经腹直肌外侧入路治疗垂直剪切型骨盆骨折合并腰骶丛神经损伤

Treatment of vertical shear pelvic fracture combined with lumbosacral plexus injury through the lateral-rectus approach

目的探讨经腹直肌外侧入路(LRA)治疗垂直剪切型骨盆骨折合并腰骶丛神经损伤的临床疗效。方法回顾性分析2010年8月至2018年8月期间南方医科大学第三附属医院骨科收治的37例垂直剪切型骨盆骨折合并腰骶丛神经损伤患者资料。男25例,女12例;年龄为18~61岁,平均36.2岁。骨折按Tile分型:C1.3型31例,C2型5例,C3型1例。所有患者均采用LRA探查、松解腰骶丛神经并复位骶骨骨折,采用骶前钢板或骶髂关节螺钉固定后环,然后固定前环并处理髋臼骨折。记录患者的手术时间、术中出血量、骨折复位质量、骨折愈合时间及神经肌力恢复情况等。结果本组患者的手术时间为105~228 min,平均155.0 min;术中出血量为680~2440 mL,平均1070 mL。所有患者术后获1~8年(平均2年)随访。术后骨折复位质量根据Matta评分标准评定:优21例,良12例,可4例,优良率为89.2%。随访期间4例患者骨折复位丢失,1例患者骨折不愈合并复位丢失;其余32例患者骨折均获骨性愈合,愈合时间为8~12周(平均10.1周)。末次随访时根据英国医学研究会神经损伤委员会提出的肌力评价标准评定术后肌力恢复情况:肌力恢复至M5(神经症状完全恢复)22例,肌力恢复至M4(神经症状恢复良好)7例,肌力恢复至M1~M3(神经症状部分恢复)5例,肌力为M0(神经症状无恢复)3例。结论LRA能较好地显露骶髂关节至耻骨联合半骨盆环内侧,可直视下松解骶前受卡压及牵拉的腰骶丛神经,结合下肢牵引可达到骨折的满意复位,是治疗垂直剪切型骨盆骨折合并腰骶丛神经损伤的一种较理想手术入路。

Objective To investigate the clinical efficacy of lateral-rectus approach(LRA)for vertical shear fracture of pelvis combined with lumbosacral plexus nerve injury.Methods A retrospective study was conducted of the 37 patients who had been treated at Department of Orthopaedics,The Third Affiliated Hospital to Southern Medical University for vertical shear pelvic fracture combined with lumbosacral plexus nerve injury from August 2010 to August 2018.They were 25 males and 12 females,aged from 18 to 61 years(mean,36.2 years).By the Tile classification,there were 31 cases of type C1.3,5 cases of type C2 and one of type C3.LRA was used in all the patients to explore and release the lumbosacral plexus nerve and to reduce the sacral fracture.The posterior ring was fixated with an anterior iliac plate or sacral screws before fixation of the anterior ring and treatment of the acetabular fracture.The operation time,intraoperative bleeding volume,quality of fracture reduction,fracture union time and recovery of nerve and muscle strength were recorded.Results For this cohort,the operation time ranged from 105 to 228 minutes(mean,155.0 minutes)and the intraoperative bleeding volume from 680 to 2,440 mL(mean,1,070 mL).Thefollow-up time ranged from 1 to 8 years(average,2 years).According to the Matta criteria,the quality of fracture reduction was evaluated as excellent in 21 cases,as good in 12 cases and as fair in 4 cases,giving an excellent and good rate of 89.2%.Follow-ups revealed reduction loss in 4 patients,nonunion and reduction loss in one patient and bony union in the other 32 patients after 8 to 12 weeks(mean,10.1 weeks).According to the criteria by the Nerve Injuries Committee of the British Medical Research Council(BMRC),the recovery of nerve and muscle strength achieved M5(full recovery of neurological symptoms)in 22 cases,M4(fine recovery of neurological symptoms)in 7 cases,M1,M2 and M3(partial recovery of neurological symptoms)in 5 cases,and M0(no recovery of neurological symptoms)in 3 cases.Conclusion LRA is an ideal surgical approach for treatment of pelvic vertical shear fractures complicated with lumbosacral plexus nerve injury,because it can well expose the medial pelvic joint from the sacroiliac joint to the symphysis pubis,allow direct release of the lumbosacral plexus nerve compressed and stretched,and,together with traction of the lower limbs,lead to satisfactory fracture reduction.