骶骨骨折固定后腹直肌外侧入路神经松解术治疗合并的骶丛神经损伤的效果分析

Nerve decompression surgery for combined sacral plexus nerve injury through the lateral-rectus approach after sacral fracture fixation

目的探讨骶骨骨折固定后腹直肌外侧入路神经松解术治疗合并的骶丛神经损伤的效果。方法回顾性分析2022年5月至2023年至5月期间中南大学湘雅医院骨科收治的10例骶骨骨折固定后仍合并骶丛神经损伤患者资料。男2例,女8例;年龄16.5(15.0,26.3)岁。患者受伤时明确诊断为骶骨骨折伴骶丛神经损伤,骶骨骨折Denis分型:Ⅱ区7例,Ⅲ区3例;骶丛神经损伤部位:L41例,L58例,S17例,S22例。伤后2周内均经后方入路行骨折复位内固定治疗,术后患者仍持续存在骶丛神经损伤表现,并通过CT、磁共振成像及神经肌电图明确诊断。内固定后(4.0±2.3)个月所有患者采用腹直肌外侧入路神经松解术治疗。记录患者的手术时间、术中出血量、住院时间、末次随访时Gibbons神经损害评分及神经功能恢复情况等。结果10例患者的手术时间为(112.0±21.5)min,术中出血量为(215.0±91.3)mL,住院时间为7.0(6.0,8.5)d。术中发现骶丛神经受压9例(骨折移位致神经受压牵拉6例,软组织瘢痕粘连致神经卡压3例),神经根撕脱损伤1例。术中无其他并发症发生。10例患者术后获(9.2±2.3)个月随访。末次随访时10例患者的Gibbons神经损害评分由术前3.0(3.0,3.3)分改善至1.0(1.0,2.0)分;英国医学研究理事会肌力分级由术前的0.0(0.0,1.3)级恢复至3.5(2.8,4.0)级(其中M5级1例,M4级4例,M3级4例,M2级1例),差异均有统计学意义(P<0.05)。结论对于骶骨骨折固定后仍合并的骶丛神经损伤,腹直肌外侧入路神经松解术的治疗效果良好,腹直肌外侧入路是一种有效且安全的手术入路。

Objective To investigate the efficacy and safety of nerve decompression surgery through the lateral-rectus approach for sacral plexus nerve injury after sacral fracture fixation.Methods A retrospective study was conducted to analyze the 10 patients with combined sacral plexus nerve injury after sacral fracture fixation who had been admitted to Department of Orthopedics,Xiangya Hospital between May 2022 and May 2023.There were 2 males and 8 females with an age of 16.5(15.0,26.3)years.At the time of injury,the patients had been clearly diagnosed as sacral fracture combined with sacral plexus nerve injury.By the Denis classification of sacral fractures:7 cases of typeⅡand 3 cases of typeⅢ;sacral plexus nerve injury sites:1 case of L4,8 cases of L5,7 cases of S1,and 2 cases of S2.All of them were treated with reduction and internal fixation via the posterior approach within 2 weeks after injury,but after surgery their manifestations of sacral plexus nerve injury still persisted which were confirmed by CT,magnetic resonance imaging and neuromuscular electromyography.Therefore,at(4.0±2.3)months after internal fixation,all patients were treated with nerve decompression surgery through the lateral-rectus approach.The operative time,intraoperative bleeding,length of hospitalization,Gibbons nerve damage score and neurological recovery at the last follow-up were recorded.Results In the 10 patients,the operative time was(112.0±21.5)min,intraoperative bleeding(215.0±91.3)mL,and length of hospitalization 7.0(6.0,8.5)d.Intraoperatively,sacral plexus nerve compression was found in 9 cases(6 cases of nerve compression and pulling due to fracture displacement,3 cases of nerve entrapment due to soft tissue scar adhesion),and 1 case of nerve root avulsion injury.No other intraoperative complications occurred.The 10 patients were followed up for(9.2±2.3)months after surgery.At the last follow-up,the Gibbons score for the 10 patients improved from preoperative 3.0(3.0,3.3)points to 1.0(1.0,2.0)point,and their British Medical Research Council(BMRC)nerve injury grading was improved from the preoperative grade 0.0(0.0,1.3)to grade 3.5(2.8,4.0)(1 case of M5,4 cases of M4,4 cases of M3,and 1 case of M2).Conclusion The lateral-rectus approach is effective and safe for exploration and decompression of the sacral plexus nerve in patients combined with sacral plexus nerve injury despite sacral fracture fixation.