经皮椎弓根螺钉固定结合髂肋肌外侧入路直接前方减压治疗Denis B型腰椎爆裂性骨折

Percutaneous pedicle screw fixation combined with the lateral iliocostalis approach for direct anterior decompression in Denis type B lumbar fractures

目的:采用后路经皮螺钉固定结合髂肋肌外侧旁入路行椎管内直接前方减压的手术方式,治疗有神经损伤症状的腰椎Denis B型爆裂性骨折,评估该术式的临床效果和应用价值。方法:28例单节段Denis B型腰椎爆裂骨折患者接受该手术,涉及节段L1~3。先采用后方短节段经皮固定伤椎及上下相邻椎体,再从髂肋肌外侧旁,经髂肋肌与腰方肌间隙,通过椎间孔到达伤椎后方的上终板附近,直接推顶复位及取除椎管前方占位的骨块直接减压。术后随访18个月,从影像学和临床疗效进行评估。结果:采用该术式完成全部纳入患者的手术。平均手术时间为(152.1±27.1)min,术中出血量为(137.8±42.0)mL。影像指标中,伤椎后凸Cobb角由术前的34.0°±6.2°恢复至术后18个月的9.7°±2.7°;伤椎前缘高度百分比由(43.3±9.4)%恢复至(66.3±7.5)%;椎管矢状径占位比值由(54.7±8.3)%恢复至(10.9±4.2)%。疗效评估指标中,视觉模拟评分(visual analogue scale,VAS)由术前的(6.1±1.2)分降至(1.4±1.0)分,Oswestry功能障碍指数(oswestry disability index,ODI)由86.1±4.2降至27.3±12.3,美国脊髓损伤协会(American Spinal Injury Association,ASIA)神经功能评级情况也明显改善。结论:腰椎后路经皮椎弓根螺钉短节段固定,结合髂肋肌外侧旁入路进行椎管前方直接减压,治疗Denis B型腰椎爆裂性骨折效果确切。这种新的微创减压入路能进行有效的椎管内前方直接减压,与经皮螺钉固定相结合的手术方式具有进一步研究和应用的价值。

Objective:To treat Denis type B lumbar burst fractures with symptoms of nerve injury by percutaneous pedicle screw fixation combined with the lateral iliocostalis approach for direct anterior decompression,and to evaluate the clinical effect and application value of this operation. Methods:Twenty-eight patients with single-segmental Denis type B lumbar burst fractures underwent this operation,involving L1-3 segments. At first,the patients underwent percutaneous three-segment fixation and anterior direct decompression by reduction or/and removal of fragments in spinal canal. Then,the posterolateral intermuscular approach for anterior direct spinal canal decompression started from the lateral side of the iliocostalis,passed through the gap between the iliocostalis and quadratus lumborum,and reached the posterior part of injured vertebra at the level of the upper endplate through the intervertebral foramen.The patients were followed up for 18 months,and the imaging and clinical efficacy were observed and evaluated. Results:All patients received the operation by this method. The mean operation time was(152.1±27.1)min,and the blood loss during the operation was(137.8±42.0)mL. According to the imaging makers,the Cobb angle of kyphosis recovered from(34.0° ± 6.2°)preoperatively to(9.7°±2.7°)18 months after operation(P<0.05);the height ratio of the anterior edge of the injured vertebra,recovered from(43.3±9.4)% to(66.3±7.5)%(P<0.05);and the ratio of sagittal diameter of spinal canal,recovered from(54.7±8.3)% to(10.9±4.2)%(P<0.05). For the curative effect evaluation indexes,significant improvements in visual analogue scale(VAS)[(6. 1 ± 1. 2) vs.(1.4 ±1.0),P <0.05],oswestry disability index(ODI) [(86.1 ±4.2) vs.(27.3 ±12.3),P <0.05],and American Spinal Injury Association(ASIA)scores were also notedly improved. Conclusion:Posterior percutaneous pedicle screw fixation combined with lateral iliocostalis bypass for direct anterior decompression in the spinal canal is effective in the treatment of type Denis B lumbar burst fractures. The posterolateral intermuscular approach is minimally invasive and effective for anterior direct decompression of the spinal canal. This new operation has potential in clinical application.