单节段胸、腰椎骨折脱位分型的建立及其临床应用

Evaluation of reliability test and clinical application of monosegment thoracic and lumbar fracture dislocation classification

目的提出一种单节段胸、腰椎骨折脱位(monosegment thoracic and lumbar fracture dislocation,mTLFD)分型系统,并评估各类型的信度及其临床疗效。方法回顾性分析2014年1月至2019年12月收治单节段胸、腰椎骨折脱位298例患者的病历资料,根据纳入及排出标准,共纳入123例纳入研究。根据不同类型的影像学特征提出mTLFD分型,即Ⅰ型(椎间盘损伤为主)和Ⅱ型(椎体爆裂性骨折为主),再根据损伤节段分布将Ⅱ型分为2个亚型:Ⅱa型(T11及其以上)和Ⅱb型(T11以下)。选取6名脊柱外科医生(3名住院医生、3名副主任医生),根据术前影像学资料对123例患者进行分型,对各类型进行信度检验,以ICC评估该分型系统的可重复性和可靠性。根据分型采用不同的治疗方法:Ⅰ型采用后路减压椎间融合内固定术;Ⅱa型采用后路减压内固定术,术中探查骨性占位若仍存在,则行椎体次全切除术;Ⅱb型采用一期后路减压、后外侧融合内固定术,术后CT检查若骨性占位仍存在,二期行前路椎体次全切除重建术。采用美国脊髓损伤协会(American Spinal Injury Association,ASIA)分级评估脊髓神经损害情况,比较各型患者术前及末次随访时疼痛视觉模拟评分(visual analogue scale,VAS)、Oswetry功能障碍指数(Oswestry disability index,ODI)和局部Cobb角。结果所有患者随访时间为(10.4±1.8)个月,3名住院医生和3名副主任医生对mTLFD分型的可重复性ICC分别平均为0.926和0.964,可信度ICC分别平均为0.746和0.907。进一步对各型进行信度检验,Ⅰ型、Ⅱa型和Ⅱb型的可重复性ICC分别为0.930、0.940和0.966,可信度ICC分别平均为0.918、0.947和0.962。术后56例患者神经功能得到不同程度的改善。Ⅰ型、Ⅱa型和Ⅱb型术前VAS分别为(8.5±1.0)分、(8.4±1.0)分和(8.3±0.9)分,末次随访时改善至(2.0±1.1)分、(1.8±1.0)分和(1.8±0.9)分(P<0.001)。Ⅰ型、Ⅱa型和Ⅱb型术前ODI分别为97.0%±2.1%、97.1%±1.9%和97.3%±2.1%,末次随访时改善至29.5%±6.8%、27.0%±6.0%和29.0%±6.7%(P<0.001)。Ⅰ型、Ⅱa型和Ⅱb型术前局部Cobb角分别为20.9°±7.1°、29.0°±9.1°和26.4°±6.9°,末次随访时矫正至12.5°±5.4°、18.0°±9.1°和13.1°±5.1°(P<0.001)。结论建立的mTLFD分型具有较强的可重复性和一致性,各型采用相应的治疗方案均取得较满意的临床疗效,对治疗胸、腰椎骨折脱位有一定指导意义。

Objective To propose a monosegment thoracic and lumbar fracture dislocation(mTLFD)classification,and to evaluate its reliability and clinical application.Methods All of 298 cases of thoracic and lumbar fracture dislocation who received surgical management in our hospital from January 2014 to December 2019 were retrospectively analyzed.123 cases were included in the study according to inclusion and exclusion criteria.mTLFD classification was proposed based on the imaging characteristics:type I(intervertebral disc injury mainly)and type II(vertebral burst fracture mainly).The type II was classified based on distribution of injury segment:type IIa(T11 and above)and Ttype IIb(below T11).Six spinal surgeons(3 residents,3 associate chief physicians)were selected to classify the 123 cases according to preoperative imaging data,and to perform reliability test of each type.The repeatability and reliability of the classification were evaluated by ICC index.Different management strategies were performedf or each type:type I was managed with posterior decompression interbody fusion and internal fixation;type IIa underwent posterior decompression and fixation,subtotal vertebral resection and fusion was performed if bony compromise was still present through intra-operative exploration.Type IIb underwent posterior decompression,posterolateral fusion and internal fixation on the first stage,while anterior subtotal vertebral resection and reconstruction was performed on the second stage if the bony compromise was still present based on post-operative CT examination.The American Spinal Injury Association(ASIA)grading of all patients was recorded,and the visual analogue scale(VAS),Oswetry disability Iindex(ODI)and local Cobb angle of each type was compared between pre-operation and final follow-up.Results The average follow-up time of all patients was 10.4±1.8 months.The average repeatability and reliability ICC index of mTLFD of 3 residents and 3 deputy chief physicians were 0.926 and 0.964,respectively,and 0.746 and 0.907,respectively.The reliability ICC index of type I,type IIa and type IIb was 0.918,0.947 and 0.962,respectively,and the repeatability ICC index was 0.930,0.940 and 0.966,respectively.The neurological function recovery was obtained in 56 patients.The preoperative VAS of type I,type IIa and type IIb were 8.5±1.0,8.4±1.0 and 8.3±0.9,and 2.0±1.1,1.8±1.0 and 1.8±0.9 at the final follow-up(all P<0.001).The ODI of type I,type IIa and type IIb were 97.0%±2.1%,97.1%±1.9%and 97.3%±2.1%before surgery,and 29.5%±6.8%,27.0%±6.0%and 29.0%±6.7%at the final follow-up(all P<0.001).The local Cobb angles of type I,type IIa and type IIb were 20.9°±7.1°,29.0°±9.1°and 26.4°±6.9°before surgery,and 12.5°±5.4°,18.0°±9.1°and 13.1°±5.1°at the final follow-up(all P<0.001).Conclusion The mTLFD classification proposed in this study has strong repeatability and reliability,and management strategy of each type have achieved satisfactory clinical efficacy,indicating that the classification has certain significance for management of thoracic and lumbar spine fracture dislocation.