一期后路蛋壳截骨联合长节段椎弓根螺钉固定治疗强直性脊柱炎后凸畸形合并急性胸腰椎骨折

Effectiveness of one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation for ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture

目的探讨一期后路蛋壳截骨联合长节段椎弓根螺钉固定治疗强直性脊柱炎后凸畸形合并急性胸腰椎骨折的安全性及有效性。方法回顾性分析2016年4月—2022年1月,采用一期后路蛋壳截骨联合长节段椎弓根螺钉固定治疗的20例强直性脊柱炎后凸畸形合并急性胸腰椎骨折患者临床资料。其中男16例,女4例;年龄32~68岁,平均45.9岁。致伤原因:扭伤10例,摔伤8例,高处坠落伤2例。受伤至手术时间1~12 d,平均7.1 d。损伤节段:T112例,T122例,L16例,L210例。X线片和CT检查示患者均有强直性脊柱炎影像学特征性表现,骨折线均累及前、中、后三柱且伴有不同程度后凸畸形、伤椎压缩;MRI检查示12例患者存在不同程度神经损伤。记录手术时间、术中出血量、术中和术后并发症发生情况,采用疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)评价患者腰背部疼痛程度及生活质量,美国脊髓损伤学会(ASIA)分级评价神经功能;摄站立位脊柱正侧位X线片,测量局部后凸Cobb角(local Cobb angle,LCA)、矢状面垂直轴(sagittal vertical axis,SVA),评价后凸畸形矫形情况。结果患者均顺利完成手术,手术时间127~254 min,平均176.3 min;术中出血量400~950 mL,平均722.5 mL。术中1例发生硬膜囊撕裂,经修补后未发生脑脊液漏,其余患者术中未出现神经及血管损伤、脑脊液漏等相关并发症。术后切口均Ⅰ期愈合,无感染、脂肪液化等发生。患者均获随访,随访时间8~16个月,平均12.5个月。术后3 d及末次随访时VAS评分、ODI、LCA、SVA均较术前改善(P<0.05),末次随访时与术后3 d差异均无统计学意义(P>0.05)。末次随访时,神经功能ASIA分级亦较术前改善(P<0.05),其中E级17例、D级3例。所有患者末次随访时均达骨性融合,无内固定物松动、断裂以及假关节形成等并发症发生。结论一期后路蛋壳截骨联合长节段椎弓根螺钉固定治疗强直性脊柱炎后凸畸形合并急性胸腰椎骨折,能显著改善患者临床症状,并且在一定程度改善局部后凸畸形,是一种安全、有效术式。

Objective To explore the safety and effectiveness of one-stage posterior eggshell osteotomy and longsegment pedicle screw fixation in the treatment of ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture.Methods A clinical data of 20 patients with ankylosing spondylitis kyphosis combined with acute thoracolumbar spine fracture,who were treated with one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation between April 2016 and January 2022,was retrospectively analyzed.Among them,16 cases were male and 4 cases were female;their ages ranged from 32 to 68 years,with an average of 45.9 years.The causes of injury included 10 cases of sprain,8 cases of fall,and 2 cases of falling from height.The time from injury to operation ranged from 1 to 12 days,with an average of 7.1 days.The injured segment was T11 in 2 cases,T12 in 2 cases,L1 in 6 cases,and L2 in 10 cases.Xray film and CT showed that the patients had characteristic imaging manifestations of ankylosing spondylitis,and the fracture lines were involved in the anterior,middle,and posterior columns and accompanied by different degrees of kyphosis and vertebral compression;and MRI showed that 12 patients had different degrees of nerve injuries.The operation time,intraoperative bleeding,intra-and post-operative complications were recorded.The visual analogue scale(VAS)score and Oswestry disability index(ODI)were used to evaluate the low back pain and quality of life,and the American spinal cord injury association(ASIA)classification was used to evaluate the neurological function.X-ray films were taken,and local Cobb angle(LCA)and sagittal vertical axis(SVA)were measured to evaluate the correction of the kyphosis.Results All operations were successfully completed and the operation time ranged from 127 to 254 minutes(mean,176.3 minutes).The amount of intraoperative bleeding ranged from 400 to 950 mL(mean,722.5 mL).One case of dural sac tear occurred during operation,and no cerebrospinal fluid leakage occurred after repair,and the rest of the patients did not suffer from neurological and vascular injuries,cerebrospinal fluid leakage,and other related complications during operation.All incisions healed by first intention without infection or fat liquefaction.All patients were followed up 8-16 months(mean,12.5 months).The VAS score,ODI,LCA,and SVA at 3 days after operation and last follow-up significantly improved when compared with those before operation(P<0.05),and the difference between 3 days after operation and last follow-up was not significant(P>0.05).The ASIA grading of neurological function at last followup also significantly improved when compared with that before operation(P<0.05),including 17 cases of grade E and 3 cases of grade D.At last follow-up,all bone grafts achieved bone fusion,and no complications such as loosening,breaking of internal fixation,and pseudoarthrosis occurred.Conclusion One-stage posterior eggshell osteotomy and long-segment pedicle screw fixation is an effective surgical procedure for ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture.It can significantly relieve patients’clinical symptoms and to some extent,alleviate the local kyphotic deformity.