后路短节段椎弓根螺钉固定联合椎体成形术或伤椎置钉治疗胸腰椎骨质疏松性骨折的疗效比较

Comparison between posterior short-segment pedicle screw fixation combined with vertebroplasty or injured vertebral transpedicular fixation in treating osteoporotic thoracolumbar burst fracture

目的 比较后路短节段椎弓根螺钉固定联合椎体成形术或伤椎置钉治疗胸腰椎Magerl A3型骨质疏松性骨折的临床疗效. 方法 采用回顾性病例对照研究分析2007年5月-2016年5月收治的39例急性创伤性胸腰椎骨质疏松性骨折患者,其中男17例,女22例;年龄52～85岁,平均61.3岁.均为单节段胸腰椎（T11～L2）骨折,骨密度T值＜-2.5 SD,Frankel神经功能分级为D或E级.按照手术方式将患者分为后路短节段椎弓根螺钉固定＋椎体成形术组（A组,22例）和后路短节段椎弓根螺钉固定＋伤椎置钉组（B组,17例）.比较两组手术时间及术中出血量,应用视觉模拟评分（VAS）及Frankel神经功能分级评估患者疼痛及神经功能恢复情况.通过X线片测量计算伤椎Cobb角及伤椎前缘高度恢复率伤椎高度恢复率.观察随访时并发症情况.结果 两组均顺利完成手术,伤口均Ⅰ/甲愈合.随访12 ～ 40个月,平均23.5个月.手术时间A组为（61.7±6.7） min,B组为（48.1 ±7.5）min（P ＜0.05）.术中出血量A组为（347.7 ±44.9） ml,B组为（288.3±41.6）ml（P＜0.05）.两组术后及末次随访VAS均较术前明显改善（P＜0.05）,但组间差异无统计学意义（P＜0.05）.A组4例和B组2例Frankel分级为D级患者转为E级.两组术后伤椎Cobb角及伤椎前缘高度恢复率均较术前明显改善（P＜0.05）,末次随访均较术后有所降低,但无差异统计学意义（P＞0.05）,两组间差异也无统计学意义（P＞0.05）.A组有4例内固定取出,B组有2例内固定取出,随访期间无内固定失效等并发症. 结论 应用短节段固定联合椎体成形术或伤椎置钉均有助于胸腰椎骨质疏松性骨折椎体高度的恢复,减少后凸畸形,两者临床疗效相当.但短节段固定联合伤椎置钉的手术时间更短,出血量更少.

Objective To investigate the clinical efficacy of posterior short-segment pedicle screw fixation combined with vertebroplasty or injured vertebral transpedicular fixation in the treatment of osteoporotic thoracolumbar Magerl type A3 fractures.Methods A retrospective case control study was conducted on 39 patients with acute traumatic osteoporotic thoracolumbar burst fractures admitted from May 2007 to May 2016.There were 17 males and 22 females,aged 52-85 years （mean 61.3 years）.All patients had single segment thoracolumbar fracture（T11-L2）,with bone mineral density T value 〈-2.5 SD and the Frankel grade D or E.According to operation method,the patients were divided into Group A （n =22） which adopted short segment pedicle screw fixation combined with vertebroplasty and Group B （n =17） which adopted pedicle screw fixation combined with injured vertebra transpedicular fixation.The operation time and blood loss were compared between the two groups.VAS and Frankel grade were used to evaluate the patients＇ pain and the recovery of neurological function.The height recovery and Cobb angle of fracture vertebra were measured according to X-ray.Complications at follow ups were observed.Results All patients underwent the operations successfully with good healing.The mean follow-up time was 23.5 months （range,12-40 months）.The operation time was （61.7 ± 6.7）minutes in Group A and （48.1 ± 7.5） minutes in Group B （P 〈 0.05）.The blood loss was （347.7 ± 44.9） ml in Group A and （288.3 ±41.6）ml in Group B （P 〈 0.05）.Postoperative VAS score and VAS at the final follow-up in both groups were significantly improved compared with those before operation （P 〈 0.05）,with no significant difference between the two groups.Four cases in Group A and two cases in Group B with Frankel grade D were classified as grade E.After operation,the recovery rate of injured vertebral Cobb angle and anterior height were significantly improved in both groups （P 〈 0.05）.The recovery rate of Cobb angle and anterior height at the last follow up was lower than that after surgery,but with no statistical difference （P 〉 0.05）,and no significant differences were found between the two groups either （P 〉 0.05）.The screws were removed from four patients in Group A and two patients in Group B.No complications or failure of internal fixation was found during follow-up.Conclusion Posterior shortsegment pedicle screw fixation combined with vertebroplasty or injured vertebra transpedicular fixation are both helpful to the height recovery of vertebral osteoporotic fractures and reduce kyphosis with similar efficacy,while the former has the advantages of shorter operation time and less bleeding.