改良微创侧方椎间融合术在胸腰段骨折合并椎间盘损伤前路支撑与重建中的应用

Application of modified minimally invasive lateral interbody fusion in anterior support and reconstruction for thoracolumbar fracture combined with intervertebral disc injury

目的探讨改良微创侧方椎间融合术应用于胸腰段骨折合并椎间盘损伤前路支撑与重建的初步临床疗效。方法采用回顾性病例系列研究分析2017年12月— 2018年5月浙江大学医学院附属第二医院收治的14例单节段胸腰段骨折合并椎间盘损伤患者的临床资料,其中男12例,女2例;年龄22~56岁[(37.4±10.2)岁]。损伤节段:L1 9例,L2 5例。病椎上位椎间盘损伤12例,下位椎间盘损伤2例。术前美国脊髓损伤协会(ASIA)分级:A级5例,B级4例,C级3例,D级2例。所有患者在后路短节段固定1周后接受改良微创侧方椎间融合术重建脊柱前中柱稳定性。记录手术时间、术中出血量、术后住院时间及并发症情况。采用视觉模拟评分(VAS)和ASIA分级评估临床疗效。比较术前和末次随访时手术节段和腰椎前凸Cobb角变化。结果患者均获随访6~14个月[(12.1±3.6)个月]。手术时间为65~210 min[(138.9±39.4)min]。术中出血量为250~600 ml[(407.1±119.1)ml]。术后住院时间为3~13 d[(7.8±2.5)d]。患者切口均Ⅰ期愈合。术前腰痛VAS为(6.3±2.4)分,腿痛VAS为(4.1±1.3)分,末次随访腰痛VAS为(2.2±0.6)分,腿痛VAS为(2.3±0.8)分,两者较术前均明显降低(P<0.01)。末次随访时ASIA分级:A级1例,B级2例,C级5例,D级1例,E级5例。术后CT显示减压充分,内固定可靠,位置良好。术前手术节段Cobb角为(-7.8±3.9)°,腰椎前凸Cobb角为(24.8±6.9)°,末次随访时手术节段Cobb角为(3.1±2.7)°,腰椎前凸Cobb角为(30.7±9.6)°,两者较术前均得到明显恢复(P<0.01)。1例患者术后出现大腿前方疼痛,1例患者出现大腿前方麻木,经非手术治疗症状均有效缓解。无股四头肌肌力减退、胸膜撕裂、血管损伤、神经经根损伤、交感神经损伤、腹膜后血肿和人工椎体移位等严重手术相关并发症发生。结论改良微创侧方椎间融合术应用于胸腰段骨折合并椎间盘损伤前路支撑与重建的手术时间短、术中出血量少、住院时间短、并发症少,患者术后疼痛缓解明显,神经功能显著改善,可获得良好的前中柱重建。

Objective To investigate the preliminary clinical efficacy of modified minimally invasive lateral interbody fusion in the anterior support and reconstruction for thoracolumbar fracture combined with intervertebral disc injury. Methods A retrospective case series study was conducted to analyze the clinical data of 14 patients with single-segment thoracolumbar fracture combined with intervertebral disc injury admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine from December 2017 to May 2018. There were 12 males and two females, aged 22-56 years [(37.4±10.2)years]. The injured segments were at L1 in nine patients and L2 in five patients. Twelve patients had upper disc injury and two patients had lower disc injury. Before operation, American Spinal Injury Association (ASIA) classification was grade A in five patients, grade B in four, grade C in three, and grade D in two. All patients received modified minimally invasive lateral interbody fusion to reconstruct the stability of the anterior and middle columns of the spine one week after posterior short-segment fixation. The operation time, intraoperative bleeding, postoperative hospital stay and complications were recorded. Pain visual analogue scale (VAS) and ASIA nerve injury grading were used to evaluate the clinical efficacy. The Cobb angle changes of the operative segment and lumbar lordosis were compared before operation and during the last follow-up. Results The patients were followed up for 6-14 months[(12.1±3.6)months]. The operation time was 65-210 minutes [(138.9±39.4)minutes], and the intraoperative blood loss was 250-600 ml [(407.1±119.1)ml], respectively. The total postoperative length of stay ranged from 3 to 13 days [(7.8±2.5)days]. The incisions healed well at stage I in all patients. VAS for back pain and leg pain before operation were (6.3±2 .4)points and (4.1±1.3)points respectively. The final VAS for back pain and leg pain were (2.2±0.6)points and (2.3±0.8)points, which were significantly lower than the preoperative VAS (both P<0.01). At the last follow-up, there was one patient with grade A, two with grade B, five with grade C, one with grade D, and five with grade E. Postoperative CT showed that decompression was complete, implants were in good position and internal fixation was reliable. Preoperative Cobb angles of lumbar lordosis and the injury segment were (-7.8±3.9)° and (24.8±6.9)° respectively. The final Cobb angles of lumbar lordosis and the injury segment were (3.1±2.7)° and (30.7±9.6)°, which were significantly restored compared with preoperative values (both P<0.01). One patient had postoperative pain in the front thigh, and another patient had numbness in the front thigh, whose symptoms were alleviated after non-surgical treatment. No serious surgical complications such as quadriceps femoris and weakness, pleural tear, vascular injury, nerve root injury, sympathetic nerve injury, retroperitoneal hematoma and artificial vertebral body displacement occurred in these patients. Conclusions For anterior reconstruction of the thoracolumbar fracture with intervertebral disc injury, the modified minimally invasive lateral interbody fusion has the advantages of less invasive, less blood loss, shorter hospitalization time, low incidence of complications. Significant pain relief, neurological function improvement, and anterior and middle column reconstruction can be achieved postoperatively.