经椎旁肌间隙短节段椎弓根钉固定治疗伴后方韧带复合体损伤的胸腰段骨折

Short segmental pedicle instrumentation via the paraspinal approach for the treatment of thoracolumbar fractures complicated with posterior ligamentous complex injury

目的探讨经椎旁肌间隙入路短节段椎弓根钉固定治疗伴后方韧带复合体损伤的胸腰段骨折的疗效。方法回顾性分析2008年10月至2010年6月收治的70例胸腰椎骨折患者资料，男44例，女26例；年龄19～55岁，平均33．4岁。根据治疗方法不同分为经椎旁肌间隙入路短竹段椎弓根钉固定组（经肌间隙固定组，35例）和传统剥离椎旁肌入路短节段椎弓根钉固定组（剥离椎旁肌固定组，35例）。评估两种术式的手术时间、术中出血蛩、术后歼始下地时间、住院时间、手术前、后和未次随访时损伤节段的局部后凸角（LKA）及椎体高度（VBH）变化、术后并发症发生情况，及螺钉置入的准确性。结果所有患者术后随访24～36个月（平均29．3个月）。剥离椎旁肌固定组的手术时间、术中出血量、术后开始下地时间、住院时间均长于或多于经肌间隙固定组，差异有统计学意义（P〈0．05）。所有患者在取出内固定前均朱出现内固定失效。两组各置入140枚螺钉，分别有7枚（5．0％）和6枚（4．3％）螺钉切出椎弓根外，两组患者螺钉切出椎弓根外发生率差异无统计学意义（P〉0．05）。两组患者的术后、末次随访时的LKA和VBH均较术前增加，差异有统计学意义（P〈0．05），而术后的LKA和VBH与末次随访时比较，差异无统计学意义（P〈0．05）。术前、术后及末次随访时的LKA和VBH．两组间比较差异均无统计学意义（P〉0．05）。结论经椎旁肌间隙入路短节段椎弓根钉固定治疗伴后力韧带复合体损伤的胸腰段骨折是安全的，有良好的临床疗效，可有效地维持骨折复位，减少手术损伤。

Objective To study the eMcacy and safety of short segmental pedicle instrumentation via the paraspinal approach for the management of neurologically intact patients with thoracohunbar burst fracture and posterior ligamentous complex injury. Methods From October 2008 to June 2010, 70 such patients were treated in our department. They were 44 males and 26 females, with an average age of 33.4 years （range, from 19 to 55 years）. They were divided into 2 groups according to 2 different operative methods. In group A, 35 patients were treated via the paraspinal approach while 35 patients in group B were treated via the traditional open approach. The 2 approaches were compared in terms of operation time, intraoperative bleed- ing, postoperative ambulant time, hospital stay, changes in local kyphosis angle （LKA） and vertebral body height （VBH） at preoperation, postoperation and the last follow-up, postoperative complications and accuracy of screw insertion. Results The time for follow-up ranged from 24 to 36 months （mean, 29. 3 months）. The operation time, intraoperative bleeding, postoperative ambulant time and hospital stay in group B were significantly more than in group A（ P 〈 0. 05） . No implant failure occurred in either group. There was no significant difference in pedicle screw cut-out between the 2 groups [7 （5.0%） versus 6 （4.3%） ] （ P 〉 0. 05） . The LKA and VBH increased significantly at postoperation and the last follow-up compared with the preoperation in both groups （ P 〈 0. 05）, but there was no significant difference between the postoperation and the last follow-up （ P 〉0. 05）. There were no significant differenees between the 2 groups regarding LKA and VBH at preoperation, postoperation and the last follow-up （ P 〉0. 05） . Conclusion The paraspinal approach may result in a good and safe clinical outcome in the treatment of thoracolumbar burst fractures with posterior ligamentous complex injury, because it can maintain the fracture reduction effectively and minimize the iatrogenic injury to soft tissues.