固定。观察围手术期的手术时间、术中出血量和术后引流量,末次随访时神经功能ASIA等级改变,术后5d及末次随访时腰背疼痛Denis分级情况,影像学测量X线侧位片上矢状位指数与椎体前缘高度压缩率,并进行比较分析。结果:所有患者均获得随访,时间14～22个月,平均18.3个月。均未发生术后感染、继发性脊髓神经损伤。对照组1例术后11个月内固定断裂,其余患者均无内固定松动发生。手术时间两组差异无统计学意义(P>0.05),术中出血量和术后引流量治疗组均明显少于对照组(P<0.01),神经功能术后均恢复良好,两组间比较差异无统计学意义(P>0.05)。腰背疼痛Denis分级比较,治疗组比对照组疼痛缓解较快,后遗腰背疼痛轻(P<0.01)。椎体前缘高度压缩率、矢状位指数观察,两组术后均能明显矫正后凸角和椎体前缘压缩,但随访时均有丢失(P<0.01)。术前椎体压缩程度和术后矫正度两组差异无统计学意义,且随访两组后凸角矫形丢失差异也无统计学意义(P>0.05);治疗组随访时尽管有椎体前缘高度矫正丢失,但丢失度低于对照组(P<0.05)。结论:在严格掌握手术适应证的前提下,采用经肌间隙入路单节段椎弓根钉固定术治疗胸腰椎骨折,能有效恢复椎体高度和纠正后凸角度,减少固定节段,与传统椎旁肌剥离双节段固定术相比,明显减少了手术创伤与出血,减轻了腰背疼痛。

Objective：To compare the clinical effect of thoracolumbar fractures between single-segment pedicle screw fixation approach for the gap of paravertebral muscles and double-segment pedicle screw fixation approach for the stripping of paravertebral muscles. Methods：From September 2008 to January 2010,65 patients with incomplete compressed thoracolumbar fractures or burst thoracolumbar fractures with unilateral endplate injury were randomly divided into two groups. Thirty patients were treated with single-segment pedicle screw fixation through the gap of paravertebral muscles（treatment group）. Thirty-five patients were treated with double-segment pedicle screw fixation through the stripping of the paravertebral muscles （control group）. All the internal fixations were taken out during 10-12 months after operation. Operative time,perioperative blood loss volume and postoperative drainage volume were compared between two groups. At final follow-up,the change of neurological ASIA grade were recorded;and postoperative 5 days and final follow-up,compared Denis classification of lumbar and back pain between two groups;and analyzed the sagittal index and compressibility of anterior border of vertebral body by X-ray lateral projection. Results：All patients were follow-up from 14 to 22 months with an average of 18.3 months. No postoperative infection,secondary spinal cord injury was found. One case of control group occurred internal fixation breakage at the 11th month after operation and other internal fixation no loosening. There was no significant difference in operative time,the recovery of neurological function between the two groups（P0.05）. Perioperative blood loss volume and postoperative drainage volume of treatment group was less than that of control group（P0.01）. And in Denis classification of lumbar and back pain,the treatment group recovered more quickly,and the residual pain of lumbar and back was less than that of control group（P0.01）. Postoperative posterior salient and compression of anterior border of vertebral body improved in two groups（P0.01）,there was no significant difference in degree of improvement between two groups（P0.05）;but both loss existed at final follow-up （P0.01）,there was no significant difference in loss of posterior salient between two groups（P0.05）. In the treatment group,theloss of rectify of anterior border of vertebral body existed,but it was less than that of the control group. Conclusion：In the premise of strict controlling surgery indications,the treatment of thoracolumbar fractures with single-segment pedicle screw fixation through the gap of paraspinal muscles,can effectively recover the height of vertebral body and rectify posterior salient,and reduce the fixed segment. Compared with the traditional operative method of double-segment pedicle screw fixation through the stripping of paraspinal muscle,it can obviously reduce the operation wound and the bleeding,lessen the pain of lumbar and back. And the recent clinical effect is satisfied.