伤椎植骨植钉与跨节段椎弓根螺钉内固定术治疗胸腰椎骨折的比较研究

A COMPARATIVE STUDY ON TREATMENT OF THORACOLUMBAR FRACTURE WITH INJURED VERTEBRA PEDICLE INSTRUMENTATION AND CROSS SEGMENT PEDICLE INSTRUMENTATION

目的比较伤椎植骨植钉术与跨节段椎弓根螺钉内固定术治疗胸腰椎爆裂或压缩骨折的临床疗效。方法将2010年6月-2012年6月收治且符合选择标准的40例胸腰椎爆裂或压缩骨折患者随机分为2组（每组20例），分别使用短节段椎弓根螺钉内固定结合伤椎植骨植钉术（A组）和跨节段椎弓根螺钉内固定结合伤椎植骨术（B组）治疗。两组患者性别、年龄、损伤节段、受伤至手术时间及术前神经功能Frankel分级、Cobb角、伤椎前缘高度压缩率、疼痛视觉模拟评分（VAS）、日本骨科协会（JOA）评分等一般资料比较，差异均无统计学意义（P〉0．05），具有可比性。比较两组手术时间、术中出血量、术后Cobb角、伤椎前缘高度压缩率、椎间隙高度丢失、神经功能恢复（Frankel分级）、JOA评分及VAS评分。结果A、B组患者手术时间和术中出血量比较，差异均无统计学意义（P〉0．05）。患者切口均I期愈合，无感染及下肢深静脉血栓形成等早期并发症发生。40例均获随访，随访时间12～16个月，平均14．8个月。无内固定物断裂、移位等并发症发生。术后12个月A、B组神经功能Frankel分级改善评分分别为（0．52±O．72）、（O．47±0．63）分，差异无统计学意义（t=0．188，P=0．853）。两组术后1周及12个月Cobb角、伤椎前缘高度压缩率、VAS评分及术后12个月JOA评分均较术前显著改善（P〈0．05）。术后各时间点A、B组Cobb角、各椎间隙高度、VAS评分及JOA评分比较差异无统计学意义（P〉0．05）；但A组伤椎前缘高度压缩率明显低于B组（P〈0．05）。术后12个月两组内固定相邻上、下位及伤椎相邻上、下位椎间隙高度均有不同程度丢失，但差异无统计学意义（P〉0．05）。结论与跨节段椎弓根螺钉内固定结合伤椎植骨术相比，短节段椎弓根螺钉内固定结合伤椎植骨植钉术治疗胸腰椎爆裂或压缩骨折能有效恢复并维持伤椎高度，但不能避免后凸畸形矫正的丢失及相邻节段的退变。

Objective To compare the effective of short-segment pedicle instrumentation with bone grafting and pedicle screw implanting in injured vertebra and cross segment pedicle instrumentation with bone grafting in injured vertebra for treating thoracolumbar fractures. Methods A prospective randomized controlled study was performed in 40 patients with thoracolumbar fracture who were in accordance with the inclusive criteria between June 2010 and June 2012. Of 40 patients, 20 received treatment with short-segment pedicle screw instrumentation with bone grafting and pedicle screw implanting in injured vertebra in group A, and 20 received treatment with cross segment pedicle instrumentation with bone grafting in injured vertebra in group B. There was no significant difference in gender, age, affected segment, disease duration, Frankel grade, Cobb angle, compression rate of anterior verterbral height, visual analogue scale （VAS） score, and Japanese Orthopaedic Association （JOA） score between 2 groups before operation （P 〉 0.05）. The operation time, blood loss, Cobb angle, compression rate of anterior vertebral height, loss of disc space height, Frankel grade, VAS and JOA scores were compared between 2 groups. Results There was no significant difference in the operation time and blood loss between 2 groups （P 〉 0.05）. Primary healing of incision was obtained in all patients, and no early complication of infection or lower limb vein thrombus occurred. Forty patients were followed up 12-16 months （mean, 14.8 months）. No breaking or displacement of internal fixation was observed. The improvement of Frankel grading score was 0.52 ± 0.72 in group A and0.47 ± 0.63 in group B, showing no significant difference （t=-0.188, P=0.853） at 12 months after operation. The Cobb angle, compression rate of anterior verterbral height, and VAS score at 1 week and 12 months, and JOA score at 12 months were significantly improved when compared with preoperative ones in 2 groups （P 〈 0.05）. No significant difference was found in Cobb angle, disc space height, VAS score, and IOA score between 2 groups at each time point （P 〉 0.05）, but the compression rate of anterior verterbral height in group A was significantly lower than that in group B （P 〈 0.05）. The loss of disc space height next to the internal fixation or the injured vertebra was observed in 2 groups at 12 months, but showing no significant difference （P 〉 0.05）. Conclusion Compared with cross segment pedicle instrumentation, short-segment pedicle screw instrumentation with bone grafting and pedicle screw implanting in injured vertebra can recover and maintain the affected vertebra height in treating thoracolumbar fractures, but it could not effectively prevent degeneration of adjacent segments and the loss of kyphosis correction degree.