伤椎置钉后路钉棒系统复位治疗胸腰椎爆裂性骨折

The fixation of injured vertebrae with pedicle screws of rod-screw implant system for posterior instrumentation in the treatment of thoracolumbar burst fractures

目的探讨骨折椎螺钉直接复位治疗胸腰椎爆裂性骨折的效果。方法 2001年6月至2008年12月治疗胸腰椎爆裂性骨折72例。男48例,女24例;年龄35～62岁,平均45.5岁。骨折部位包括:T_(11)6例,T_(12)27例,L_133例,L_26例。其中T_(12)L_1两节段60例,占83.3%。均为单节段爆裂骨折。AO分型:A1型36例,A2型10例,A3型21例,B1型5例。按ASIA脊髓神经功能障碍分级标准:B级3例,C级8例.D级13例,E级48例。按椎管阻塞面积分为IV°:椎管阻塞Ⅰ°(<1/4阻塞)13例,Ⅱ°(1/4～1/2阻塞)45例,Ⅲ°(1/2～3/4阻塞)10例,Ⅳ°(>3/4阻塞)4例。采用经骨折椎钉直接复位的5步操作法进行复位。术后评估矢状面Cobb角、骨折椎前缘高度比、神经功能恢复情况、骨块复位情况、疼痛视觉模拟评分及Oswestry功能障碍指数。结果随访时间16-38个月,平均25个月。骨折愈合时间12-21周,平均13.6周。无内固定失败病例。矢状面Cobb角由术前23.55°±7.80°恢复到术后的9.66°±5.81°;骨折椎前缘高度比由术前53.39%±9.80%提高到术后的82.36%±7.54%;骨折椎管面积比由术前44.6%±8%提高到术后的92.1%±6%。24例神经功能部分损害病例19例恢复正常,占79.2%。无术后脊髓神经功能损害加重。疼痛视觉模拟评分(VAS),末次随访平均(1.9±0.8)分;Oswestry功能障碍指数(ODI)末次随访平均(18.5±1.8)。结论骨折椎螺钉直接复位5步操作法可提高复位质量,后期骨折稳定性维持满意。

Objective To investigate the outcomes of the treatment ofthoracolumbar burst fractures by direct reduction on fractured vertebrae with pedicle screws. Methods From June 2001 to December 2008, 72 patients （48 males and 24 females） with thoracolumbar burst fractures were treated. The mean age of these patients was 45.5 years old （range; 35-62 years）. The fracture sites were listed as follows： 6 cases in T11, 27 cases in T12, 33 cases in L1 and 6 cases in L2. Among them, there were 60 cases in T12-Ll, accounting for 83.3%. They were all monosegmental burst fractures. According to the AO classification： 36 cases were of type A1, 10 cases type A2, 21 cases type A3 and 5 cases type B1. According to the American Spinal Injury Association （ASIA） grading standard of spinal cord neurological dysfunction, there were 3, 8, 13 and 48 cases of grade B, C, D and E respectively. The blockage area of vertebral canal was classified into IV° grades. The blocked vertebral canal was listed as follows： 13 cases of grade I° （〈1/4 blockage）, 45 cases of grade II° （1/4-1/2 blockage）, 10 cases of grade III° （1/2-3/4 blockage） and 4 cases of grade IV° （〉3/4 blockage）. The direct reduction on the fractured vertebrae with pedicle screws in 5 steps was taken. The sagittal Cobb＇s angle, the height ratio of anterior vertebral fractures, the conditions of neurological functional recovery, the conditions of bone block restoration, the visual analogue scale （VAS） and the oswestry disability index （ODI） were evaluated postoperatively. Results The patients were followed up for an average period of 25 months （range; 16-38 months）. The bone fracture healing time was 1316 weeks on average （range; 12-21 weeks）. No failed internal fixation was found. The Cobb＇s angle in sagittal plane was improved from 23.55°±7.80° preoperatively to 9.66°±5.81° postoperatively. The height ratio of anterior vertebral fractures was improved from 53.39%±9.80% preoperatively to 82.36%±7.54% postoperatively. The ratio of the blockage area of vertebrae canal was improved from 53.39%±9.80% preoperatively to 82.36%±7.54% postoperatively. 19 of 24 patients with partially neurological dysfunction preoperatively retumed to normal, accounting for 79.2%. The neurological dysfunction of the spinal cord did not aggravate postoperatively. The mean VAS and ODI scores were 1.9±0.8 and 18.5±1.8 respectively in the latest follow-up. Conclusions The direct reduction on fractured vertebrae with pedicle screws in 5 steps can improve the quality of reduction, which also maintains the stabilization of fractures in the later period satisfactory.