核磁神经成像术在骶骨骨折合并腰骶神经损伤诊治中的应用价值

The clinical value analysis of MRN on diagnosis and treatment of lumbosacral nerve injury associated with sacral fractures

目的探讨核磁神经成像术在骶骨骨折合并腰骶神经损伤诊治中的应用价值,总结骶骨骨折合并腰骶神经损伤的临床特征。方法根据纳入及排除标准,收集2018年10月至2020年10月天津医院收治骶骨骨折合并腰骶神经损伤40例患者的病历资料。单侧骶骨骨折24例,均为Tile分型C1型,Denis分型Ⅱ型16例、Ⅲ型8例;双侧骶骨骨折16例,均为Tile分型C3型,Denis分型Ⅱ型,均为骶骨"U"形骨折。所有患者均存在腰骶神经损伤表现,采用对比增强三维核磁神经成像术(contrast-enhanced three-dimensional magnetic resonance neurography,CE-3D MRN)检查明确骶神经损伤部位及严重程度。将L_(5)及S_(1)~S_(4)神经依据侧别及椎管内(intraspinal type,IS)、椎间孔内(intraforaminal type,IF)及椎间孔外(extraforaminal type,EF)进行分段定位,并判断神经损伤严重程度(轻度、中度及重度)。将各段神经损伤数量进行整体及两两配对χ^(2)检验。11例患者进行神经探查术,根据术中所见记录神经损伤部位及严重程度,并与CE-3D MRN检查结果进行统计分析。结果CE-3D MRN显示腰骶神经损伤发生侧均存在骶骨骨折,共239段神经发生不同程度及部位的损伤。统计分析显示神经损伤发生由多至少依次为S_(1)、S_(2)、L_(5)、S_(3)、S_(4)神经;除S_(1)、S_(2)间及S_(3)、S_(4)间的差异无统计学意义外,其余各神经损伤发生例数两两比较的差异均有统计学意义。11例手术患者术中直视下见神经损伤部位及严重程度与影像检查结果差异无统计学意义(Fisher检验,P=1.000)。结论核磁神经成像术能够清晰、准确显示骶骨骨折合并腰骶神经损伤的部位及严重程度,可作为此类损伤的首选检查方法,具有重要的临床应用价值;腰骶神经损伤具有S_(1)、S_(2)最为多发,L_(5)次之,S_(3)、S_(4)最少的特征。

Objective To discuss the clinical value of magnetic resonance neurography(MRN)on diagnosis and treatment of lumbosacral nerve injury associated with sacral fractures and analyze the characters of nerve injury which was caused by sacral fractures.Methods The clinical data of 40 patients who had lumbosacral nerve injury associated with sacral fractures and accepted treatment in Tianjin hospital from August 2018 to December 2020 were collected based on inclusion and exclusion criteria.Twenty-four patients had unilateral sacral fractures(Tile C1)which included 16 Denis II type fractures and 8 Denis III type fractures.Sixteen patients had bilateral sacral fractures which were all Tile C3,U shaped and Denis II type sacral fractures.All patients had symptoms or signs of lumbosacral nerve injury,and accepted contrast-enhanced three-dimensional magnetic resonance neurography(CE-3D MRN)to diagnose the injury part and severity degree.The L_(5)-S_(4) nerves were separated to three parts based on injured side and intraspinal type(IS),intraforaminal type(IF)and extraforaminal type(EF)location,and were judged the mild,medium or severe degree of nerve injury severity.Overall and pairwise Chi-square test was performed on the number of nerve injuries.Eleven patients accepted the operation of nerve dissection and exploration.The nerve injury part and severity were recorded under direct vision,and were statistically analyzed with CE-3D MRN outcome.Results The outcome of 239 lumbosacral nerve injuries which had different part and severity were found by MRN,and all combined with sacral fractures of the same side.The nerves which ranked from largest to fewest according to injured numbers were L_(5),S_(1),S_(2),S_(3) and S_(4).The statistical analysis showed that there were significant differences of injured nerve numbers except between S_(1) and S_(2),S_(3) and S_(4),and there were no significant difference of nerve injury part and severity degree between the direct visual judgement intraoperatively and preoperative CE-3D MRN examination.Conclusion MRN can reveal the part and severity degree of lumbosacral nerve injury associated with sacral fracture clearly and accurately,which has important clinical value and should become the preferred examination of such injuries.The lumbosacral nerve injury has the most frequent features of S_(1) and S_(2),followed by L_(5),and the least in S_(3) and S_(4).