陈旧性胸腰椎骨折并脊髓损伤的后路手术治疗

Surgical treatment by posterior approach for old thoracolumbar fractures with spinal cord injury

目的探讨陈旧性胸腰椎骨折并脊髓损伤的后路手术方法和临床治疗效果。方法69例陈旧性胸腰椎骨折并脊髓损伤患者,年龄15～75岁,平均35.6岁。受伤至本次手术时间3个月～11年,平均25个月。患者均存在脊髓前方压迫及后凸畸形,并有不同程度的脊髓损伤。其中10例后凸角>20°,平均35°(21°～75°);59例后凸角<20°,平均9°(0°～16°),以后凸角的大小作为选择手术方式的标准,对后凸角<20°者行后路椎管侧前方减压术,对后凸角>20°者行后路经椎弓根椎体楔形截骨术。结果术后随访10个月～6年,平均12.5个月,59例(85.5%)患者获得满意的减压。10例行后路经椎弓根椎体楔形截骨的患者获得满意的后凸畸形矫正,术后后凸角平均10.8°(0°～40°)。44例(63.8%)患者神经功能得到不同程度的恢复,全瘫患者的恢复率为17.6%,主要是感觉功能恢复,而不全瘫患者的恢复率为78.8%,感觉和运动功能都有所恢复,两者之间差异有非常显著性意义(P<0.01)。结论对陈旧性胸腰椎骨折并脊髓损伤患者可以根据其后凸角大小选择经后路椎管侧前方减压术或经椎弓根椎体楔形截骨术。术后患者可获得满意的减压和后凸畸形矫正,神经功能有不同程度的恢复。

Objective To evaluate the surgical technique and its outcomes by posterior approach for old thoracolumbar fractures with spinal cord injury. Methods 69 cases of old thoracolumbar fractures with spinal cord injury, aging from 15 to 57 years with an average of 35.6 years, were recruited in this study. The mean time from injury to the index operation was 25 months ranging from 3 months to 11 years. The fracture location consisted of T11 in 3, T12 in 13, L1 in 45 and L2 in 8. Prior to the index surgery, 22 patients received conservative treatment, and 47 patients underwent laminectomy with internal fixation using Harrington rod in 8, Luque rod in 15, pedicles screws in 10 and spinous process immobilization in 8. The common characteristics of the patients were anterior compression to spinal cord, kyphotic deformity, and complicated with neurological dysfunction caused by spinal cord injuries. There were complete paraplegia in 17 cases and incomplete paraplegia in 52 cases. The patients were found with remained kyphotic deformity of a mean 28°, in which 10 cases>20°, ranging from 21° to 75°(average, 35°), and 59 cases <20°, ranging from 0° to 16°(average, 9°). According to the deformity angles, transpedicular anterior decompression was performed in cases of <20°, and transpedicular osteotomy for those of >20°. Results Successful decompression in which the distance from the middle point of connecting line between bilateral transverse processes to the posterior wall of vertebral body was more than 8 mm, was achieved in 59 cases (85.5%); satisfied correction of kyphosis was noticed in 10 cases. Post-operatively the mean angle of kyphosis deformity was 10.8° ranging from 0° to 40°. During the mean follow-up period of 12.5 months, neurological functional recovery was noticed in 63.8% of total cases. For complete spinal cord injury, 17.6% of cases recovered partially(sensory function), whereas neurological function recovery was noted in 78.8% of cases with incomplete spinal cord injury, the statistical difference was significant between the incomplete and complete spinal cord injury cases. Conclusion The old thoracolumbar fracture with incomplete spinal cord injury could be treated with transpedicular anterior decompression and osteotomy, neurological functional recovery is expected.