经椎板间隙小开窗与经椎弓根椎体内植骨治疗胸腰椎爆裂型骨折的比较研究

Comparative study on treatment of thoracolumbar burst fractures with bone grafting by transpedicular approach and by interlaminal small fenestration

目的探讨经椎板间隙小开窗与经椎弓根椎体内植骨治疗Denis A、B型胸腰椎爆裂型骨折的重建效果和远期稳定性差异。方法回顾分析2012年1月—2014年2月,采用椎体内植骨成形联合椎弓根钉棒系统内固定术治疗的50例Denis A、B型胸腰椎爆裂型骨折患者的临床资料。其中,30例术中采用经伤椎椎板间隙小开窗椎体内植骨(A组),20例采用经伤椎单侧椎弓根椎体内植骨(B组)。两组患者除术前Cobb角比较,差异有统计学意义(P<0.05)外,性别、年龄、致伤原因、伤后至手术时间、骨折分型、损伤节段以及术前神经功能Frankel分级、伤椎前缘高度百分比、疼痛视觉模拟评分(VAS)等一般资料比较,差异均无统计学意义(P>0.05)。记录并比较两组患者后凸Cobb角、伤椎前缘高度百分比及腰背部疼痛、神经功能恢复情况。结果两组患者均获随访,A组随访时间16~31个月,平均19.1个月;B组17~25个月,平均20.2个月。两组术后切口均Ⅰ期愈合,无神经损伤等手术相关并发症发生。两组术前存在神经功能损伤患者,除Frankel A级患者外,其余患者神经功能均有不同程度改善。两组患者腰背部疼痛均较术前缓解,术后3个月、末次随访时VAS评分与术前比较,差异均有统计学意义(P<0.05);两组间术后各时间点间比较,差异无统计学意义(P>0.05)。X线片复查示,随访期间两组均未发生断钉、退钉、断棒、内固定松动等;伤椎椎体内植骨填充良好,植骨融合。术后伤椎椎体高度均恢复良好,A、B组术后1周、3个月及末次随访时伤椎前缘高度百分比及后凸Cobb角与术前比较,差异有统计学意义(P<0.05);术后各时间点间比较,差异均无统计学意义(P>0.05)。两组间术后各时间点以上两指标比较,差异均无统计学意义(P>0.05)。结论对于Denis A、B型胸腰椎爆裂型骨折,经椎板间隙小开窗或经椎弓根进行椎体内植骨联合椎弓根钉棒系统内固定术治疗均能较好恢复椎体高度和矫正后凸并维持椎体稳定,降低了内固定物松动、断裂等并发症发生风险。因此,可根据患者椎管占位严重程度、椎体塌陷情况及脊髓神经损伤程度,选择合适植骨通道。

Objective To investigate the effectiveness and long-term stability of small fenestration vertebral bone grafting and transpedicular bone grafting in the treatment of Denis types A and B thoracolumbar burst fractures. Methods Between January 2012 and February 2014, 50 patients with Denis type A or B thoracolumbar burst fractures were treated with vertebroplasty and pedicle screw rod fixation system, and the clinical data were retrospectively analyzed. Small fenestration vertebral bone grafting by trans-interlaminar approach was used in 30 cases （group A）, and bone grafting by unilateral transpedicular approach was used in 20 cases （group B）. X-ray and CT examinations of the thoracolumbar vertebrae were performed routinely before and after operation. There was no significant difference in sex, age, cause of injury, time from injury to operation, fracture type, injury segment, and preoperative Frankel classification, the percentage of the anterior body height of the injured vertebra, and visual analogue scale （VAS） score between two groups （P〉0.05）. There was significant difference in preoperative Cobb angle ofkyphosis between two groups （P〈0.05）. The Cobb angle of kyphosis, the percentage of the anterior body height of the injured vertebra, and the recovery of neurological function were recorded and compared between two groups. Results The patients were followed up for 16-31 months （mean, 19.1 months） in group A and for 17-25 months （mean, 20.2 months） in group B. Primary healing of incisions was obtained in the two groups; no nerve injury and other operative complications occurred. The neurological function was improved in varying degrees in the other patients with neurological impairment before operation except patients at grade A of Frankel classification. The lumbar back pain was relieved in two groups. There was significant difference in VAS score between before operation and at 3 months after operation or last follow-up in two groups （P〈 0.05）, but no significant difference was found between at 3 months and last follow-up in two groups and between two groups at each time point after operation （P〉0.05）. X-ray examination showed that there was no breakage of nail and bar, or dislocation and loosening of internal fixation during follow-up period. The bone grafts filled well and fused in the fractured vertebra. The vertebral height recovered well after operation. The percentage of the anterior body height of the in- jured vertebra and Cobb angle of kyphosis at I week, 3 months, and last follow-up were significantly better than preope- rative ones in two groups （P〈0.05）, but there was no significant difference between different time points after operation （P〉0.05）, and between two groups at each time point after operation （P〉0.05）. Conclusion For Denis types A and B thoracolumbar burst fractures, vertebral bone grafting and pedicle screw internal f＇Lxation through interlaminal small fene- stration or transpedicular approach can restore the vertebral height, correct kyphosis, and maintain the vertebral stability, which reduce the risk of complications of loosening and breakage of internal fixators. The appropriate bone grafting approach can be chosen based on the degree of spinal canal space occupying, collapse of vertebral and spinal cord injury.