经皮与开放椎弓根螺钉内固定术治疗无神经损伤胸腰段骨折的疗效对比

Comparison of clinical results between percutaneous and traditional open pedicle screw fixation for thoracolumbar fractures without neurological deficit

目的 ：比较经皮椎弓根螺钉内固定术和开放椎弓根螺钉内固定术治疗无神经损伤胸腰段骨折的临床疗效。方法：对2009年4月～2012年4月手术治疗的18～60岁、伤后2周内、单节段胸腰椎A1～A3型压缩或爆裂性骨折、椎弓根及小关节突完整、压缩程度小于椎体前缘高度50%的70例无神经损伤胸腰段骨折患者进行回顾性分析。根据手术方式不同分为A、B两组,A组32例,采用经皮椎弓根螺钉内固定术治疗,男23例,女9例,年龄42.24±3.21岁;B组38例,采用开放椎弓根螺钉内固定术,男28例,女10例,年龄41.23±3.18岁。术前、末次随访均进行腰痛视觉模拟评分（visual analog scale,VAS）和Oswestry功能障碍指数（Oswestry disability index,ODI）评分。比较两组患者的手术时间、术中出血量、住院天数及并发症;比较两组患者术前、末次随访的疼痛评分（VAS）及ODI;比较两组患者术前伤椎的椎体前缘高度与后凸Cobb角、术后Cobb角恢复值与伤椎高度恢复率及末次随访时Cobb角丢失值与伤椎高度丢失率。结果：两组患者年龄、性别构成比、受伤至手术时间、骨折部位及术前的伤椎Cobb角、伤椎前缘高度、VAS评分和ODI差异均无统计学意义（P〉0.05）。A组手术时间为48.38±2.24min,术中失血量为55.00±21.24ml,住院时间为5.03±0.78d,恢复日常活动时间为14.64±6.32d,住院费用为5.21±0.78万元;B组手术时间为88.43±5.28min,术中失血量为153.00±33.24ml,住院时间为7.02±1.23d,恢复日常活动时间为30.25±6.14d,住院费用为3.33±1.23万元。两组手术时间、出血量、住院时间、恢复日常生活时间及住院费用的差异均有统计学意义（P〈0.001）。A组未出现术后并发症,B组1例术后手术切口浅表感染经简单清创换药处理后愈合,两组并发症发生情况无统计学差异（P〉0.05）。70例获得18.3～34.3个月的随访,其中A组随访25.1±2.45个月,B组随访25.5±1.99个月,两组差异无统计学意义（P〉0.05）。术后Cobb角恢复值、伤椎高度恢复率及末次随访时Cobb角丢失值、伤椎高度丢失率两组间比较均无统计学差异（P〉0.05）。末次随访时,VAS评分和ODI两组间差异无统计学意义（P〉0.05）。结论 ：经皮椎弓根螺钉内固定术治疗无神经损伤胸腰段骨折的临床疗效与开放椎弓根螺钉内固定术相近,但在手术时间、术中出血量、住院时间、恢复日常生活时间等方面有明显优势,可在把握严格手术适应证的前提下作为治疗无神经损伤胸腰段骨折的主要手术方法。

Objectives： To compare the efficacy and safety of percutaneous pedicle screw fixation and traditional open surgery for thoracolumbar fractures without neurological deficit. Methods： Seventy adult patients with single thoracolumbar fracture between April 2009 and April 2012 were recruited in this study. Those patients aged from 18 to 60 years old and were injured within two weeks. All patients had single level thora-columbar spine fracture, with pedicles and facet joints intact and vertebral body compression less than 50%.All cases were divided as percutaneous pedicle screw fixation group（group A） and traditional open surgery group（group B）. Group A was undergoing percutaneous pedicle screw fixation including 32 patients（23 males,9 females, average age of 42.24y）. Group B was undergoing traditional open surgery including 38 patients（28males, 10 females, average age of 41.23y）. Functional outcomes of preoperation and final follow-up were evaluated by visual analog scale（VAS） and Oswestry disability index（ODI）. Clinical and surgical evaluation including surgery time, blood loses, hospital stay and complication were performed. Cobb angle and front height loss of fracture vertebral before surgery, Cobb angle restoration and fracture vertebral body front height restoration rate after surgery, Cobb angle loss and fracture vertebral body front height loss rate were assessed from lateral lumbar X-ray for radiological evaluation. Results： There were no statistical differences between two groups in age, gender, injury site, Cobb angle, anterior height of fracture vertebral body, VAS and ODI（P〉0.05）. The average operation time of group A was 48.38±2.24 mins, blood loss was 55.00±21.24 ml, hospital stay was 5.03±0.78 d, the period of return to daily life after surgery was 14.64±6.32 d, hospitalization expense was 5.21±0.78 ten thousand yuan. The average operation time of group B was 88.43±5.28 min, blood loss was 153.00±33.24 ml,hospital stay was 7.02±1.23 d, the period of return to daily life after surgery was 30.25±6.14 d, hospitalization expense was 3.33±1.23 ten thousand yuan. There were significantly statistical differences between two groups in operation time, blood loss, hospital stay, period of return to daily life after surgery, hospitalization expenses（P〈0.001）. No complication in group A and 1 case of superficial skin incision infection was noted in group B.There were no statistical differences in terms of complication and Cobb angle restoration and fracture height restoration rate after surgery, Cobb angle loss and fracture vertebral body front height loss rate at final follow up between two approaches（P〉0.05）. Conclusions： Both percutaneous and traditional open pedicle screw fixation have good clinical results for thoracolumbar fractures without neurological deficit. But percutaneous pedicle screw fixation group has shorter operation time, less blood loses, shorter hospital stay and recovery period but more hospital costs. This procedure is safe and minimally invasive under strict surgical indications.