应用翼状工作通道经椎旁肌间隙入路治疗胸腰椎骨折疗效分析

Paraspinal muscle approach with winglike working channel in the treatment of thoracic and lumbar spine fracture

目的 探讨应用翼状工作通道经椎旁肌间隙入路治疗胸腰椎骨折的临床疗效和影像学结果.方法 2010年10月至2012年8月有51例无神经症状的胸腰椎骨折患者在山东大学齐鲁医院骨科接受手术治疗,其中通过翼状工作通道经椎旁肌间隙入路治疗26例（翼状工作通道组）,传统手术入路治疗25例（传统手术入路组）.两组患者的骨折均为伤后2周内的新鲜骨折,无明显神经症状,椎管内占位≤1/3椎管矢状径,受伤椎体压缩≤2/3.排除病理性骨折、严重骨质疏松症的患者.对两组病例术前及术后视觉模拟评分（VAS）和影像学参数进行配对样本和独立样本t检验,对分类资料进行x2检验,对非正态分布参数进行Mann-Whitney U检验和Wilcoxon配对检验.结果 翼状工作通道组与传统手术入路组术中出血量分别为（91.5±36.6） ml和（209.2±38.3）ml（t=-11.216,P=0.000）,术后引流量分别为（13.7±4.4） ml和（162.3±56.6）ml（t=-13.352,P=0.000）,术后卧床时间分别为（87.3±11.5）h和（118.4±20.4）h（t=-6.727,P=0.000）,术后3d背痛VAS分别为5.5±1.0和6.4±0.8（t=-3.304,P=0.002）,末次随访背痛VAS分别为1.0（1.0）和2.0（1.0）（U=191.0,P=0.008）,两组之间差异均有统计学意义.而两组病例手术时间分别为（109.0±29.7）min和（119.2±26.8）min,差异无统计学意义（t=-1.283,P=0.206）.按改良Macnab疗效评定标准,两组病例对比差异无统计学意义（x2=0.513,P=0.774）.两组病例术前伤椎椎体前缘高度百分比分别为（57.2±11.8）％和（55.2±10.9）％,术后1周分别为（95.2±8.3）％和（95.3±5.8）％,末次随访时分别为（92.9±6.7）％和（92.1±5.6）％,两组病例伤椎椎体前缘高度百分比在术前（t=0.685,P=0.496）、术后1周（t=-0.068,P=0.946）和末次随访时（t=0.505,P=0.615）差异均无统计学意义.两组病例矢状面后凸Cobb角术前分别为21.0°（12.5 °）和23.0°（12.0°）,术后1周分别为3.0°（5.5°）和4.0°（4.5°）,末次随访时分别为4.0°（5.5°）和6.0°（6.0°）,两组病例矢状面后凸Cobb角在术前（U=316.0,P=0.544）、术后1周（U=342.5,P=0.893）和末次随访时（U =328.5,P=0.701）差异均无统计学意义.结论 通过翼状工作通道经椎旁肌间隙入路治疗胸腰椎骨折,能够取得良好的临床疗效和影像学效果.

Objective To evaluate the clinical and radiological efficacy of paraspinal muscle approach with winglike working channel in the treatment of thoracic and lumbar spine fracture.Methods From October 2010 to August 2012,a total of 51 patients with thoracic and lumbar spine fractures without neurological symptoms were enrolled in the study,including 32 males and 19 females.All patients were divided into two groups：26 patients were treated through posterior paraspinal muscle approach with winglike working channel,and 25 patients were treated through traditional posterior approach.In all patients,the interval between injury and operation was less than two weeks;the vertebral canal blocked area was less than 1/3 in sagittal diameter; the compression of the fractured vertebra height was less than 2/3.And the patients with pathological fracture and severe osteoporosis were excluded.The perioperative index including operative blood loss,draining loss,operative time,postoperative bed time were recorded.The clinical results were evaluated by visual analogue scale （VAS） for back pain preoperatively,at 3 days,3 months,the last follow-up postoperatively and modified Macnab criteria at the last follow-up.The radiological results were evaluated by sagittal Cobb angle and the anterior height of the fractured vertebra.The data of two groups were compared statistically with paired and independent t test,x2 test,Mann-Whitney U test and Wilcoxon test.Results All patients were followed up with average of 16.6 months.In the two groups,the operative blood loss was respectively （91.5 ± 36.6） ml and （209.2 ± 38.3） ml （t =-11.216,P =0.000）,draining loss was （13.7 ± 4.4） ml and （162.3 ± 56.6） ml （t =-13.352,P =0.000）,postoperative bed time was （87.3 ± ll.5）hours and （118.4 ± 20.4） hours （t =-6.727,P =0.000）,VAS for back pain at 3 days postoperatively was 5.5 ± 1.0 and 6.4 ± 0.8 （t =-3.304,P =0.002）,also VAS at the last follow-up was 1.0（1.0）and 2.0（1.0） （U =191.0,P =0.008）.Data above showed significant differences between the two groups.No significant differences were found in operative time,（109.0 ± 29.7） min vs.（119.2 ± 26.8） min （t =-1.283,P =0.206）,and modified Macnab criteria （x2 =0.513,P =0.774） between the two groups.The anterior height of the fractured vertebra preoperatively,at 1 week and the last follow-up postoperatively of the two groups were respectively （57.2 ± 11.8）% and （55.2 ± 10.9）% （t =0.685,P =0.496）,（95.2±8.3）% and （95.3 ±5.8%） （t =-0.068,P =0.946）,（92.9 ±6.7）% and （92.1 ± 5.6） % （t =0.505,P =0.615）.The sagittal Cobb angles preoperatively,at 1 week and the last follow-up postoperatively of the two groups were respectively 21.0° （12.5°） and 23.0° （12.0°） （U =316.0,P =0.544）,3.0°（5.5°） and 4.0° （4.5°） （U =342.5,P =0.893）,4.0°（5.5°） and 6.0°（6.0°） （U =328.5,P =0.701）.There were no significant differences of these radiological results between the two groups in the same time point.Conclusion The paraspinal muscle approach with winglike working channel in the treatment of thoracic and lumbar spine fracture is an efficient surgical option which can acquire satisfactory clinical and radiological results.