胸腰椎骨折后椎体“空壳”现象的手术治疗策略

Surgical treatment strategy for the “shell” phenomenon after thoracolumbar fracture

目的探讨胸腰椎骨折后椎体"空壳"的手术治疗策略,为"空壳"的干预及治疗提供临床参考。方法 2015年6月—2017年1月,根据选择标准纳入53例胸腰椎骨折术后有椎体"空壳"高危发生风险的患者进行前瞻性研究。全部患者根据就诊顺序按随机表法分为两组:治疗组27例,采用短节段钉棒固定联合伤椎重建;对照组26例,采用单纯短节段钉棒固定。两组患者性别、年龄、致伤原因、骨折Denis分型、骨折节段、伤椎前缘压缩程度、骨密度、美国脊髓损伤协会(ASIA)分级等一般资料比较差异均无统计学意义(P>0.05),具有可比性。计算并比较两组患者术前、术后即刻及末次随访时伤椎前缘压缩程度、疼痛视觉模拟评分(VAS)和Oswestry功能障碍指数(ODI),同时观察术后椎体"空壳"及手术并发症情况。结果所有患者均获随访,随访时间12～18个月,平均14.4个月。术后治疗组有5例发生"空壳",末次随访时不愈合4例;对照组有23例发生"空壳",末次随访时不愈合19例;两组比较差异有统计学意义(P<0.05)。治疗组1例发生切口脂肪液化、4例发生骨水泥渗漏,对照组发现2例螺钉松动、1例单侧连接棒断裂,两组并发症发生率比较差异无统计学意义(χ~2=0.504,P=0.478)。术后即刻及末次随访时两组患者伤椎前缘压缩程度、VAS评分和ODI评分均较术前显著改善(P<0.05)。术后即刻两组伤椎前缘压缩程度比较差异无统计学意义(P>0.05),但末次随访时对照组显著高于治疗组(P<0.05);除末次随访时对照组ODI评分显著高于治疗组外(P<0.05),其余时间点两组VAS评分及ODI评分比较差异均无统计学意义(P>0.05)。结论采用短节段钉棒固定联合伤椎重建治疗胸腰椎骨折能有效预防椎体"空壳",有利于伤椎高度的维持和远期功能的改善,临床治疗效果满意。

Objective To explore the surgical treatment strategy of the vertebral "shell" after thoracolumbar fracture, and provide clinical reference for the intervention and treatment of "shell". Methods Between June 2015 and January 2017, 53 patients with high risk of vertebral "shell" after thoracolumbar fracture surgery were enrolled in a prospective study according to the selection criteria. All patients were randomly divided into two groups according to the order of treatment, 27 cases in the treatment group were treated with short-segment fixation combined with vertebral reconstruction, 26 cases in the control group were treated with short-segment fixation. There was no significant difference in gender, age, injury cause, Denis classification, fracture segment, the degree of injured vertebra compression,bone mineral density, and American Spinal Cord Injury Association(ASIA) classification between the two groups(P>0.05). The degree of injured vertebra compression, visual analogue scale(VAS) score, and Oswestry disability index(ODI) score at preoperation, immediate after operation, and last follow-up were calculated and compared between the two groups. The "shell" phenomenon and surgery complications were observed at the same time. Results All patients were followed up 12-18 months with an average of 14.4 months. There were 5 cases of "shell" phenomenon in the treatment group and 4 cases of nonunion at last follow-up, 23 cases of "shell" phenomenon in the control group and 19 cases of nonunion at last follow-up; there was a significant difference between the two groups(P<0.05). In the treatment group, 1 case had incision fat liquefaction and 4 cases had bone cement leakage; in the control group, 2 cases had screw loosening and 1 case had unilateral connecting rod rupture; there was no significant difference in the incidence of complications between the two groups(χ~2=0.504, P=0.478). The degree of injured vertebra compression, VAS score, and ODI score were significantly improved in both groups at immediate after operation and last follow-up(P<0.05). There was no significant difference in the degree of injured vertebra compression between the two groups at immediate after operation(P>0.05), but which was significantly higher in the control group than that in the treatment group at last followup(P<0.05). Except that the ODI score of the control group was significantly higher than that of the treatment group at last follow-up(P<0.05), there was no significant difference in VAS score and ODI score between the two groups at the other time points(P>0.05). Conclusion The treatment of thoracolumbar fracture with short-segment fixation combined with injured vertebral reconstruction can effectively prevent the "shell" phenomenon, which is conducive to maintaining the height of injured vertebral and improving the long-term function. The effectiveness is satisfactory.