强直性脊柱炎胸腰椎骨折手术方法的选择

Operative strategies for thoracolumbar fractures in ankylosing spondylitis

目的探讨慢直性脊柱炎（AS）胸顺椎骨折手术方法的选择。方法对1997年6月至2010年1月收治的17例AS胸腰椎骨折患者资料进行回顾性研究，男16例，女1例；年龄32～61岁．平均47．8岁、依据AS胸腰椎骨折的损伤机制、影像学特征，将其分为椎体型（VB型）和椎间隙型（IS型）．其中VB型骨折6例，采用经椎弓根椎体楔形截骨、后路内固定术；IS型骨折11例，采用前路椎管减压支撑植骨、前后联合内阍定术。结果所有患者均在术中狭得骨折断面的有效接触，并解除脊髓脏迫、改善胸腰椎欠状州平衡。所有患者术后获1．5～4．0年（平均26个月）随访；骨折愈合时间为16～20吲，平均18．0周。未发生内固定松动或断裂、骨折不愈合及神经性和感染性的并发症。末次随访时多数患荇神经功能Frankel分级有所改善．所有患者术后腰背疼痛立即得到缓解；术前cobb角平均为48．0°±8．5°，术后即刘为30．4°±1．3°，末次随访时为30．9°±1．3°．术后即刻与末次随访时较术前均明显改善，謦异均有统计学意义（F=2525．147，P=0．000），而术后即刎与术次随访时比较差异尤统计学意义（P〉0．05）．结论依据AS胸腰椎骨折的类型与损伤机制选择手术方式，能增强骨折断面间的稳定性，有效恢复椎管容积及脊柱的应力轴线，减少脊髓损伤并发症。

Objective To explore the operative strategies for thoracicolumbar fractures in ankylosing spondylitis. Methods From June 1997 to January 2010, 17 cases of thoracolnmbar fracture in ankylosing spondylitis were operated on in our department. They were 16 men and one woman, aged from 32 to 61 years （average, 47.8 years）. The thnraeolumbar fractures were in the vertebral body （VB type） and the intervertebral space （IS type） based on the injury. mechanisms and radiographic manisfestations. Six cases of V B type underwent wedge osteotomy via tbe vertebral pediclc and posterior internal fixation, and I 1 cases of IS type underwent auterior decompression of the spinal canal and strut bone graft fusion followed by anterior-posterior intenrnal fixation. Results All eases gained effective bone contact between tbe fracture ends, relieved spinal compression and improved balance of the thoraeolnmbar spine in sagittal plane during the operation. All the patients were followed for 1.5 to 4. 0 years after operation （average, 26 months）. The fracture beahled at an average of 18.0 weeks （range, from 16 to 20 weeks）. No implant loosening or rupture, nonunion signs, neurolngie or infectious complications were observed. At the final tollow-t.p, the Frankle grading fiw neurologie function was improved in most patiens. Alter surgery, low back pain was relieved immediately in all patients. The average eobb＇s angle was 48.0° ± 8.5° preoperation, 30.4° ± 1.3° postoperation and 30. 9° ± 1.3° at the final follow-up. There was a significant difference between preoperation and postoperation （ F = 2525. 147, P = 0. 000）, but no significant difference between postoperation and the final tbllow-up （ P 〉 0. 05） . Conclusions Operative strategies shouhl be based on the type and injur biomechanism of the thoracolumbar fracture in ankylosing spondylitis. An appropriate strategy ean lcad to increased stability of fYacture ends, effective restoration of canal volume and stress axis of the spine and decreased complications associated with the spinal cord injury.