胸腰段爆裂骨折伴不完全脊髓损伤的手术疗效分析

Curative effect of surgical treatment on thoracolumbar burst fracture complicated with incomplete spinal cord injury

目的探讨创伤性胸腰段脊柱脊髓损伤的手术时机和手术方法。方法回顾性分析2011年2月-2014年3月手术治疗的创伤性胸腰段爆裂骨折伴不完全脊髓损伤52例（61椎），其中男45例，女7例；年龄19—67岁，平均41．8岁。其中29例伴多发伤，损伤严重度评分（ISS）16—50分，平均23分。其中T11 2椎，T12 10椎，L1 29椎，L2 20椎，共61个胸腰段椎体骨折呈爆裂性，合并2个椎体骨折10例，合并3个椎体骨折2例。美国脊髓损伤协会（ASIA）分级B级16例，C级15例，D级21例。2例行前路减压固定融合，其余行后路复位减压植骨融合椎弓根长节段或短节段内固定术。按手术距受伤时间分为1～3d18例，4～7d23例，9～22d 11例。分析不同手术时机感觉运动评分的变化、术后椎管狭窄、Cobb角改善情况，以及术后ASIA分级改善情况。结果52例获13—50个月[（32．8±10．4）个月]随访。术后ASIA分级B级3例，C级14例，D级16例，E级19例（P〈0．01）。感觉、运动评分均有不同程度改善，伤后1—3d内手术优于伤后4～7d、9～22d手术（P〈0．05或0．01）。伤后4—7d手术椎管狭窄及Cobb角改善不明显，但好于9～22d手术（P〈0．05）。结论对创伤性胸腰段椎体爆裂骨折伴不完全脊髓损伤，应争取在伤后3d内手术，手术减压及纠正畸形不超过伤后1周；早期手术选择后路减压固定融合可以获得较好的效果。

Objective To investigate the timing and methods in surgical treatment of thoracolumbar burst fracture complicated with incomplete spinal cord injury. Methods A retrospective analysis was conducted on 52 patients who had surgical treatment for thoracolumbar burst fracture complicated with incomplete spinal cord injury from February 2011 to March 2014. The patients comprised 45 males and 7 females, at mean 41.8 years of age （range, 19-67 years）. Multiple trauma was noted in 29 patients. Mean injury severity score （ISS） was 23 points （range, 16-50 points）. There were altogether 61 fractured segments including 2 T11, 10 T12, 29 L1 and 20 L2. Ten patients suffered from bi-segmental lesions and 2 tri-segmental lesions. American Spinal Injury Association （ASIA） scale was B in 16 patients, C in 15 and D in 21. Two patients underwent anterior spinal decompression and fusion, and the remaining patients were treated by posterior reduction, decompression, interbody fusion and pedicle screw fixation. ASIA scale, sense or motion score, spinal stenosis and Cobb angle were recorded and their correlation with different operation time was evaluated. Results All patients were followed up for 13-50 months[ （32.8 ±10.4） months]. ASIA scale （3 grade B, 14 grade C, 16 grade D and 19 grade E） and sense or motion score presented some improvements after operation, with the results much better in patients operated within 1-3 d after injury than those operated 4-7 d and 9-22 d after injury （ P 〈 0.05 or 0.01 ）. Operation within 4-7 d postinjury exhibited no apparent improvements in spinal stenosis and Cobb angle, but the result was still better than that when operation was done 9-22 days postinjury （ P 〈 0.05 ）. Conclusions Thoracolumbar burst fracture complicated with incomplete spinal cord injury should adopt active operation treatment within 3 days postinjury as soon as possible. The time of decompression and deformity correction should not be over 1 week postinjury. Early operation of posterior spinal decompression and fusion appears to have good effects.