胸腰段脊柱骨折合并亚急性进行性上升性瘫痪(附9例报告)

Thoraco-lumbar spinal fracture complicated with subacute progressive ascending paraplegia

目的:探讨胸腰段脊柱骨折后出现进行性瘫痪平面上升的原因。方法:回顾性分析1995年9月~2001年11月收治的385例胸腰段脊柱骨折患者中9例合并进行性瘫痪平面上升患者的临床特点、病程转归、手术探查所见及预后。结果:9例患者于受伤后24h^72h瘫痪平面开始上升,持续进展1~2周后稳定于某一平面,上升到C5脊髓平面1例、C71例、T22例、T41例、T6~T71例、T7~T82例、T101例。9例均由不完全性瘫痪发展为完全性截瘫。二次手术探查时发现其肉眼病理变化为:脑脊液明显减少或消失,骨折平面以上的长段脊髓呈紫绀色缺血坏死状改变,脊髓萎陷变细,搏动消失。随访5个月～3年,1例随访5个月瘫痪无恢复,6例于伤后1～2.5年死于各种并发症,2例存活超过3年者瘫痪平面和程度无改善。结论:胸腰段脊柱骨折合并进行性瘫痪平面上升的发生率约2.3%,预后差,其发生的直接原因是上升性脊髓缺血性坏死所致。

Objective:To report the special cases of thoraco-lumbar spinal fractures complicated with suba-cute progressive ascending paraplegia,and to explore its mechanism.Method:Retrospectively summarizing and analyzing the clinical course,features,outcome,and surgical findings of9patients who sustained subacute pro-gressive ascending paraplegia posttrauma of thoraco-lumbar spinal fractures.Result:The paraplegic level began to ascend posttraumaticly24～72hours in all the9patients,and continued to go up for1～2weeks.And then stayed at a certain level.One of the nine patients showed the paraplegia level at C5,one at C7,two at T2,one at C4,two at T7-8,one at C6-7,and one at T10.All the patients showed complete paraplegia although they showed incomplete paraplegia initially.The second exploring operations were performed,and the following macro-pathological changes were found:(1)There was no hemorrhage in epidural space or within spinal cord.There was no obstruction in the epidural space.(2)Cerebrospinal fluid greatly diminished or distinguished.(3)A long segment of spinal cord above fracture level showed dark purple color,and no pulse of spinal cord was seen.(4)The spinal cord shrank and thinned.The follow-up time was5months to3years.6cases died from various complications posttraumaticly1～2.5years.3cases survived3years without improvement in their para-plegia.Conclusion:Thoraco-lumbar spinal fracture complicated with subacute progressive ascending paraplegia is a special type spine fracture,its occurrence rate is about2.3%in our series and no effective method to prevent its progression results in a catastrophic prognosis.The direct cause is ascending ischemia necrosis of spinal cord.