后路经皮椎弓根钉内固定术与经肌间隙椎弓根钉内固定术治疗胸腰椎骨折的比较

Comparison of clinical effect of thoracolumbar vertebral fracture treated with pedicle screw fixation via posterior percutaneous way and paraspinal muscle approach

目的比较后路微创经皮与经肌间隙入路椎弓根螺钉治疗胸腰椎骨折的临床效果。方法回顾性分析2014年1月—2016年1月期间因胸腰段骨折在陆军军医大学大坪医院野战外科研究所脊柱外科住院手术患者共79例,其中男性47例,女性32例;平均年龄46.3岁(17~65岁);高处坠落伤59例,道路交通伤20例;受伤至手术时间2~9(平均3.6)d。根据最新的AO胸腰椎损伤分型系统分型,A1型47例,A2型7例,A3型14例,A4型11例。载荷分享(Load-sharing)评分3~6(平均4.5)分。分别采用微创经皮入路(微创经皮组,35例)和经肌间隙入路(经肌间隙组,44例)椎弓根螺钉短节段固定伤椎。比较两组患者的切口长度、手术时间、出血量、术中透视次数、术后第1天疼痛评分、伤椎高度恢复、术后ODI评分等指标。结果平均随访18个月(12~30个月)。与经肌间隙组相比,微创经皮组切口长度较短[(7.1±0.9)cm vs.(9.3±1.8)cm],术后第1天切口疼痛减轻(VAS评分3.7±1.3 vs.5.8±1.3),而经肌间隙组较微创经皮组术中透视时间少[(3.25±0.56)min vs.(2.17±0.75)min],两组比较差异均有统计学意义(P<0.05),两组手术的手术时间、出血量、术后ODI评分比较差异无统计学意义(P>0.05)。与术前比较,两组术后即刻的伤椎前缘高度和矢状面Cobb角均得到明显矫正,差异有统计学意义(P<0.05),而两组末次随访时的伤椎前缘高度和矢状面Cobb角与术后即刻相比,差异无统计学意义(P>0.05)。结论微创经皮入路与经肌间隙入路椎弓根螺钉内固定术是治疗胸腰椎骨折的有效方法,两者临床效果相同。微创经皮入路术后患者疼痛更轻,皮肤切口更小。而经肌间隙可以使用传统开放型手术器械实现微创治疗胸腰椎骨折,医生学习掌握相关技术较快,术中医护人员和患者减少了遭受医源性辐射概率,对在基层医疗单位的医疗工作者来讲,建议优先考虑使用。

Objective To compare the effect of pedicle screw fixation in the treatment of thoracolumbar fractures via the posterior percuteneous way and paraspinal muscle approach.Methods Between Jan.2014 and Jan.2016,79 patients with thoracolumbar fracture were treated in our hospital,including 47 males and 32 females.The average age was 46 years(range 17-65).There were 59 cases injured from high falling and 20 cases from car accident injury.All the patients underwent surgery 2-9 days after injury.According to the newly revised AO thoracolumbar injury classification system,47 cases were A1 type,7 cases were A2 type,14 cases were A3 type,and 11 cases were A4 type.Load-sharing score was 3-6(4.5±1.1)points.35 patients(44.3%)underwent reduction and internal fixation with pedicle screw via the percutaneous approach and 44 patients(55.7%)underwent the operation via the paraspinal muscle approach.Length of incision,operation duration,blood loss,number of intraoperative fluoroscopy,recovery of vertebral height and postoperative Oswestry Disability Index(ODI)were compared between the two groups after surgery.Results The mean follow-up period was 18 months(range 12-30 months).Compared with the paraspinal muscle group,the percutaneous group had the shorter incision length and less pain on the first postoperative day.The percutaneous group had more fluoroscopy(P<0.05).There was no significant difference in operation duration,intraoperative blood loss,postoperative ODI between the two groups(P>0.05).Compared with preoperative,the anterior height and sagittal Cobb angle of the two groups were significantly corrected(P<0.05).The height of the anterior margin and sagittal Cobb angle of the two groups at the last follow-up were compared with that immediately after surgery,showing that the difference was not statistically significant(P>0.05).Conclusion Minimally invasive percutaneous pedicle screw fixation via posterior percutaneous way and paraspinal muscle approach for treatment of single-segment thoracolumbar fractures have the same clinical effects.And the paraspinal muscle approach can achieve minimally invasive treatment with the use of traditional open surgical instruments.Meanwhile,it allows doctors to learn to master the relevant technology faster,and reduces the risk of iatrogenic radiation for intraoperative medical staff and patients.It is proposed to be the initial choice.