下腰椎爆裂性骨折不同手术方案的选择

Choice of surgeries for low lumbar burst fractures

目的探讨下腰椎爆裂性骨折损伤特点和不同手术方法的选择。方法本组22例下腰椎爆裂性骨折,分为两类:合并有椎管内占位,采用后路减压+椎弓跟螺钉内固定手术12例,其中4例结合伤椎椎体增强;单纯爆裂性骨折不合并椎管内占位10例,其中6例采用经皮闭合复位内固定手术,4例采用后路切开复位内固定手术。术前术后X线片测量伤椎前缘高度、伤椎平均高度、Cobb角,CT片测量椎管内占位率。以美国脊髓损伤协会(ASIA)损伤分级标准(AIS)评定神经功能,以腰视觉模拟量表评分(VAS)及Oswestry功能障碍指数(ODI)评分评估患者功能改善情况。结果所有病例均顺利完成手术,随访24~56个月,平均(32.9±11.4)个月。伤椎前缘高度术前(23.8±5.3)mm,术后2周(31.9±3.4)mm及末次随访(30.2±4.0)mm(P<0.05);伤椎平均高度术前(24.3±4.6)mm,术后2周及末次随访(30.3±2.9)mm、(29.7±3.1)mm,差异有统计学意义(P<0.05);Cobb角术前(9.2°±9.6°),术后2周(18.5°±7.0°)及末次随访(16.3°±7.3°),差异有统计学意义(P<0.05);椎管内占位面积由术前平均43.6%(30%~70%)减少到7.72%(0%~15%),差异有统计学意义(P<0.05);AISA分级提高0~1级;术后2周及末次随访腰痛VAS评分及ODI评分较术前明显改善(P<0.01)。结论下腰椎爆裂性骨折系不稳定骨折,早期接受手术治疗可以达到较好的恢复效果。术式的选择取决于脊柱稳定性、神经损伤、椎管内占位情况及合并症等。

Objective To analyze the characteristics of low lumbar burst fractures and the choice of surgery plans. Methods Twenty-two patients with low lumbar burst fractures were included in the study and classified into two groups. Specifically, 12 patients who had bone fragment in canal were treated with posterior decompression and short segmental pedicle screw fixation,in which 4 patients were treated in combination with vertebral augmentation; 10 patients had simple vertebral fracture, in which 6 patients received percutaneous pedicle screw fixation and other 4 patients received open surgery with pedicle screw fixation. Average height of anterior vertebral border, average height of injured vertebral body,and Cobb ’ s angle were evaluated before and after operation with X-ray. Intraspinal mass rate was evaluated on CT scan, neurofunction with American Spinal Injury （ASIA） Association impairment scale （AIS）, and clinical outcomes using visual analogue score （VAS） and oswestry disability index （ODI）. Results All patients were followed up for 24-56 months after successful operations,with an average of （32. 9 ±11.4） months. The average height of anterior vertebral border changed from preoperative （ 23. 8 ± 5. 3） mm to （31.9 ±3.4） mm two weeks after operationand （30.2 ±4.0） mm in the last follow-up （P 〈 0 .0 5 ） . The average height of injured vertebral body changed from preoperative （24. 3 ± 4. 6） mm to （30. 3 ± 2. 9） mm two weeks after operation and （29.7 ± 3？ 1） mm in the last follow-up （P 〈0.05） . The Cobb’s angle increased from preoperative （9.2.± 9 .6.）to （1 8 .5.± 7 .0.）two weeks after operation and （16.30±7.30） in the last follow-up （P〈0.05）. The intraspinal mass rate decreased from preoperative 43.6% （30% -70% ） to postoperative 7.72% （0% - 15% ）. AISA scores increased 0-1 grade. VAS score and ODI score of low back pain showed significant improvement after operation （P 〈0. 01）. Conclusion Low lumbar burst fractures, which are unstable, should be treated with surgeries as early as possible. The best choice of surgery depends on the stability of spine,nerve injury,intraspinal mass,and complications.