经腹直肌外侧切口治疗骨盆、骶骨骨折合并腰骶丛损伤的临床疗效

Lateral-rectus approach for treatment of pelvic and sacral fracture complicated with lumbosacral plexus injury

目的探讨经腹直肌外侧切口治疗骨盆、骶骨骨折合并腰骶丛损伤的手术方法及临床疗效。方法回顾性分析2013年1月至2015年1月，采用经腹直肌外侧切口治疗9例骨盆、骶骨骨折合并腰骶丛损伤患者资料，男4例，女5例；年龄21-61岁，平均38岁；伤后至手术时间：6例为7-20d，3例为21-59d。骨盆骨折Tile分型：B2型2例，B3型1例，cl型2例，c2型1例，c3型3例；骶骨骨折Denis分型：I型3例，Ⅱ型6例；神经损伤分级：完全损伤1例，部分损伤8例；其中3例合并髋臼骨折，3例合并同侧股骨中段骨折，2例合并胫骨骨折，其他脏器损伤5例。术前通过3D打印制作1：1骨折模型，并在电脑上进行骨折模拟复位；5例患者术前1h在血管造影下行患侧髂内动脉栓塞术。手术经腹直肌外侧切口进入，于腰骶干外侧显露骶髂关节，在骶正中血管与腰骶干、髂内血管间分离显露s，椎体前方，复位骶骨骨折并松解腰骶丛，紧贴骨面放置钢板跨骶髂关节固定，而后再处理合并的耻骨支及髋臼骨折。结果9例患者均顺利完成手术，手术时间125-224min，平均183min；术中出血440-2760ml，平均1150ml。术后影像学检查示骨折复位固定良好，无一例发生手术相关并发症，骶骨骨折均愈合，愈合时间8-12周，陈旧骨折与新鲜骨折愈合时间无明显差异；术后3个月，6例新鲜骨折中5例腰骶丛损伤症状完全恢复，1例恢复良好；3例陈旧骨折患者，其中2例于术后6个月神经症状大部分恢复，1例无恢复。结论采用经腹直肌外侧切口入路能较好显露骶髂关节周围，松解骨折压迫的腰骶丛神经根，通过腰骶干下方跨骶髂关节钢板固定能达到较好的固定效果，是治疗骶骨骨折合并腰骶丛损伤的一种可行洼手术方法。

Objective To explore the lateral-rectus approach for surgical treatment of pelvic and sacral fracture with lum- bosacral plexus injury and its effect. Methods From January 2013 to January 2015, 9 patients had undergone internal fixation and decompression of the sacral nerve via the lateral-rectus approach. Classification of pelvic fracture included Tile B2 in 2 pa- tients, Tile B3 in 1 patient, Tile C1 in 2 patients, Tile C2 in 1 patient, Tile C3 in 3 patients. According to Denis classification, 3 cases were type I and 6 were type II. Among them, 3 cases involved acetabular fracture, 5 cases complicated with limbs fracture and 5 cases had organ injury. The durations before operations were 7-59 days after the trauma. The fracture model was manufac- tured by 3D printing and fracture reduction was simulated on computer preoperatively. 5 of 9 patients underwent DSA to block the internal iliac artery 1 hour before surgery. The patient was in supine position, after general anesthesia, the sacroiliac joint was ex- posed via the lateral-rectus approach. Then S was approached between median sacral artery and lumbosacral trunk and internal il- iac artery. After reduction of the sacral fracture and release of the sacral plexus nerve, the sacroiliac joint was fixed with a plate. Fi- nally, the fracture of acetabulum and anterior ring of pelvis was repaired. Postoperative treatment included prevention of infection and thrombosis. Results All the 9 cases underwent the operation successfully. The average surgical time was 183 min （range, 125-224 min） and the mean blood loss was 1 150 ml （range, 440-2 760 ml）. Postoperative X-ray and CT indicated an excellent re- duction of fracture. No complication was observed. 5 of 6 patients with fresh fracture had recovery of neurologic function 3 months after operation and one was good. The neurological outcome of old fractures was good in two, unrecovered in one. Conclusion In surgical treatment of sacral fractures, the lateral-rectus approach provides adequate exposure of sacroiliac joint and the sacral plex- us nerve could be well decompressed. A stable fixation could be achieved with a plate crossing the sacroiliac joint.