经皮与Wiltse入路椎弓根钉置钉治疗无神经损伤胸腰椎骨折的临床疗效比较

Comparison of clinical outcome between the percutaneous pedicle screw fixation and Wiltse approach for the treatment of thoracolumbar fractures without neurological injury

目的比较经皮与Wiltse入路2种微创椎弓根钉置入方式治疗无神经损伤单节段胸腰椎骨折的有效性及安全性。方法回顾性分析2020年1月—2022年6月首都医科大学附属北京友谊医院收治的因单节段胸腰椎骨折行单纯微创椎弓根钉内固定的80例患者的临床数据,其中男性46例,女性34例,年龄27~60岁,平均(45.93±7.91)岁。根据手术方式不同分为经皮椎弓根钉内固定组(n=44)和Wiltse入路椎弓根钉组(Wiltse组,n=36)。比较两组患者手术时间、术中显性出血量、围手术期隐性失血量、总失血量、术中透视次数、切口总长度、术后住院时间、术后下地时间。分别在术前及术后3 d、6个月、1年记录并比较两组患者的视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、椎体前缘高度比例、伤椎椎体终板角。采用术后CT评估椎弓根钉的置钉准确率及关节突关节侵扰率。观察患者围手术期相关的并发症。正态分布的计量资料以均数±标准差(x±s)表示,组间比较采用t检验;计数资料以例(%)表示,组间比较采用χ^(2)检验。结果所有患者均随访至少12个月。在术中显性失血量、术后住院时间、术后下地时间、术后VAS评分和ODI评分、术后第3天伤椎椎体高度比例、术后3 d伤椎终板角、椎弓根置钉准确率、围手术期并发症方面差异无统计学意义(P>0.05)。经皮椎弓根内固定组的手术时间、隐性失血量、总出血量、术中透视次数、关节突关节侵占率显著高于Wiltse入路组(P<0.05)。经皮椎弓根内固定组在术后6个月及1年伤椎椎体前缘高度比例显著低于Wiltse组;经皮椎弓根内固定组在术后6个月及1年伤椎终板角显著高于Wiltse组(P<0.05)。结论经皮与Wiltse入路椎弓根置钉对于无神经损伤的胸腰椎骨折均是安全有效的微创手术方式。Wiltse入路置钉能够有效减少透视次数,减少围手术期隐性失血,减少对关节突关节的侵扰,更好的维持复位。

Objective To compare the safety and efficacy of two different minimally invasive approaches to implant pedicle screw for the treatment of single-segment thoracolumbar spine fractures without nerve injury.Methods This was a retrospective study.Eighty patients with mono-segmental thoracolumbar fractures treated with minimally invasive pedicle screw fixation at Beijing Friendship Hospital,Capital Medical University from January 2020 to June 2022 were included.There were 46 males and 36 females,the age was(45.93±7.91)years old,and ranged from 27 to 60 years old.They were divided into two groups according to different surgical techniques:percutaneous pedicle screw fixation group(n=44)and Wiltse approach group(n=36).The operative time,operative visible blood loss,hidden blood loss,total blood loss,fluoroscopy times,incision length,hospital time after surgery and ambulation time were compared.Visual analogue scale(VAS),Oswestry disability index(ODI),ratio of the vertebral anterior height,angle of injured vertebral endplate were recorded and compared between two groups before surgery and at 3 days,6 months and 1 year after surgery.The accuracy of pedicle screw position and the facet joint violation rate were evaluated by using the postoperative CT scan.Perioperative related complications were investigated.Normally distributed numerical data were presented as mean±standard deviation,and differences between the groups were compared using t-test.The counting data were expressed as percentages or rates and compared usingχ^(2) test.Results All patients were followed for a minimum of 12 months.There is no significant difference between the two groups in intraoperative visible blood loss,hospital time after surgery,ambulation time,postoperative VAS and ODI,ratio of vertebral anterior height and angle of injured vertebral endplate at 3 days after surgery,pedicle screw position accuracy and perioperative complications(P>0.05).The operative time,hidden blood loss,total blood loss,intraoperative fluoroscopy times,facet joint violation rate in the percutaneous pedicle screw fixation group were remarkably higher than in the Wiltse approach group(P<0.05).The ratio of vertebral anterior height in the percutaneous pedicle screw fixation group was dramatically lower than in the Wiltse approach group at 6 months and 1 year after surgery(P<0.05).The postoperative injured vertebral endplate angle was higher in the percutaneous pedicle screw fixation group than that in the Wiltse approach group at 6 months and 1 year(P<0.05).Conclusions Both percutaneous pedicle screw fixation and Wiltse approach were safe and effective minimally invasive surgical procedures for the treatment of thoracolumbar fractures without neurological injury.The Wiltse approach can reduce fluoroscopy times and perioperative hidden blood loss,reduce the risk of facet joint violation,and maintain a better reduction than percutaneous pedicle screw fixation.