微创经皮椎弓根植钉并同切口通道下减压治疗A3型胸腰椎骨折

Percutaneous pedicle screw fixation and minimally invasive decompression in the same incision for type A3 thoracolumbar burst fracture

目的探讨微创经皮椎弓根植钉并同切口通道下减压治疗A3型(AO分型)胸腰椎骨折的临床疗效。方法回顾分析2014年5月—2016年2月收治的43例符合选择标准纳入研究的伴或不伴有神经损伤,但需椎管减压的A3型胸腰椎爆裂骨折患者临床资料,其中21例行微创经皮椎弓根植钉并同切口通道下减压治疗(经皮组),22例行传统开放手术椎弓根螺钉内固定并椎板切除椎管治疗(开放组)。两组患者性别、年龄、致伤原因、骨折累及节段及术前美国脊柱损伤协会(ASIA)脊髓损伤分级、胸腰椎损伤评分系统(TLICS)评分、载荷分享评分、伤椎前缘和后缘高度百分比、伤椎后凸Cobb角及椎管侵占率等一般资料比较差异均无统计学意义(P>0.05),具有可比性。记录并比较两组患者棘旁肌肉剥离长度、手术时间、术中出血量、术后引流量、患者术中X射线暴露次数、术后1 d切口疼痛视觉模拟评分(VAS);末次随访时行日本骨科协会(JOA)评分及腰痛VAS评分,并评价ASIA损伤级别恢复情况;检测术后伤椎前缘和后缘高度百分比、伤椎后凸Cobb角、椎管侵占率等影像学指标。结果经皮组剥离肌肉长度、术中出血量、术后引流量、术后1 d切口VAS评分均优于开放组(P<0.05);两组手术时间比较差异无统计学意义(P>0.05);但患者X射线暴露次数开放组优于经皮组(P<0.01)。两组患者均获随访,随访时间12~19个月,平均15.1个月。所有患者均获得良好减压;均未发生医源性神经损伤、感染、内固定物松动或断裂等并发症。两组术后3 d伤椎前缘高度百分比、伤椎后缘高度百分比、伤椎后凸Cobb角、椎管侵占率均较术前显著改善(P<0.05);两组间术后3 d上述指标比较以及末次随访时后凸Cobb角矫正丢失度比较,差异均无统计学意义(P>0.05)。末次随访时经皮组腰椎JOA评分、腰痛VAS评分均显著优于开放组(P<0.05)。末次随访时两组ASIA脊髓神经损伤分级E级以下者均较术前有1级及以上改善,两组间比较差异无统计学意义(Z=0.480,P=0.961)。结论微创经皮椎弓根植钉并同切口通道下减压术治疗伴或不伴有神经功能损伤的A3型胸腰椎爆裂骨折临床效果满意,且创伤小、恢复快、安全可靠。

Objective To assess the effectiveness of percutaneous pedicle screw fixation and minimally invasive decompression in the same incision for type A3 thoracolumbar burst fracture. Methods Between May 2014 and February 2016, 43 cases of type A3 thoracolumbar burst fracture with or without nerve symptoms were treated with pedicle screw fixation and neural decompression. Of them, 21 patients underwent percutaneous pedicle screw fixation and minimally invasive decompression in the same incision （percutaneous group）, and the other 22 patients underwent traditional open surgery （open group）. There was no significant difference in gender, age, cause of injury, fractures level, preoperative American Spinal Injury Association （ASIA） grade, thoracolumbar injury classification and severity （TLICS） score, loadsharing classification, height of injury vertebrae, kyphotic Cobb angle, and spinal canal encroachment between 2 groups （P〉0.05）. The length of soft tissue dissection, operation time, intraoperative blood loss, postoperative drainage, X-ray exposure times, and incision visual analogue scale （VAS） score at 1 day after operation were recorded and compared. At last follow-up, Japanese Orthopaedic Association （JOA） score and low back pain VAS score were recorded and compared respectively. The ASIA grade recovery was evaluated; the height of injury vertebrae, kyphotic Cobb angle, and spinal canal encroachment were assessed postoperatively. Results Percutaneous group was significantly better than open group in the length of soft tissue dissection, intraoperative blood loss, postoperative drainage, and incision VAS at I day after operation （P〈O.05）, but no significant difference was found in operation time between 2 groups （P〉0.05）; however, X-ray exposure times of open group were significantly better than that of percutaneous group （P〈0.01）. The patients were followed up 12 to 19 months （mean, 15.1 months） in 2 groups. All patients achieved effective decompression. No complications of iatrogenic neurological injury and internal fucation failure occurred. The height of injury vertebrae, kyphotic Cobb angle, and spinal canal encroachment of the fractured vertebral body were significantly improved at 3 days after operation when compared with preoperative ones （P〈0.05）, but no significant difference was found between 2 groups （P〉0.05）. At last follow-up, JOA score and low back pain VAS score of percutaneous group were significantly better than those of open group （P〈0.05）. The neurological function under grade E was improved at least one ASIA grade in 2 groups, but no significant difference was shown between 2 groups （Z=0.480, P=0.961）. Conclusion Percutaneous pedicle screw fixation and minimally invasive decompression in the same incision for type A3 thoracolumbar burst fracture has satisfactory effectiveness. And it has the advantages of minimal trauma, quick recovery, safeness, and reliableness.