胸腰椎完全性骨折脱位的手术治疗

Surgical treatment of complete thoracolumbar fracture and dislocation

目的 探讨后路固定融合治疗胸腰椎完全性骨折脱位的方法与疗效. 方法 选择2006年1月-2012年12月收治8例胸腰椎完全性骨折脱位患者,其中男7例,女1例；平均年龄31.9岁（19 ～49岁）.受伤至手术时间平均8.1 d（4～12 d）.骨折脱位分型：AO分型为C型,Denis分类为三柱损伤,Meyerding创伤性滑脱Ⅴ级的骨折脱位.脊髓神经损伤采用美国脊柱损伤协会（American Spinal Injury Association,ASIA）分级：A级5例,B级1例,C级1例,E级1例.骨折脱位节段：T5～T6 1例,T12 ～L13例,L1～L2 2例,L3 ～L4 1例,L4～L5 1例.所有患者均采用后路椎弓根钉棒系统进行固定融合. 结果 平均手术时间220.6 min（135 ～335m in）,术中平均出血量1 150 ml（500 ～2 400 ml）,7例术中发现有硬膜撕裂,予以缝合硬膜或自体脂肪片覆盖修补,其中3例术后发生脑脊液漏,经保守治疗后治愈.6例获得解剖复位,1例部分复位,1例未行复位.后凸Cobb角由术前平均29.3°（8°～51°）恢复至术后1.9°（-5°～10°）.平均随访39.3个月（2～76个月）,末次随访时2例分别由术前ASIA分级A/B恢复至C级,余6例患者（A级4例,C级1例,E级1例）无明显变化.所有患者随访期间未发现钉棒断裂松动等内固定相关并发症.1例于术后4年死于肺部相关并发症,1例术后3周出现腰椎深部感染,采用保留内置物的清创冲洗引流处理方法. 结论 后路固定融合是胸腰椎完全性骨折脱位总的治疗原则,复位情况的把握取决于脊髓损伤的严重程度.

Objective To investigate the methods and effects of posterior fixation and fusion in treatment of complete thoracolumbar fracture and dislocation. Methods The study enrolled 8 cases of complete thoracolumbar fracture and dislocation treated by posterior fixation and fusion with pedicle screw- rod system between January 2006 and December 2012. There were 7 males and 1 female, at mean age of 31.9 years （range, 19-49 years）. Mean time interval between injury and surgery was 8.1 days （range, 4-12 days）. Fracture-dislocation classification was At type C, Denis three-column injury, and Meyerding grade V. According to American Spinal Injury Association （ASIA）, there 5 cases at grades A, 1 at grade B, 1 at grade C 1 at grade E. Fracture-dislocation segments included T5-Ts in 1 case, T^z-L~ in 3, L1-L2 in 2, L3-L4 in 1 and L4-Ls in 1. Results Mean duration of surgery was 220.6 minutes （range, 135- 335 minutes） and mean intraoperative blood loss was 1 150 ml （range, 500-2 400 ml）. Seven cases sus- tained dural laceration during the operation, which were sutured or covered with autologous fat grafts, but 3 of them were subjected to cerebrospinal fluid leakage and healed after conservative therapy. Anatomic reduction was achieved in 6 cases, partial reduction in 1 and non-reduction in 1. Mean Cobb angle im- proved from 29.3~ （ range, 8^-51 ~） preoperatively to 1.9~ （ range, - 5^-10~） postoperatively. After a mean follow-up of 39.3 months （range, 2-76 months）, 2 cases were recovered from preoperative ASIA grade A and B to C respectively and 6 cases （4 A, 1 C, 1 E） revealed no significant improvement. There was no implant loosening or breakage. One case was died of lung-related complications at postoperative g years. One case sustained lumbar deep infection at postoperative 3 weeks and managed by debridement, ir- rigation, drainage and implant retention. Conclusion Posterior fixation and fusion is the general treat- ment principle for complete thoracolumbar fracture and dislocation, but the degree of reduction depends on severity of the injured spinal cord.