脊柱损伤合并长骨骨折多发伤患者不同期手术围术期效果比较

Perioperative effect comparison of simultaneous fixation and staging fixation in polytrauma patients combined with spine injury and long bone fracture

目的探讨脊柱损伤合并长骨骨折多发伤患者手术同期固定与分期固定的围术期效果。方法采用回顾性病例对照研究分析2009年6月-2015年6月收治的41例不稳定脊柱损伤合并长骨骨折严重多发伤患者临床资料,其中男30例,女11例;年龄21~66岁[(41.2±12.2)岁]。脊柱损伤节段:颈椎11例,胸椎15例,腰椎23例,骶尾椎2例,脊柱非连续节段2处以上损伤10例。四肢长骨骨折部位:肱骨6例,尺桡骨14例,股骨15例,胫腓骨14例,合并2处及以上四肢长骨骨折8例。损伤严重度评分(ISS)≥15分。根据手术时机不同分为同期手术组(20例)和分期手术组(21例)。同期手术组男16例,女4例;年龄(43.1±12.6)岁。Ⅰ期行脊柱和长骨骨折内固定或外固定术。分期手术组男14例,女7例;年龄(40.1±11.9)岁。先行脊柱固定手术,情况稳定后再行长骨骨折手术。脊柱固定手术方法包括前路椎体次全切除、植骨钢板内固定和后路椎板切除减压、侧块螺钉或者椎弓根钉内固定术。长骨骨折内固定采用钢板和交锁钉,外固定采用单臂支架。比较两组术前住院时间、手术时间、手术失血量(术中出血和术后引流)、住院时间、术后并发症和术前术后脊髓损伤Frankel评分等。结果同期手术组术前住院时间为(9.3±6.7)d,分期手术组为(5.6±5.0)d(P>0.05)。同期手术组手术时间为(4.9±2.0)h,长于分期手术组(3.2±1.2)h(P<O.01)。同期手术组手术失血量为(1322.6±507.1)m1,显著多于分期手术组(1036.7±233.9)ml(P<0.05)。同期手术组住院时间为(22.8±12.6)d,显著短于分期手术组(33.0±15.4)d(P<0.05)。同期手术组术后并发症发生率为45%(9/20),显著低于分期手术组86%(18/21)(P<0.01)。同期手术组Frankel评分为(3.3±1.7)分,分期手术组为(3.1±1.5)分(P>0.05)。结论与分期手术治疗相比,同期手术治疗脊柱损伤合并四肢长骨骨折多发伤患者可缩短住院时间,降低并发症发生率。

Objective To investigate the perioperative effects of simultaneous fixation and staging fixation in polytrauma patients combined with spine injury and long bone fracture.Methods A retrospective case control study was conducted to analyze the clinical data of 41 severe polytrauma patients with unstable spine combined with long bone fracture admitted from June 2009 to June 2015.There were 30 males and 11 females,aged 21-66years [(41.2±12.2)years].The injured spinal segments included cervical vertebrae in 11 patients,thoracic vertebrae in 15,lumbar vertebrae in 23,sacrococcygeal vertebrae in two,as well as injuries at two or more different segments in 10patients.The long bone fracture segments included humerus in six patients,radius and ulna in 14,femur in 15,tibia and fibula in 14,as well as injuries at two or more different segments in eight patients.The injury severity score(ISS)were all>115 points.According to the timing of operation,the patients were divided into the simultaneous operation group (20patients )and the staging operation group (21 patients ).In the simultaneous operation group,there were 16 males and four females,aged (43.1±12.6)years,and internal or external fixations of spine and long bone were performed at stage I.In the staging operation group,there were 14males and seven females,aged (40.1±11.9)years.Spine fixation surgery was performed first, and then surgery for long bone fracture was performed after the conditions were stabilized.Spinal surgery methods included anterior subtotal vertebral resection,bone graft plate internal fixation,posterior laminectomy and decompression,and lateral mass screw or pedicle screw internal fixation.Plate and interlocking nail were used for internal fixation of long bone fracture,and single arm bracket for external fixation.The preoperative hospitalization time,operation time,operative blood loss (intraoperative hemorrhage and postoperative drainage),postoperative complications,hospitalization time and Frankel score of spinal cord injury before and after operation were compared between the two groups.Results The preoperative hospital stay was (9.3±6.7)days in the simultaneous operation group and (5.6±5.0)days in the staging operation group (P>0.05).The simultaneous operation group had significantly longer operation time [(4.9±2.0)hours ]than the staging operation group [(3.2±1.2)hours ](P <0.01), more operative blood loss [(1322.6±507.1)ml]than the staging operation group [(1036.7±233.9)ml ] (P<0.05),and shorter hospitalization stay [(22.8±12.6)days]than the staging operation group [(33.0+15.4)days ](P<0.05).The complication incidence of the simultaneous operation group [45%(9/20)]was significantly lower than that of the staging operation group [86%(18/21)](P < 0.01).No significant difference was found in Frankel score between the simultaneous operation group [(3.3±1.7)points]and the staging operation group [(3.1±1.5)points](P>0.05).Conclusion For polytrauma patients combined with spine injury and long bone fracture,simultaneous operation can reduce hospitalization time and complication incidence compared with staging operation.