陈旧性胸腰椎骨折不典型压迫致迟发型脊髓损伤的手术治疗

Surgical treatment of delayed spinal cord injury caused by atypical compression of old thoracolumbar fractures

目的探讨陈旧性胸腰椎骨折不典型压迫致迟发型脊髓损伤的临床特点及手术治疗策略。方法 2011年1月—2018年6月,收治符合选择标准的陈旧性胸腰椎骨折不典型压迫致迟发型脊髓损伤患者32例,根据手术方式不同分为A组(20例,行前路椎体次全切除+钛网重建+钉棒内固定术)和B组(12例,行后路椎管270°环形减压+钛网重建+钉棒内固定术)。两组患者年龄、性别、致伤原因、骨折节段、病程及术前美国脊髓损伤协会(ASIA)分级、背部疼痛视觉模拟评分(VAS)、腰椎日本骨科协会(JOA)评分、后凸角、椎管侵占率比较,差异均无统计学意义(P>0.05)。记录并比较两组患者切口长度、手术时间、术中出血量、并发症发生情况及重建椎体节段骨性融合时间;手术前后采用后凸角、背痛VAS评分及腰椎JOA评分评价患者疗效。结果除A组切口长度显著短于B组(t=-4.865,P=0.000)外,两组术中出血量、手术时间比较差异均无统计学意义(P>0.05)。两组均无死亡和术后截瘫患者,未发生深部感染或皮肤感染。A组发生脑脊液漏1例、下腔静脉损伤1例、乳糜漏1例,B组未发生严重并发症,两组并发症发生率比较差异无统计学意义(P=0.274)。32例患者均获随访,随访时间12~61个月,平均20.8个月;A、B组随访时间分别为(19.35±5.30)个月和(23.25±12.20)个月,差异无统计学意义(t=-1.255,P=0.219)。术后患者重建椎体节段均获骨性融合,A、B组融合时间分别为(8.85±2.27)个月和(8.50±2.50)个月,差异无统计学意义(t=0.406,P=0.688)。两组患者术后各时间点后凸角、背痛VAS评分及腰椎JOA评分均较术前显著改善(P<0.05);术后随时间延长腰椎JOA评分进一步改善(P<0.05),后凸角、背痛VAS评分无明显变化(P>0.05)。术后各时间点两组间比较后凸角、背痛VAS评分及腰椎JOA评分,差异均无统计学意义(P>0.05)。末次随访时,A、B组JOA评分改善率分别为83.87%±0.20%和84.50%±0.14%,差异无统计学意义(t=–0.109,P=0.914);两组手术治疗效果均判定为显效。结论陈旧性胸腰椎骨折在治疗后期,即便轻度后凸畸形与椎管占位也可能诱发迟发型脊髓损伤,通过手术矫形、减压能显著促进受损脊髓功能恢复;后路手术较前路手术具有创伤小、操作方便、并发症少等优势,若非翻修,可优先选择。

Objective To explore the clinical characteristics and surgical treatment strategies of delayed spinal cord injury(SCI)caused by atypical compression of old thoracolumbar fracture.Methods Between January 2011 and June 2018,32 patients with delayed SCI caused by atypical compression of old thoracolumbar fracture who met the inclusion criteria were admitted and divided into group A(20 cases,underwent anterior subtotal vertebral body resection+titanium mesh reconstruction+screw rod internal fixation)and group B(12 cases,underwent posterior 270°ring decompression of vertebral canal+titanium mesh reconstruction+screw rod internal fixation)according to the different operation approaches.There was no significant difference between the two groups in age,gender,cause of injury,fracture segment,disease duration,preoperative American Spinal Injury Association(ASIA)classification,and preoperative back pain visual analogue scale(VAS)score,lumbar Japanese Orthopaedic Association(JOA)score,kyphosis angle,and vertebral canal occupational ratio(P>0.05).The incision length,operation time,intraoperative blood loss,complications,and bone fusion time of reconstructed vertebrae were recorded and compared between the two groups;the kyphosis angle,back pain VAS score,and lumbar JOA score were used to evaluate the effectiveness.Results Except that the incision length in group A was significantly shorter than that in group B(t=-4.865,P=0.000),there was no significant difference in intraoperative blood loss and operation time between the two groups(P>0.05).There was no deaths or postoperative paraplegia cases in the two groups,and no deep infection or skin infection occurred.There was 1 case of cerebrospinal fluid leakage,1 case of inferior vena cava injury,and 1 case of chyle leakage in group A.No serious complications occurred in group B.There was no significant difference in the incidence of complications between the two groups(P=0.274).All 32 patients were followed up 12-61 months,with an average of 20.8 months.The follow-up time for groups A and B were(19.35±5.30)months and(23.25±12.20)months respectively,and the difference was not significant(t=-1.255,P=0.219).The reconstructed vertebrae in all cases obtained bony fusion postoperatively.The fusion time of groups A and B were(8.85±2.27)months and(8.50±2.50)months respectively,and the difference was not significant(t=0.406,P=0.688).The kyphosis angle,back pain VAS score,and lumbar JOA score of the two groups at each time point after operation and last follow-up were significantly improved when compared with preoperatively(P<0.05);the lumbar JOA score was further improved with time postoperatively(P<0.05),while the kyphosis angle and the VAS score of back pain remained similarly(P>0.05).Comparison of kyphosis angle,back pain VAS score,and lumbar JOA score between the two groups at various time points postoperatively showed no significant difference(P>0.05).At last follow-up,the JOA score improvement rate in groups A and B were 83.87%±0.20%and 84.50%±0.14%,respectively,and the difference was not significant(t=–0.109,P=0.914);the surgical treatment effects of the two groups were judged to be significant.Conclusion In the later stage of treatment of old thoracolumbar fractures,even mild kyphosis and spinal canal occupying may induce delayed SCI.Surgical correction and decompression can significantly promote the recovery of damaged spinal cord function.Compared with anterior approach surgery,posterior approach surgery has the advantages of less trauma,convenient operation,and fewer complications,so it can be preferred.