脊柱骨折伴硬膜损伤的特点和治疗

Characteristics and treatments of spinal fractures associated with dural tears

目的探讨脊柱骨折伴硬膜损伤的特点和治疗效果。方法回顾性分析2013年2月-2015年2月收治185例脊柱骨折患者的临床资料，其中男103例，女82例；年龄17—73岁，平均58岁。致伤原因：高处坠落伤72例，交通伤58例，重物砸伤41例，跌伤12例，撞击伤2例。颈椎骨折65例，胸椎骨折51例，腰骶椎骨折69例。美国脊髓损伤协会（ASIA）分级：A级24例，B级22例，C级26例，D级37例，E级76例。80例采用单纯前路手术，97例采用单纯后路手术，8例采用前、后路联合手术。根据术中情况证实是否有硬膜损伤，将患者分为硬膜损伤组（A组，21例）和无硬膜损伤组（B组，164例）。比较硬膜损伤在颈椎、胸椎和腰骶椎骨折的发生率。比较两组患者术前脊髓神经损伤、伴有椎板骨折情况、平均椎管侵占率，并统计侵占率〉50％所占比例。观察神经功能恢复情况及术后并发症。结果A组ASIA分级A级10例，B级5例，C级3例，D级1例，E级2例。硬膜损伤在颈椎骨折的发生率为11％（7／65），在胸椎骨折的发生率为10％（5／51），在腰骶椎骨折的发生率为13％（9／69），三者问差异无统计学意义（P〉0．05）。A组91％（19／21）伴有脊髓神经损伤，B组54．9％（90／164）伴有脊髓神经损伤（P〈0．01）。A组中86％（18／21）伴有椎板骨折，B组仅有9．1％（15／164）伴有椎板骨折（P〈0．01）。A组椎管侵占率为（62．3±12．1）％，其中椎管侵占率〉50％的比例高达81％（17／21），B组椎管侵占率为（36．2±15．6）％，其中椎管侵占率〉50％的比例仅占15．2％（25／164）（P〈0．01）。A组中11例采用直接缝合，4例采用胸腰筋膜修补，3例采用人工硬脊膜覆盖，3例采用纤维蛋白胶封堵。A组术后获随访19例，1例在术后1周出现持续性脑脊液漏，经蛛网膜下腔闭式引流、伤口清创缝合、加压包扎、大量补液、抗感染治疗后痊愈。其并发症发生率为5．3％（1／19）。末次随访时，ASIA分级A级10例中2例恢复到B级，B级5例中l例恢复到C级，C级3例中1例恢复到D级，D级1例恢复到E级。结论脊柱骨折伴硬膜损伤患者绝大部分存在严重脊髓神经损伤、严重的椎管侵占、椎板骨折。脊柱骨折硬膜损伤在颈椎、胸椎和腰骶椎的发生率差异无统计学意义。硬膜损伤患者术后出现硬膜修补相关并发症发生率低，术后脊髓神经功能恢复差。

Objective To investigate the characteristics and treatment effects in patients with spinal fractures associated with dural tears. Methods A retrospective analysis was made on 185 patients with spinal fractures presenting to hospital from February 2013 to February 2015. There were 103 males and 82 females, aged 17-73 years （mean, 58 years）. Causes of injury were high falls in 72 patients , traffic collisions in 58, hitting by heavy objects in 41, ground-level falls in 12, and collision events in two. Cervical spine fractures were seen in 65 patients, thoracic vertebra fractures in 51, and lumbosacral vertebral fractures 69. Neurologic deficit was assessed using the American Spinal Injury Association （ASIA） score, including grade A in 24 patients, grade B in 22, grade C in 26, grade D in 37 and grade E in 76. Eighty patients were managed by simply anterior surgery, 97 by posterior surgery, and eight by anterior-posterior surgery. Twenty-one patients were found with dural tears （group A） and 164 patients without dural tears （group B）. Incidence of dural tears in cervical, thoracic and lumbosacral vertebral fractures were recorded and compared. Preoperative neurologic deficit, laminar fracture and spinal canal encroachment rate were compared between groups. Neurological function and complications associated with dural repair were detected. Results In group A, ten patients were rated ASIA grade A, five grade B, three grade C, one grade D and two grade E. In group B, 14 patients were rated ASIA grade A, 17 grade B, 23 grade C, 36 grade D and 74 grade E. Group A accounted for 11% （7/65） of cervical, 10% （5/51 ） of thoracic, and 13 % （9/69） of lumbosacral spine fractures （ P 〉 0.05 ）. Nineteen patients （91%） in group A were complicated with neurological deficit, compared to ninety patients （54.9%） in group B （P 〈 0. O1 ）. Eighteen patients （86%） in group A had laminar fractures, compared to fifteen patients （9.1%） in group B （P 〈0.01 ）. In group A, rate of spinal canal encroachment was （62.3 ± 12.1 ） % and 17 patients （ 81% ） showed spinal canal encroachment of greater than 50%. While in group B, rate of spinal canal encroachment was （ 36.2 ± 15.6 ） % and 25 patients （ 15.2% ） showed spinal canal encroachment of greater than 50% （P 〈 0.01 ）. For dural tears in group A, ll patients were treated by direct suturing, four by thoracolumbar fascia repair, three by artificial dural coverage and three by fibrin glue sealing. In group A, 19 patients were followed up and one of them presented persistent cerebral spinal fluid leak that necessitated an irrigation and debridement to cure. ASIA score was improved from grade A to B in two patients, grade B to C in one, grade C to D in one and grade D to E in one at the final follow-up. Conclusions Majority patients with spinal fractures associated with dural tears exist severe neurologic deficit, spinal canal encroachment and laminar fractures. Incidence of dural tear in cervical, thoracic and lumbosacral vertebral fractures is similar. Incidence of complications related to dural tear repair is low, but the neurological function recovery is poor after operation.