Wiltse肌间隙入路与传统入路治疗胸腰椎骨折的比较
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摘要
[目的]比较Wiltse肌间隙入路与传统入路伤椎置钉内固定治疗无神经损伤胸腰椎骨折的临床疗效。[方法]回顾性研究2012年2月～2015年8月收治的87例单节段胸腰椎骨折患者,其中采用Wiltse肌间隙入路伤椎置钉6钉椎弓根钉-棒内固定47例,采用传统4钉椎弓根钉-棒固定40例。比较两组手术时间、术中出血量、术后引流量,术后1周、1年及2年伤椎矢状面Cobb角、末次随访腰背部疼痛VAS评分、ODI评分情况。[结果]87例患者手术顺利完成,未发生严重并发症。两组在手术时间上差异无统计学意义(P>0.05),但Wiltse组术中失血量与术后引流量均少于传统组,差异有统计学意义(P<0.05)。所有患者获得12～36个月随访,平均(23.13±8.15)个月。末次随访时,Wiltse组的VAS评分明显小于传统组,两组间差异有统计学意义[(3.13±1.85)vs(4.93±1.98),P<0.05]。Wiltse组的ODI明显小于传统组,两组间差异有统计学意义[(9.30±3.20)vs(12.20±3.11),P<0.05]。术后1周两组后突Cobb角的差异无统计学意义(P>0.05),但术后1年、2年时Wiltse组的后突Cobb角显著小于传统组,差异有统计学意义(P<0.05)。[结论]与传统后路内固定术相比,Wiltse肌间隙入路联合伤椎置钉短节段椎弓根螺钉内固定减少了术中损伤,有效复位和维持复位更好,是治疗单节段胸腰椎骨折更好的方法。
[Objective] To compared the clinical efficacy of the pedicle screw-rod fixation plus screw placement on the injured vertebrae through Wiltse paravertebral approach versus the traditional pedicle screw-rod fixation through the midline approach for thoracolumbar fracture without nerve injury.From February 2012 to August 2015,a retrospective study was conducted on 87 patients with single segment thoracolumbar fractures without nerve injuries.Among them,47 patients were treated by the pedicle screw-rod fixation plus screw placement on the injured vertebrae with 6 pedicle screws through Wiltse paravertebral approach,while the remaining 40 patients received a classic pedicle screw-rod fixation with 4 pedicle screws through the traditional posterior midline approach.The clinical and radiographic parameters were compared between the two groups.All the 87 patients had operation performed smoothly without serious complication.Despite no a statistical difference in operation time between them(P>0.05),the Wiltse group had significantly less intraoperative blood loss and postoperative drainage than the traditional group(P<0.05).All patients were followed up from 12 to 36 months with an average of(23.13±8.15)months.At the latest follow up,the Wiltse group got significantly less visual analogue scale(VAS)of back pain than the traditional group[(3.13±1.85)versus(4.93±1.98),P<0.05].In addition,the Wiltse group was marked significantly less Oswestry disability index(ODI)than the traditional group[(3.13±1.85)versus(4.93±1.98),P<0.05].Although no statistical difference was noticed in the Cobb angle at 1 week postoperatively,the Wiltse group was proved statistically less Cobb angle at 1 and 2 years after operation(P<0.05).The pedicle screw-rod fixation plus screw placement on the injured vertebrae through Wiltse paravertebral approach has advantages of minimized intraoperative injuries,more effective fracture reduction and more efficient maintenance of the reduction over the traditional pedicle screw-rod fixation through the midline approach,is better technique for single segmental thoracolumbar fractures
[Objective] To compared the clinical efficacy of the pedicle screw-rod fixation plus screw placement on the injured vertebrae through Wiltse paravertebral approach versus the traditional pedicle screw-rod fixation through the midline approach for thoracolumbar fracture without nerve injury.From February 2012 to August 2015,a retrospective study was conducted on 87 patients with single segment thoracolumbar fractures without nerve injuries.Among them,47 patients were treated by the pedicle screw-rod fixation plus screw placement on the injured vertebrae with 6 pedicle screws through Wiltse paravertebral approach,while the remaining 40 patients received a classic pedicle screw-rod fixation with 4 pedicle screws through the traditional posterior midline approach.The clinical and radiographic parameters were compared between the two groups.All the 87 patients had operation performed smoothly without serious complication.Despite no a statistical difference in operation time between them(P>0.05),the Wiltse group had significantly less intraoperative blood loss and postoperative drainage than the traditional group(P<0.05).All patients were followed up from 12 to 36 months with an average of(23.13±8.15)months.At the latest follow up,the Wiltse group got significantly less visual analogue scale(VAS)of back pain than the traditional group[(3.13±1.85)versus(4.93±1.98),P<0.05].In addition,the Wiltse group was marked significantly less Oswestry disability index(ODI)than the traditional group[(3.13±1.85)versus(4.93±1.98),P<0.05].Although no statistical difference was noticed in the Cobb angle at 1 week postoperatively,the Wiltse group was proved statistically less Cobb angle at 1 and 2 years after operation(P<0.05).The pedicle screw-rod fixation plus screw placement on the injured vertebrae through Wiltse paravertebral approach has advantages of minimized intraoperative injuries,more effective fracture reduction and more efficient maintenance of the reduction over the traditional pedicle screw-rod fixation through the midline approach,is better technique for single segmental thoracolumbar fractures
引文
[1]陈中强,袁文.AO脊椎手册[M].2版.山东:山东科学技术出版社,2011:26-48.
[2]Me Corulack T,Km'aikovic E,Gaines RW.The load sharing classification of spine fractures[J].Spine,1994,19:1741-1744.
[3]Wiltse LL,Spencer CW.New uses and refinements of the paraspinal approach to the lumbar spine[J].Spine(Phila Pa1976),1988,13(6):696-706.
[4]Kawaguchi Y,Yabuki S,Styf J,et al.Back muscle injury after posterior lumbar spine surgery.Topographic evaluation of intramuscular pressure and blood now in the porcine back muscle during surgery[J].Spine(Phila Pa 1976),1996,2l(22):2683-2688.
[5]Gejo R,Matsui H,Kawaguchi Y,et a1.Serial changes in tmnk muscle performance after posterior lumbar surgery[J].Spine(Phila Pa 1976),1999,24(10):1023-1028.
[6]Park P,Garton HJ,Gala Vc,et al.Adjacent segment disease after lumbar or lumbosacral fusion:review of the literature[J].Spine(Phila Pa 1976),2004,29(17):1938-1944.
[7]胡正霞,李开南,何智勇,等.改良多裂肌间隙与传统后正中入路椎弓根螺钉置入修复胸腰椎骨折:伤椎稳定性及相关指标比较[J].中国组织工程研究,2015,19(4):544-547.
[8]Hu ZJ,Fang XQ,Fan SW.Iatrogenic injury to the erector spinae during posterior lumbar spine surgery:underlying anatomical considerations,preventable root causes and surgical tips and tricks[J].Eur J Orthop Surg Traumatol,2014,24(2):127-135.
[9]Hoh DJ,Wang MY,Ritland SL.Anatomic features of the paramedian muscle-splitting approaches to the lumbar spine[J].Neurosurgery,2010,66(3 Suppl Operative):13-25.
[10]姚晓聪,崔永锋,朱宝华,等.Wiltse肌间隙入路与常规入路治疗胸腰椎骨折的临床比较[J].中医正骨,2013,25(11):16-18.
[11]Shen WJ,Liu TJ,Shen YS.Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit[J].Spine(Phila Pa 1976),200l,26(9):1038-1045.
[12]王森龙,方煜丽,赵伟儿.胸腰段爆裂骨折传统短节段与经伤椎椎弓根植骨螺钉固定的疗效观察[J].中医正骨,2013,25(2):46-48.
[13]沈毅弘,王庆敏,李毅嵩,等.Wiltse肌间隙入路伤椎单侧置钉短节段椎弓根螺钉内固定治疗单节段胸腰椎骨折[J].中医正骨,2014,26(10):43-45.
[14]Dick JC,Jones MP,Zdeblick TA,et al.A biomechanical comparison evaluating the use of intermediate screws and cross link age in lumbar pedicle fixation[J].J Spinal Disord,1994,7(5):402-407.
[15]Mahar A,Kim C,Wedemeyer M,et al.Short segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture[J].Spine(Phila Pa 1976),2007,32(14):1503-1507.
[16]Guven O,Kocaoglu B,Bezer M,et al.The use of screw at the fracture level in the treatment of thoracolumbar burst fractures[J].J Spinal Disord Tech,2009,22(6):417-421.
[17]Anekstein Y,Brosh T,Mirovsky Y.Intermediate screws in short segment pedicular fixation for thoracic and lumbar fractures:a biomechanical study[J].J Spinal Disord Tech,2007,20(1):72-77.
[18]陈艺,白波,孙辉,等.短节段椎弓根钉固定术的生物力学研究[J].中华创伤杂志,2010,26(1):39-43.
[19]王洪伟,李长青,周跃,等.胸腰椎骨折伤椎单侧置钉与术后脊柱侧方成角的关系分析[J].中国矫形外科杂志,2012,20(2):184-186.
[20]潘兵,张志敬,宋舟锋,等.胸腰椎骨折伤椎短椎弓根钉固定的生物力学研究[J].中国矫形外科杂志,2013,2l(4):368~372.
[21]曾至立,程黎明,李山珠,等.伤椎置钉结合短节段椎弓根螺钉固定治疗胸腰椎骨折[J].中华医学杂志,2013,93(27):2117-2121.
[22]葛云林,卢一生,潘兵,等.伤椎单侧与双侧置钉治疗胸腰椎骨折的近期临床观察[J].颈腰痛杂志,2010,31(3):229~230.
[23]曾至立,程黎明,钱列,等.单侧伤椎置钉联合短节段椎弓根螺钉内固定治疗轻中度不稳定性胸腰椎骨折[J].中华外科杂志,2012,50(3):234-237.
[2]Me Corulack T,Km'aikovic E,Gaines RW.The load sharing classification of spine fractures[J].Spine,1994,19:1741-1744.
[3]Wiltse LL,Spencer CW.New uses and refinements of the paraspinal approach to the lumbar spine[J].Spine(Phila Pa1976),1988,13(6):696-706.
[4]Kawaguchi Y,Yabuki S,Styf J,et al.Back muscle injury after posterior lumbar spine surgery.Topographic evaluation of intramuscular pressure and blood now in the porcine back muscle during surgery[J].Spine(Phila Pa 1976),1996,2l(22):2683-2688.
[5]Gejo R,Matsui H,Kawaguchi Y,et a1.Serial changes in tmnk muscle performance after posterior lumbar surgery[J].Spine(Phila Pa 1976),1999,24(10):1023-1028.
[6]Park P,Garton HJ,Gala Vc,et al.Adjacent segment disease after lumbar or lumbosacral fusion:review of the literature[J].Spine(Phila Pa 1976),2004,29(17):1938-1944.
[7]胡正霞,李开南,何智勇,等.改良多裂肌间隙与传统后正中入路椎弓根螺钉置入修复胸腰椎骨折:伤椎稳定性及相关指标比较[J].中国组织工程研究,2015,19(4):544-547.
[8]Hu ZJ,Fang XQ,Fan SW.Iatrogenic injury to the erector spinae during posterior lumbar spine surgery:underlying anatomical considerations,preventable root causes and surgical tips and tricks[J].Eur J Orthop Surg Traumatol,2014,24(2):127-135.
[9]Hoh DJ,Wang MY,Ritland SL.Anatomic features of the paramedian muscle-splitting approaches to the lumbar spine[J].Neurosurgery,2010,66(3 Suppl Operative):13-25.
[10]姚晓聪,崔永锋,朱宝华,等.Wiltse肌间隙入路与常规入路治疗胸腰椎骨折的临床比较[J].中医正骨,2013,25(11):16-18.
[11]Shen WJ,Liu TJ,Shen YS.Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit[J].Spine(Phila Pa 1976),200l,26(9):1038-1045.
[12]王森龙,方煜丽,赵伟儿.胸腰段爆裂骨折传统短节段与经伤椎椎弓根植骨螺钉固定的疗效观察[J].中医正骨,2013,25(2):46-48.
[13]沈毅弘,王庆敏,李毅嵩,等.Wiltse肌间隙入路伤椎单侧置钉短节段椎弓根螺钉内固定治疗单节段胸腰椎骨折[J].中医正骨,2014,26(10):43-45.
[14]Dick JC,Jones MP,Zdeblick TA,et al.A biomechanical comparison evaluating the use of intermediate screws and cross link age in lumbar pedicle fixation[J].J Spinal Disord,1994,7(5):402-407.
[15]Mahar A,Kim C,Wedemeyer M,et al.Short segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture[J].Spine(Phila Pa 1976),2007,32(14):1503-1507.
[16]Guven O,Kocaoglu B,Bezer M,et al.The use of screw at the fracture level in the treatment of thoracolumbar burst fractures[J].J Spinal Disord Tech,2009,22(6):417-421.
[17]Anekstein Y,Brosh T,Mirovsky Y.Intermediate screws in short segment pedicular fixation for thoracic and lumbar fractures:a biomechanical study[J].J Spinal Disord Tech,2007,20(1):72-77.
[18]陈艺,白波,孙辉,等.短节段椎弓根钉固定术的生物力学研究[J].中华创伤杂志,2010,26(1):39-43.
[19]王洪伟,李长青,周跃,等.胸腰椎骨折伤椎单侧置钉与术后脊柱侧方成角的关系分析[J].中国矫形外科杂志,2012,20(2):184-186.
[20]潘兵,张志敬,宋舟锋,等.胸腰椎骨折伤椎短椎弓根钉固定的生物力学研究[J].中国矫形外科杂志,2013,2l(4):368~372.
[21]曾至立,程黎明,李山珠,等.伤椎置钉结合短节段椎弓根螺钉固定治疗胸腰椎骨折[J].中华医学杂志,2013,93(27):2117-2121.
[22]葛云林,卢一生,潘兵,等.伤椎单侧与双侧置钉治疗胸腰椎骨折的近期临床观察[J].颈腰痛杂志,2010,31(3):229~230.
[23]曾至立,程黎明,钱列,等.单侧伤椎置钉联合短节段椎弓根螺钉内固定治疗轻中度不稳定性胸腰椎骨折[J].中华外科杂志,2012,50(3):234-237.