经关节突入路前方垫高植骨融合术治疗陈旧性胸腰椎压缩骨折伴后凸畸形

Anterior cage inserting for old thoracolumbar fractures with kyphosis through facet joint approach

目的探讨经关节突入路前方垫高植骨融合术治疗陈旧性胸腰椎压缩骨折伴后凸畸形的临床疗效。方法回顾性分析2018年1月至2019年12月收治的陈旧性胸腰椎压缩骨折伴后凸畸形患者32例,男14例、女18例;年龄(47.3±13.1)岁(范围26~70岁)。初次损伤时胸腰椎损伤分类及损伤程度评分(thoracolumbar injury classification and severity score,TLICS)为3~5分,平均4.0分。经(6.3±2.9)个月(范围3~16个月)保守治疗仍有顽固性胸腰背疼痛。手术采用经关节突入路前方垫高植骨融合术(前方垫高组)15例、后路伤椎置钉植骨融合术(伤椎置钉组)17例。前方垫高组和伤椎置钉组术前矢状面Cobb角分别为27.0°±3.9°和26.8°±4.6°,差异无统计学意义(t=0.07,P=0.946);矢状面平衡(sagittal vertical axis,SVA)分别为(4.2±1.8)cm和(4.1±2.1)cm,差异无统计学意义(t=0.14,P=0.887);前方垫高组美国脊柱损伤协会损伤分级(ASIA impairment scale,AIS)为C级1例、D级4例、E级10例,伤椎置钉组为C级2例、D级2例、E级13例,组间差异无统计学意义(χ^(2)=1.34,P=0.520)。比较两组手术时间、术中出血量、手术并发症、疼痛视觉模拟评分(visual analogue scale,VAS)、伤椎椎体前缘高度、脊柱矢状面后凸Cobb角、SVA及AIS分级。结果32例均完成随访,前方垫高组随访(12.2±3.1)个月、伤椎置钉组随访(12.0±3.3)个月。前方垫高组与伤椎置钉组的手术时间分别为(128±24.5)min和(123±40.6)min(t=0.42,P=0.681),术中出血量分别为(485±12.6)ml和(478±16.3)ml(t=0.13,P=0.894)。末次随访时,前方垫高组VAS评分改善率为90%±10%,大于伤椎置钉组的75%±20%,差异有统计学意义(t=3.17,P=0.004);两组伤椎椎体前缘高度分别增加(1.02±0.10)cm和(0.29±0.14)cm,前方垫高组变化率(67.1%±31.5%)大于伤椎置钉组(19.0%±14.9%),差异有统计学意义(t=16.29,P<0.001);前方垫高组矢状面Cobb角为7.4°±1.5°,小于伤椎置钉组的11.6°±2.5°,差异有统计学意义(t=-5.85,P<0.001);前方垫高组SVA为(1.1±0.6)cm,小于伤椎置钉组的(1.6±0.6)cm,差异有统计学意义(t=2.35,P=0.025);前方垫高组AIS分级为E级15例,伤椎置钉组为D级1例、E级16例,组间差异无统计学意义(χ^(2)=0.83,P=0.706)。结论经关节突入路前方垫高植骨融合术治疗陈旧性胸腰椎骨折伴后凸畸形较后路伤椎置钉植骨融合可获得更好的术后近期后凸畸形矫形效果和胸腰背部顽固性疼痛症状改善。

Objective To investigate the clinical effects of anterior cage inserting for old thoracolumbar fractures with kyphosis through facet joint approach.Methods A retrospective analysis was conducted on 32 patients with old thoracolumbar fractures complicated with kyphosis admitted from January 2018 to December 2019,including 14 males and 18 females.The average age was 47.3±13.1 years(range,26-70 years).Thoracolumbar injury classification(TLICS)scores of patients with initial injury were 3-5 points,with an average of 4.0 points.After 6.3±2.9 months(range,3-16 months)conservative treatment,intractable thorax and lumbar or back pain still existed.Anterior cage inserting via articular protrusion was performed in 15 cases and posterior screw placement and bone grafting fusion of injured vertebrae was performed in 17 cases.Preoperative sagittal Cobb angle was 27.0°±3.9°and 26.8°±4.6°in the anterior cage inserting group and fixation on fractured vertebrae group(t=0.07,P=0.946),respectively.Sagittal vertical axis(SVA)was 4.2±1.8 cm and 4.1±2.1 cm(t=0.14,P=0.887),respectively.The number of patients with ASIA impairment scale(AIS)of the anterior cage inserting group before surgery was 1 in grade C,4 in grade D and 10 in grade E.However,the number of that in fixation on fractured vertebrae group was 2 in grade C,2 in grade D and 13 in grade E.There was no significant difference between the two groups(χ^(2)=1.34,P=0.520).Results All 32 patients were followed up for 12.2±3.1 months in the anterior cage inserting group and 12.0±3.3 months in fixation on fractured vertebrae group.The operative duration of the anterior cage inserting group and fixation on fractured vertebrae was 128±24.5 min and 123±40.6 min(t=0.42,P=0.681).The intraoperative blood loss was 485±12.6 ml and 478±16.3 ml(t=0.13,P=0.894),respectively.At the last follow-up,the improvement rate of VAS score of the anterior cage inserting group was higher than that of fixation on fractured vertebrae group(90%±10%vs.75%±20%,t=3.17,P=0.004).The height of anterior margin of injured vertebra in the two groups was increased by 1.02±0.10 cm and 0.29±0.14 cm,the change rate of anterior cage inserting group was higher than that of fixation on fractured vertebrae group(67.1%±31.5%vs.19.0%±14.9%,t=16.29,P<0.001).The sagittal Cobb angle of the anterior cage inserting group was significantly lower than that of fixation on fractured vertebrae group(7.4°±1.5°vs.11.6°±2.5°,t=-5.85,P<0.001).The SVA of anterior cage inserting group was lower than that of fixation on fractured vertebrae group(1.1±0.6 cm vs.1.6±0.6 cm,t=2.35,P=0.025).There were 15 patients in AIS grade E in the anterior cage inserting group,while 1 patient in grade D and 16 patients in grade E in fixation on fractured vertebrae group without significant difference between the two groups(χ^(2)=0.83,P=0.706).Conclusion The treatment of old thoracolumbar fractures with kyphosis through facet joint approach and anterior fixation could achieve satisfied effects and could relieve pain symptoms of thoracolumbar and back,compared with posterior fusion for injured vertebra with nail and bone grafting.