传统入路与椎旁肌间隙入路置入椎弓根螺钉治疗胸腰段骨折

Pedicle screw placement via paraspinal approach versus conventional approach for the treatment of thoracolumbar vertebral fracture

背景:胸腰椎骨折治疗上多采用椎弓根螺钉棒系统固定,传统后正中入路广泛剥离椎旁肌,部分患者在治疗后出现腰背疼痛。目的:观察经椎旁肌间隙入路与传统入路治疗胸腰段骨折的疗效及对多裂肌影响。方法:选择安徽医科大学附属省立医院骨科2010年6月至2012年6月收治的45例胸腰段骨折患者,依据Denis骨折分型,压缩型骨折11例,爆裂型骨折34例,并且椎管占位小于1/3,后柱均完整,ASIA分级均为E级,无神经症状。随机分为椎旁肌间隙入路21例和传统正中入路24例,比较两组患者围手术期参数及影像学指标,治疗后进行目测类比评分系统评分以及6个月随访腰背痛日本骨科协会(JOA)评分,比较两组治疗前及治疗后1,3,5d肌酸激酶水平,随访时行多裂肌肌内静息肌电图评估。结果与结论:治疗后两组在Cobb角恢复上差异无显著性意义,椎旁肌间隙入路组手术时间、术中出血量、术后引流量、肌酸激酶水平及术后目测类比评分低于传统正中入路组,两组比较差异有显著性意义(P<0.05);6个月随访腰背痛JOA评分椎旁肌间隙入路组低于传统正中入路组,但差异无显著性意义(P>0.05)。6个月随访行多裂肌肌电图检查,椎旁肌间隙入路组出现失神经纤颤电位少于传统正中入路组,差异有显著性意义(P<0.05)。结果可见经椎旁肌间隙入路疗效确切,具有创伤小、出血少,手术时间短等优点。

BACKGROUND： Pedicle screw and rod fixation system is a common method for the treatment of thoracolumbar vertebral fracture. Conventional approach is the midline approach which needs to cut paraspinal muscle widely, and parts of patients suffer from back pain after surgery.OBJECTIVE： To observe the clinical outcome and paraspinal muscle injury after the treatment of thoracolumbar fractures via paraspinal approach and conventional approach.METHODS： A total of 45 patients with thoracolumbar fractures were selected from Department of Orthopedics, Affiliated Provincial Hospital of Anhui Medical University during June 2010 to June 2012. According to Denis fracture classification, there were 11 compression fractures and 34 burst fractures with intact posterior column, and the spinal canal occupied for less than 1/3. American Spinal Injury Association grade was E-class with no neurological symptoms. Randomly, 21 patients adopted paraspinal approach and the other 24 patients underwent the conventional approach. The perioperative parameters and intervertebral indicators were compared between two groups. The visual analogue scale score and Japanese Orthopaedic Association score were analyzed postoperatively, and the postoperative and 1, 3, and 5 days preoperative serum level of creatine kinase were compared, also multifidus muscle electromyography assessment was adopted during follow-up.RESULTS AND CONCLUSION： There was no significant difference in the Cobb＇s angle restoration between two groups, but the operation time, blood loss, volume of drainage, serum level of creatine kinase and postoperative visual analogue scale score in the paraspinal approach group were significantly lower than those in the conventional approach group （P 〈 0.05）. The Japanese Orthopaedic Association score at 6 months postoperatively in the paraspinal approach group was lower than that in the conventional approach group, but the difference was not statistically significant （P 〉 0.05）. The multifidus muscle electromyography assessment after 6 months showed that the fibrillation potentials in the paraspinal approach group were less than that in the conventional approach group, and the difference was statistically significant （P 〈 0.05）. Paraspinal approach has satisfactory curative effect with the advantages of less trauma and bleeding as well as shorter operation time.