后路长节段经皮置钉内固定术治疗强直性脊柱炎并胸腰椎骨折的临床效果
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摘要
目的:观察后路长节段经皮置钉内固定术治疗强直性脊柱炎(AS)合并胸腰椎骨折的临床疗效。方法:回顾性分析山东省中医院骨科2014年11月～2018年11月收治的强直性脊柱炎并胸腰椎骨折患者共50例,其中完成1年随访患者41例纳入本研究。根据手术方式进行分组,21例行后路长节段经皮置钉内固定术治疗(经皮组),男13例,女8例,年龄48～85岁,平均65.0±5.2岁。20例行后路长节段切开复位内固定术治疗(切开组),男12例,女8例,年龄35～76岁,平均52.0±4.7岁。术后随访12～48个月,平均28.4±2.3个月。记录两组手术时间、术中出血量、术后下床时间和术后切口愈合情况,通过术中C型臂X线机透视来计算椎弓根螺钉误置率(螺钉未通过椎弓根置入),术后6个月电话或门诊随访评估患者胸腰椎骨折处视觉模拟评分法(VAS)评分,术后3个月、6个月、1年所行的CT、MRI上病椎骨折线及信号改变来评估骨折愈合、脊髓损伤情况并测量术前、术后6个月的伤椎Cobb角。结果:两组患者均顺利手术,术后切口均为甲级愈合。所有患者无椎弓根螺钉位置置入错误、医源性神经损伤、切口感染、肺栓塞、下肢深静脉血栓等并发症发生。末次随访时所有患者骨折部位均达到临床骨性愈合,未出现钉棒松动断裂现象。经皮组手术时间123.7±9.9min,出血量375.6±30.8ml,平均2.3±0.4d下床活动,而切开组手术时间178.6±14.9min,出血量580.5±27.7ml,平均4.4±0.5d下地活动。经皮组与切开组相比,在手术时间、术中出血量、术后下床时间方面比较差异有统计学意义(P<0.05);而经皮组术后6个月VAS疼痛评分2.3±0.4分、伤椎Cobb角8.7°±1.2°较术前7.6±0.2分、24.6°±4.6°有明显改善,同样切开组术后6个月VAS疼痛评分2.5±0.5分、脊柱后凸Cobb角9.8°±1.3°较术前7.8±0.7分、25.7°±6.3°也有明显改善,两组间差异无统计学意义(P>0.05)。结论:后路长节段经皮置钉内固定术所需手术时间较短,创伤较小,出血量少,且在改善患者疼痛及脊柱后凸畸形方面能够达到与传统切开方式相近的效果。
Objectives: To observe the clinical efficacy of posterior long segmental percutaneous fixation for the treatment of ankylosing spondylitis(AS) with thoracolumbar fractures. Methods: 50 patients with ankylosing spondylitis and thoracolumbar fractures were analyzed retrospectively from November 2014 to November 2018 in our hospital. Among them, 41 patients who completed 1 year follow-up were included in the study. According to the surgical method, 21 cases underwent posterior long segment percutaneous fixation(percutaneous group, 13 males and 8 females, aged 48-85 years, mean age 65.0±5.2 years). Twenty patients underwent open reduction and internal fixation by posterior approach(cut group, 12 males and 8 females, aged 35-76 years, mean age 52.0±4.7 years). The operation time, intraoperative blood loss and postoperative bedtime were recorded. The misplaced rate of pedicle screws was calculated by intraoperative C-arm fluoroscopy(screws not inserted through the pedicle). VAS scores were assessed by telephone or outpatient follow-up. Fracture healing was evaluated by CT and MRI on the fracture line and signal changes at 3 months, 6 months and 1 year after operation. Results: Both groups underwent successful operation. All the incisions reached grade A healing.All patients were cured. There were no such complications as pedicle screw placement, iatrogenic nerve injury, wound infection, pulmonary embolism and deep venous thrombosis of the lower extremity. The patients were followed up for 12 to 48 months, and the average follow-up was 28.4±2.3 months. All the fracture sites reached the clinical bone healing, and there was no loosening nail rod. The operation time of percutaneous group was 123.7±9.9 min, the amount of bleeding was 375.6±30.8 ml, and the average activity was 2.3±0.4 days. The operation time of the cut group was 178.6±14.9 min, and the amount of bleeding was 580.5±27.7 ml, with an average of 4.4±0.5 days. There was a statistically significant difference between the percutaneous group and the cut group in terms of operation time, intraoperative blood loss and postoperative bedtime(P<0.05). The percutaneous group had a VAS pain score of 2.3±0.4 points after 6 months, with kyphosis Cobb angle 8.7°±1.2° significantly improved compared with preoperative 7.6±0.2 points and 24.6°±4.6°. In the cut group, VAS pain score was 2.5±0.5 points and kyphosis Cobb was 9.8°±1.3° 6 months after operation, which significantly improved compared with 7.8 ±0.7 points and 25.7° ±6.3° before operation, but there was no significant difference between the two groups(P>0.05). Conclusions: For posterior long segment percutaneous fixation, the required operation time is shorter, the trauma is less, the amount of bleeding is less, and the effect similar to the traditional incision method can be achieved in improving the pain and kyphosis of patient.
Objectives: To observe the clinical efficacy of posterior long segmental percutaneous fixation for the treatment of ankylosing spondylitis(AS) with thoracolumbar fractures. Methods: 50 patients with ankylosing spondylitis and thoracolumbar fractures were analyzed retrospectively from November 2014 to November 2018 in our hospital. Among them, 41 patients who completed 1 year follow-up were included in the study. According to the surgical method, 21 cases underwent posterior long segment percutaneous fixation(percutaneous group, 13 males and 8 females, aged 48-85 years, mean age 65.0±5.2 years). Twenty patients underwent open reduction and internal fixation by posterior approach(cut group, 12 males and 8 females, aged 35-76 years, mean age 52.0±4.7 years). The operation time, intraoperative blood loss and postoperative bedtime were recorded. The misplaced rate of pedicle screws was calculated by intraoperative C-arm fluoroscopy(screws not inserted through the pedicle). VAS scores were assessed by telephone or outpatient follow-up. Fracture healing was evaluated by CT and MRI on the fracture line and signal changes at 3 months, 6 months and 1 year after operation. Results: Both groups underwent successful operation. All the incisions reached grade A healing.All patients were cured. There were no such complications as pedicle screw placement, iatrogenic nerve injury, wound infection, pulmonary embolism and deep venous thrombosis of the lower extremity. The patients were followed up for 12 to 48 months, and the average follow-up was 28.4±2.3 months. All the fracture sites reached the clinical bone healing, and there was no loosening nail rod. The operation time of percutaneous group was 123.7±9.9 min, the amount of bleeding was 375.6±30.8 ml, and the average activity was 2.3±0.4 days. The operation time of the cut group was 178.6±14.9 min, and the amount of bleeding was 580.5±27.7 ml, with an average of 4.4±0.5 days. There was a statistically significant difference between the percutaneous group and the cut group in terms of operation time, intraoperative blood loss and postoperative bedtime(P<0.05). The percutaneous group had a VAS pain score of 2.3±0.4 points after 6 months, with kyphosis Cobb angle 8.7°±1.2° significantly improved compared with preoperative 7.6±0.2 points and 24.6°±4.6°. In the cut group, VAS pain score was 2.5±0.5 points and kyphosis Cobb was 9.8°±1.3° 6 months after operation, which significantly improved compared with 7.8 ±0.7 points and 25.7° ±6.3° before operation, but there was no significant difference between the two groups(P>0.05). Conclusions: For posterior long segment percutaneous fixation, the required operation time is shorter, the trauma is less, the amount of bleeding is less, and the effect similar to the traditional incision method can be achieved in improving the pain and kyphosis of patient.
引文
1.纪向辉.强直性脊柱炎的发病机制与治疗进展[D].成都中医药大学, 2007.
2 . Anwar F, Al-Khayer A, Joseph G, et al. Delayed presentation and diagosis of cervical spine injuries in long-stangding ankylosing spondylitis[J]. Eur Spine J, 2011, 20(3):403-407.
3 .汪雷,宋跃明.强直性脊柱炎合并脊柱骨折脱位的手术治疗[J].华西医学, 2011, 26(11):1659-1662.
4 . Van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis:a proposal for modification of the New York criteria[J]. Arthritis Rheum,1984, 27(4):361-368.
5 .潘涛,钱邦平,邱勇.强直性脊柱炎胸腰椎后凸畸形患者步态及其意义的研究进展[J].中国脊柱脊髓杂志, 2013, 23(7):658-661.
6 . Montala N, Juanola X, Collantes E, et al. Prevalence of vertebral fractures by semiautomated morphometry in patients with ankylosing spondylitis[J]. J Rheumatol, 2011, 38(5):893-897.
7 . Sambrook PN, Geusens P. The epidemiology of osteoporosis and fractures in ankylosing spondylitis[J]. Ther Adv Musculoskelet Dis, 2012, 4(4):287-292.
8 . Gill JB, Levin A, Burd T, et al. Corrective osteotomies in spine surgery[J]. J Bone Joint Surg Am, 2008, 90(11):2509-2502.
9 . Graham B, Van Peteghem PK. Fractures of the spine in ankylosing spondylitis. Diagnosis, treatment, and complications[J]. Spine, 1989, 14(8):803-807.
10 .黄玉国,李永民,申勇.强直性脊柱炎脊柱骨折的临床特点和手术治疗策略[J].中国矫形外科杂志, 2012, 20(7):644-646.
11 .张文生,郑闽前,邹国友,等.强直性脊柱炎胸腰椎骨折手术方法的选择[J].中华创伤骨科杂志, 2012, 14(9):778-781.
12 .杜辉,付勤,陈洪亮,等.强直性脊柱炎合并胸腰椎骨折的外科治疗[J].中国骨与关节损伤杂志, 2011, 26(5):448-449.
13 .武兴国,黄健,蒋煜青,等.多节段椎弓根钉置入治疗强直性脊柱炎合并胸腰椎骨折:1年随访[J].中国组织工程研究,2014, 18(9):1368-1373.
14 . Heintel TM, Berglehner A, Meffert R. Accuracy of percutaneous pedicle screws for thoracic and lumbar spine fractures:a prospective trial[J]. Eur Spine J, 2013, 22(3):495-502.
15 . Yang WE, Ng ZX, Koh KM, et al. Percutaneous pedicle screw fixation for thoracolumbar burst fracture:a Singapore experience[J]. Singapore Med J, 2012, 53(9):577-581.
16 .徐骏,左才红,黄照国,等.经皮椎弓根螺钉内固定治疗胸腰椎骨折疗效的中期随访[J].皖南医学院学报, 2015, 34(5):472-475.
17 .邓红平,胡灏,林格生,等.胸腰椎骨折后路内固定两种显露方式疗效比较[J].临床骨科杂志, 2011, 14(1):5-6, 17.
18 .文天林,孟浩,王飞,等.经皮与开放椎弓根螺钉内固定术治疗无神经损伤胸腰段骨折的疗效对比[J].中国脊柱脊髓杂志, 2016, 26(5):401-407.
19 .杨泗华,张翔,于一凡,等. 3D打印辅助经后路椎弓根钉棒内固定治疗强直性脊柱炎合并胸腰段椎体骨折的临床应用研究[J].中国数字医学, 2016, 11(7):77-80, 87.
2 . Anwar F, Al-Khayer A, Joseph G, et al. Delayed presentation and diagosis of cervical spine injuries in long-stangding ankylosing spondylitis[J]. Eur Spine J, 2011, 20(3):403-407.
3 .汪雷,宋跃明.强直性脊柱炎合并脊柱骨折脱位的手术治疗[J].华西医学, 2011, 26(11):1659-1662.
4 . Van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis:a proposal for modification of the New York criteria[J]. Arthritis Rheum,1984, 27(4):361-368.
5 .潘涛,钱邦平,邱勇.强直性脊柱炎胸腰椎后凸畸形患者步态及其意义的研究进展[J].中国脊柱脊髓杂志, 2013, 23(7):658-661.
6 . Montala N, Juanola X, Collantes E, et al. Prevalence of vertebral fractures by semiautomated morphometry in patients with ankylosing spondylitis[J]. J Rheumatol, 2011, 38(5):893-897.
7 . Sambrook PN, Geusens P. The epidemiology of osteoporosis and fractures in ankylosing spondylitis[J]. Ther Adv Musculoskelet Dis, 2012, 4(4):287-292.
8 . Gill JB, Levin A, Burd T, et al. Corrective osteotomies in spine surgery[J]. J Bone Joint Surg Am, 2008, 90(11):2509-2502.
9 . Graham B, Van Peteghem PK. Fractures of the spine in ankylosing spondylitis. Diagnosis, treatment, and complications[J]. Spine, 1989, 14(8):803-807.
10 .黄玉国,李永民,申勇.强直性脊柱炎脊柱骨折的临床特点和手术治疗策略[J].中国矫形外科杂志, 2012, 20(7):644-646.
11 .张文生,郑闽前,邹国友,等.强直性脊柱炎胸腰椎骨折手术方法的选择[J].中华创伤骨科杂志, 2012, 14(9):778-781.
12 .杜辉,付勤,陈洪亮,等.强直性脊柱炎合并胸腰椎骨折的外科治疗[J].中国骨与关节损伤杂志, 2011, 26(5):448-449.
13 .武兴国,黄健,蒋煜青,等.多节段椎弓根钉置入治疗强直性脊柱炎合并胸腰椎骨折:1年随访[J].中国组织工程研究,2014, 18(9):1368-1373.
14 . Heintel TM, Berglehner A, Meffert R. Accuracy of percutaneous pedicle screws for thoracic and lumbar spine fractures:a prospective trial[J]. Eur Spine J, 2013, 22(3):495-502.
15 . Yang WE, Ng ZX, Koh KM, et al. Percutaneous pedicle screw fixation for thoracolumbar burst fracture:a Singapore experience[J]. Singapore Med J, 2012, 53(9):577-581.
16 .徐骏,左才红,黄照国,等.经皮椎弓根螺钉内固定治疗胸腰椎骨折疗效的中期随访[J].皖南医学院学报, 2015, 34(5):472-475.
17 .邓红平,胡灏,林格生,等.胸腰椎骨折后路内固定两种显露方式疗效比较[J].临床骨科杂志, 2011, 14(1):5-6, 17.
18 .文天林,孟浩,王飞,等.经皮与开放椎弓根螺钉内固定术治疗无神经损伤胸腰段骨折的疗效对比[J].中国脊柱脊髓杂志, 2016, 26(5):401-407.
19 .杨泗华,张翔,于一凡,等. 3D打印辅助经后路椎弓根钉棒内固定治疗强直性脊柱炎合并胸腰段椎体骨折的临床应用研究[J].中国数字医学, 2016, 11(7):77-80, 87.