腹直肌旁入路结合骶前减压术治疗陈旧性Denis Ⅱ型骶骨骨折合并上骶丛损伤的疗效分析

Lateral rectus abdominis approach combined with presacral decompression for old Denis type Ⅱ sacral fractures complicated with upper sacral plexus injury

目的探讨腹直肌旁入路结合骶前减压术治疗陈旧性DenisⅡ型骶骨骨折合并上骶丛损伤的临床疗效。方法采用回顾性病例系列研究分析2010年6月—2016年12月武汉大学中南医院收治的9例陈旧性DenisⅡ型骶骨骨折合并上骶丛(L4~S1)损伤患者的临床资料,其中男6例,女3例;年龄15~58岁[(33.1±7.5)岁]。患者均于术前2 h在数字减影血管造影(DSA)下行髂内动脉栓塞并预置腹主动脉球囊。均采用腹直肌旁入路行骶前减压治疗。记录手术时间、术中出血量及术后完全负重时间;摄X线片及CT观察内固定及骨折愈合情况;比较患者术前、末次随访时视觉模拟评分(VAS)及欧洲五维健康量表(EQ-5D)评分;采用Gibbons骶神经损伤分级评价神经功能;观察术中、术后并发症情况。结果患者均获随访24~52个月[(35.2±5.2)个月]。手术时间(2.9±0.6)h;术中出血量(573±138)ml;完全负重时间为术后(11.6±1.2)周。VAS和EQ-5D评分由术前(7.8±0.6)分和(0.34±0.07)分改善为末次随访时(0.8±0.3)分和(0.81±0.05)分(P<0.05)。术后1年随访Gibbons骶神经损伤分级:Ⅰ级8例,Ⅱ级1例(P<0.01),下肢放射性疼痛较术前明显改善,其中8例患者疼痛消失,完全恢复正常;1例仍残留患侧肢体的麻木及感觉减退。术中无医源性腰骶丛神经、重要血管及盆腔脏器损伤。术后随访中仅1例出现创伤性髋关节炎,于术后6个月接受全髋关节置换术。其余患者无伤口感染、压疮、内固定物松动或断裂等并发症发生。结论采用腹直肌旁入路行骶前减压治疗陈旧性DenisⅡ型骶骨骨折合并上骶丛损伤,可充分松解卡压的上骶丛神经,缓解疼痛及促进功能康复,且并发症发生率低,是一种可供选择的手术方式。

Objective To investigate the clinical effect of lateral rectus abdominis approach combined with presacral decompression for surgical treatment of old Denis type Ⅱ sacral fractures complicated with upper sacral plexus injury.Methods A retrospective case series study was performed on the clinical data of 9 patients with old Denis type Ⅱ sacral fractures complicated with upper sacral plexus injury(L4-S1)admitted to Zhongnan Hospital of Wuhan University from June 2010 to December 2016.There were 6 males and 3 females,aged(33.1±7.5)years(range,15-58 years).Embolization of internal iliac artery and preimplantation of abdominal aortic balloon were performed 2 hours before operation under the guidance of digital subtraction angiography(DSA).Surgery was performed using a single lateral rectus abdominis approach combined with presacral decompression.The operation time,intraoperative blood loss and full weight-bearing time were recorded.The visual analogue scale(VAS)and European QOL Five Dimensional health scale(EQ-5D)were compared before and after operation.The Gibbons'impairment scale was used to assess neurological function.X-ray and CT scan were used to observe internal fixation and fracture healing.The complications during and after operation were recorded.Results The patients were followed up for 24-52 months[(35.2±5.2)months].The operation time was(2.9±0.6)hours.The intraoperative bleeding was(573±138)ml,and the full weight-bearing time was(11.6±1.2)weeks.X-ray and CT scan showed bone healing in all patients at the latest follow-up.The VAS and EQ-5D scale improved from preoperative(7.8±0.6)points and(0.34±0.07)points to the final follow-up of(0.8±0.3)points and(0.81±0.05)points(P<0.05).According to Gibbons classification,8 patients were grade I and 1 patient was grade Ⅱ one year after operation(P<0.01).Namely,the radiation pain of lower extremities was significantly improved in all patients,among which 8 patients showed pain disappeared and completely returned to normal and 1 patient showed residual numbness and hypoesthesia of the affected limbs.No major complications(eg,iatrogenic lumbosacral plexus injury,vital blood vessels or pelvic organs injury)occurred during the operation.During the follow-up period,only one patient developed traumatic hip arthritis and underwent total hip arthroplasty 6 months after operation.Fractures of the remaining patients were healed well without complications like infection,pressure ulcer or implant failure.Conclusions For old Denis type Ⅱ sacral fractures complicated with upper sacral plexus injury,lateral rectus abdominis approach combined with presacral decompression can fully decompress the upper sacral plexus nerve,relieve pain,and promote functional rehabilitation,with low incidence of complications.It is an alternative surgical method for the treatment of old Denis type Ⅱ sacral fractures complicated with upper sacral plexus injury.