后路钉棒反弓折顶技术结合椎弓根植骨治疗胸腰段椎体爆裂骨折

Inverse arch roof breaking technique combined with pedicle screw and bone graft in the treatment of thoracolumbar burst fractures

背景:胸腰段爆裂骨折发病率较高,后路单纯撑开技术在维持椎体高度、降低并发症方面的疗效不甚满意,因此试图探索更佳治疗方案。目的:探讨采用反弓折顶技术结合椎弓根植骨治疗胸腰段椎体爆裂骨折的效果。方法:前瞻性纳入78例胸腰段椎体爆裂骨折患者,均为闭合性新鲜骨折,均采用后路手术,伤后至手术时间4-14 d,平均7.8 d。随机分为2组,单纯撑开组38例行单纯椎弓根钉棒系统撑开复位固定,反弓折顶植骨组40例行后路钉棒反弓折顶技术结合椎弓根植骨固定。2组患者对治疗方案均知情同意,且得到医院伦理委员会批准。对比2组手术时间及术中出血量、骨折愈合时间、术后伤椎前缘高度比值、Cobb角、目测类比评分、生活活动能力(Barthel指数)及术后并发症发生情况。结果与结论:①所有患者获得10-22个月随访;②单纯撑开组手术时间及术中出血量均优于反弓折顶植骨组(P<0.01);③2组术后伤椎前缘高度比值、Cobb角差异有显著性意义(P<0.01),反弓折顶植骨组优于单纯撑开组;④2组骨折愈合时间、术后生活活动能力(Barthel指数)差异均有显著性意义(P<0.01),反弓折顶植骨组优于单纯撑开组;⑤术后2组均未发生深部感染,反弓折顶植骨组未发生内固定失败、椎体高度过度丢失等并发症;单纯撑开组发生内固定失败螺钉拔出3例,钛棒断裂2例,椎体高度明显丢失10例;⑥提示与单纯撑开复位固定相比,后路钉棒反弓折顶植骨并伤椎置钉固定可形成伤椎压缩中心骨性支撑,重建前、中柱高度方面疗效确切,具有力学强度高、椎体高度维持好、骨愈合率高、并发症少的优点,将是治疗胸腰椎爆裂骨折较为理想的选择。

BACKGROUND:The morbidity rate of thoracolumbar burst fracture is high;however,the simple posterior distraction and reduction technique has poor patient satisfaction on maintaining vertebral height and reducing complications.Therefore,we attempt to explore a better therapeutic regimen.OBJECTIVE:To assess the efficacy of inverse arch roof breaking technique combined with pedicle screw and bone graft in treatment of thoracolumbar burst fractures.METHODS:This was a retrospective study of 78 patients with thoracolumbar burst fractures.All the patients suffered from fresh closed fractures,and all of them were operated by posterior approach.The time from injury to surgery ranged from 4 to 14 days,with an average of 7.8 days.They were randomly assigned to two groups.The 38 cases in the simple distraction group were treated with simple vertebra pedicle screw-rod system distraction and reduction fixation.The 40 cases in the inverse arch roof breaking and bone graft group were treated with inverse arch roof breaking technique combined with pedicle screw and bone graft in fractured vertebra.All patients signed the informed consent.The study was approved by the Hospital Ethics Committee.Operation time,intraoperative blood loss,fracture healing time,anterior height ratio of injured vertebrae,Cobb angle,visual analogue score,Barthel Index and postoperative complications were measured between the two groups.RESULTS AND CONCLUSION:(1)The follow-up period for all patients was 10-22 months.(2)Operation time and intraoperative blood loss were better in the simple distraction group than in the inverse arch roof breaking and bone graft group(P<0.01).(3)The ratio of anterior height of injured vertebra and Cobb angle were significantly different between the two groups(P<0.01).Above indexes were better in the inverse arch roof breaking and bone graft group than in the simple distraction group.(4)There were significant differences in fracture healing time and life activity function(Barthel index)between the two groups(P<0.01),and above indexes were better in the inverse arch roof breaking and bone graft group than in the simple distraction group.(5)No deep infection was found in both groups.There were no complications such as internal fixation failure and excessive loss of vertebral height in arch roof breaking and bone graft group.In the simple distraction group,there were 3 cases of screw pull-out because of failed internal fixation,2 cases of titanium rod breakage,and 10 cases of obvious vertebral height loss.(6)These findings suggest that compared with simple distraction and reduction fixation,inverse arch roof breaking technique combined with pedicle screw and bone graft can provide bony support to compression center of fractured vertebra.The efficacy was identified in reconstructing the height of anterior and middle columns.This method has the advantages of high mechanical strength,strong vertebral height maintenance,high bone healing rate and few complications,which will be the ideal choice in the treatment of thoracolumbar burst fracture.