影响骶管减压髂腰固定治疗“H”形骶骨骨折疗效的相关因素分析

The surgical outcome of sacral decompression and lumbopelvic fixation for H-shaped sacral fracture and correlation fac- tors analysis

目的探究影响骶管减压髂腰固定治疗“H”形骶骨骨折疗效的相关因素及并发症处理。方法回顾性分析2008年1月至2016年1月行骶管减压髂腰固定治疗“H”形骶骨骨折的45例患者资料，男29例，女16例；年龄24-53岁，平均（41．2±10．7）岁；受伤距手术时间1～23d，平均（7．2±5．9）d。采用Pohlemann骨盆结果评分评估患者术后疗效，将术后疗效满意组与不满意组患者的性别、年龄、受伤机制、L5椎弓根骨折马尾损伤程度、Roy—Camille分型、L5S1小关节损伤、骶骨横行骨折线走行、术前骨折后凸角、手术时机、减压方式、置入骶骨螺钉等进行统计学分析，确定影响骶管减压髂腰固定治疗“H”形骶骨骨折疗效的相关因素。同时记录患者术后并发症的情况。结果手术时间100-220min，平均（161．2±37．9）min；术中出血量370-1000ml，平均（491．6±95．3）ml；随访时间16-93个月，平均（52．6±15．7）个月。骨盆结果评分，31例（68．9％）为疗效满意，14例（31．1％）为疗效不满意。统计学分析湿示马尾损伤程度、Roy—Camille分型、骶骨横行骨折线走行、术前骨折后凸角、手术时机、减压方式、置入骶骨螺钉与疗效密切相关，而性别、年龄、受伤机制、L5椎弓根骨折、L5S1小关节损伤与疗效无关。术后2例出现伤口深部感染，选用敏感抗生素并行手术清创后愈合；3例因髂骨螺钉钉尾突出压迫皮肤而出现疼痛，内固定取出后症状消失；1例于术后3-6个月出现一侧连接棒断裂，观察至术后9个月达到骨性愈合。结论骶管减压联合髂腰固定治疗“H”形骶骨骨折能获得有效的神经功能恢复，有利于早期负重活动；影响术后疗效的因素包括尽早手术、术前或术中骨牵引、置入骶骨螺钉、马尾不完全性损伤、Roy—CamilleⅡ型骨折、横行骨折线穿过S1、术前骨折后凸角〈40°。

Objective To investigate the correlation factors for surgical outcome of sacral decompression and lumbopelvic fixation in H-shaped sacral fracture and the methods to prevent and treat the complications. Methods From January 2008 to January 2016, 45 patients with H-shaped sacral fracture treated by sacral decompression and lumbopelvic fixation were respectively analyzed, including 29 men and 16 women, mean age 41.2 （range, 24-53 years）, mean follow-up time 52.6 months （range, 16- 93 months）. The surgical outcome was evaluated by pelvic outcome score, and correlation factors were analyzed. We analyzed whether each factor was in correlation with pelvic outcome score. Then we integrated the statistically significant indicators into Logistic regression equation to determine the related factors. Postoperative complications were all recorded. Results The average operation time was 161.2 min （range, 100-220 min）, average blood loss was 491.6 ml （range, 370-1 000 ml）, injury-surgery interval was 7.2 d （range, 1-23 d）. In terms of pelvic outcome score, 31 （68.9%） patients had satisfactory result and 14 （31.3%） patients had unsatisfactory result. Univariate X2 analysis suggested that cauda equina injury, Roy-Camille classification, L5S1 facet injury, fracture line, kyphotic angle, injury-surgery interval, decompression approach and inserting sacral screws were correlated with pel- vic outcome score, but gender, age, injury mechanism and L5 pedicle fracture had no relation with pelvic outcome score. The muhi- variate Logistic regression analysis showed that cauda equina injury, Roy-Camille classification, fracture line, kyphutic angle, injury-surgery interval, decompression approach and inserting sacral screws were closely related to pelvic outcome score, but L5S1 fac et injury was excluded. 2 patients required early surgical procedures with proper antibiotics for deep wound infection; 3 patients complained pain related to hardware prominence and the pain subsided after removal of implants; 1 patient gut unilateral rod breakage at 3-6 months and achieved bony fusion after nine months of observation. Conclusion Sacral decompression and lum- bopelvic fixation is effective in neurological recovery and early ambulation in treating H-shaped sacral fracture. Better surgical outcome is related to timely surgery, preoperative or intraoperative bone traction, sacral screws insertion, incomplete cauda equina injury, Roy-Camille type Ⅱ, fracture line penetrating S2 and kyphotic angle less than 40°.