经椎板间隙开窗伤椎椎体内植骨治疗胸腰椎爆裂骨折

TREATMENT OF THORACOLUMBAR BURST FRACTURES BY POSTERIOR LAMINOTOMY DECOMPRESSION AND BONE GRAFTING VIA INJURED VERTEBRAE

目的探讨经椎板间隙开窗、椎管减压、伤椎椎体内植骨治疗胸腰椎爆裂骨折的临床疗效。方法2010年11月-2012年11月,对58例胸腰椎爆裂骨折行经椎板间隙开窗、椎管减压、伤椎椎体内植骨治疗。其中男40例,女18例;年龄25~58岁,平均48岁。骨折根据Denis分型均为爆裂骨折(B型)。脊髓损伤程度根据美国脊柱损伤委员会(ASIA)分类标准:A级5例,B级18例,C级20例,D级14例,E级1例。根据胸腰椎爆裂骨折椎管内骨折块CT分型:A型5例,B1型20例,B2型10例,C型23例。受伤至手术时间10 h^9 d,平均7.2 d。手术前后行CT检查计算伤椎椎管狭窄率,摄X线片测量伤椎相对高度评估椎体高度恢复、Cobb角评估后凸矫正情况,通过ASIA分类标准评估神经功能恢复情况。结果患者均顺利完成手术,术后切口均Ⅰ期愈合。58例均获随访,随访时间12~18个月,平均15个月。术后1年CT示伤椎椎体内植骨部分吸收,但伤椎骨折均愈合,无螺钉松动及断钉、断棒现象发生。术前和术后1年伤椎椎管狭窄率分别为47.56%±14.61%和1.26%±0.62%,术后1年较术前明显恢复(t=24.46,P=0.00)。术前、术后1周、术后1年和取出内固定物后3个月Cobb角分别为(16.98±3.67)、(3.42±1.45)、(3.82±1.60)、(4.84±1.70)°,术后各时间点均较术前明显改善(P<0.05);伤椎相对高度分别为57.10%±6.52%、96.26%±1.94%、96.11%±1.97%、96.03%±1.96%,术后各时间点均较术前明显恢复(P<0.05)。术后1年56例患者神经功能均有1~3级改善,ASIA分级为A级1例,B级4例,C级10例,D级23例,E级20例。结论经椎板间隙开窗、椎管减压、伤椎椎体内植骨在椎管充分减压同时,椎体内植骨重塑了椎体形状和高度,伤椎愈合良好,是治疗胸腰椎爆裂骨折的有效方法。

Objective To study the effectiveness of posterior laminotomy decompression and bone grafting via the injured vertebrae for treatment of thoracolumbar burst fractures. Methods Between November 2010 and November 2012, 58 patients with thoracolumbar burst fractures were treated by posterior fixation combined with posterior laminotomy decompression and intervertebral bone graft in the injured vertebrae. There were 40 males and 18 females with a mean age of 48 years（range, 25-58 years）. According to Denis classification, 58 cases had burst fractures（Denis type B）; based on neurological classification of spinal cord injury by American Spinal Injury Association（ASIA） classifications, 5 cases were rated as grade A, 18 cases as grade B, 20 cases as grade C, 14 cases as grade D, and 1 case as grade E. Based on thoracolumbar burst fractures CT classifications there were 5 cases of type A, 20 cases of type B1, 10 cases of type B2, and 23 cases of type C. The time between injury and operation was 10 hours to 9 days（mean, 7.2 days）. The CT was taken to measure the space occupying of vertebral canal. The X-ray film was taken to measure the relative height of fractured vertebrae for evaluating the vertebral height restoration, Cobb angle for evaluating the correction of kyphosis, and ASIA classification was conducted to evaluate the function recovery of the spinal cord. Results The operations were performed successfully, and incisions healed primarily. All the patients were followed up 12-18 months（mean, 15 months）. CT showed good bone graft healing except partial absorption of vertebral body grafted bone; no loosening or breakage of screws and rods occurred. The stenosis rates of fractured vertebral canale were 47.56% ± 14.61% at preoperation and 1.26% ± 0.62% at 1 year after operation, showing significant difference（t=24.46, P=0.00）. The Cobb angles were（16.98 ± 3.67）° at preoperation,（3.42 ± 1.45）° at 1 week after operation,（3.82 ± 1.60）° at 1 year after operation, and（4.84 ± 1.70）° at 3 months after removal of internal fixation, showing significant differences between at pre- and post-operation（P〈0.05）. The relative heights of fractured vertebrae were 57.10% ± 6.52% at preoperation, 96.26% ± 1.94% at 1 week after operation, 96.11% ± 1.97% at 1 year after operation, and 96.03% ± 1.96% at 3 months after removal of internal fixation, showing significant differences between at pre- and post-operation（P〈0.05）. At 1 year afteroperation, the neural function was improved 1-3 grades in 56 cases. Based on ASIA classifications, 1 case was rated as grade A, 4 cases as grade B, 10 cases as grade C, 23 cases as grade D, and 20 cases as grade E. Conclusion Treatment of thoracic and lumbar vertebrae burst fractures by posterior laminotomy decompression and bone grafting via the injured vertebrae has satisfactory effectiveness, which can reconstruct vertebral body shape and height with spinal cord decompression and good vertebral healing. It is a kind of effective solution for thoracolumbar burst fracture.