局麻下经皮椎弓根螺钉钉棒杠杆复位技术治疗胸腰椎骨折的策略及疗效观察
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摘要
目的评价局部麻醉下经皮椎弓根螺钉钉棒杠杆复位及内固定治疗胸腰椎骨折的复位效果及临床疗效。方法回顾性分析2013年6月至2015年3月我科收治的26例胸腰椎创伤性骨折患者,均于伤后3天内手术,其中男20例,女6例;年龄18～62岁,平均45.2岁;骨折部位:T_(10)骨折1例,T_(11)骨折1例,T_(12)骨折9例,L_1骨折9例,L_2骨折7例。术前进行脊柱正、侧位X线、CT和MRI检查,评价椎体、椎管、椎间盘及韧带损伤情况。根据脊柱骨折Magerl分型:A1型骨折16例,A2型骨折3例,A3型骨折5例,B1型骨折1例,B2型骨折1例。神经功能Franke1分级E级14例,D级9例,C级3例。在局麻X线监视下,通过一系列置钉及复位方法来矫正压缩及后凸角。记录手术时间和术中失血量,随访观察治疗效果。结果本组手术时间(85.9±12.4)min,术中失血(24.3±10.1)ml,切口长度(6.3±0.3)cm,术中麻醉评分优良率为84.6%,伤处疼痛VAS评分由术前(7.2±0.8)分减轻为术后(2.1±0.6)分。矢状面后凸Cobb’s角由术前(9.4±9.4)°减少为术后(3.0±7.7)°,伤椎前缘高度百分比由术前(74.0±15.3)%恢复至术后(101.8±18.5)%。无神经损伤加重或其它并发症。术后随访3～15个月,平均13.2个月,存在神经功能不全损伤患者术后获得1级及以上神经功能恢复。椎体高度和后凸矫正较术后无明显丢失(P>0.05),VAS评分得到进一步缓解(P<0.05)。结论局麻下经皮椎弓根螺钉钉棒杠杆复位技术能有效恢复胸腰椎骨折椎体高度和矫正后凸畸形,临床效果满意,为临床进一步推广提供参考。
Objective To evaluate the feasibility and safety of percutaneous transpedicular screw internal fixation and reduction in the treatment of traumatic thoracolumbar fracture by local anesthesia.Methods A retrospective study was made in 26 patients with traumatic fracture of the thoracolumbar spine from June 2013 to March 2015.All patients were treated within 3 days after injury.There were 20 males and 6 females with the average of 45.2 years(range:18-62 years).Fracture locations:T_(10) in 1,T_(11) in 1,T_(12) in 9,L_l in 9,L_2 in 7.Preoperative anteroposterior and lateral radiographs of the fractured spine were made to evaluate the injury severity,spinal canal,disc and ligament as well as CT and MRI.Magerl classification:16 were of type A1 fracture,3 of type A2,5 of type A3,1 of type B1,1 of type B2.Frankel classification:14 were of type E,9 of type D,3 of type C.A series of pedicle screw placement and reduction were performed to correct the kyphotic deformity and decompression of the fracture.Operative time and intraoperative blood loss were recorded to observe clinical results.Results The average operation time was(85.9±12.4)minutes,with a mean intraoperative blood loss of(24.3±10.1)ml.The incision size was(6.3±0.3)cm.The effective rate of intraoperative local anesthesia was 84.6%.Before the operation,the visual analogue(VAS),Sagittal kyphposis Cobb’s angle and anterior height of the fracture vertebral body were(7.2±0.8),(9.4±9.4)°and(74.0±15.3)%,which were improved to(2.1±0.6),(3.0±7.7)°and(101.8±18.5)%respectively after the operation.No neurological deficits or other surgery-related complications were observed.All patients were followed up for 3-15 months(average:13.2 months).Grade 1 neurofunction recovery was observed at final follow-up.No significant vertebral body height loss was observed(P>0.05).VAS was significantly improved(P<0.05).Conclusions Percutaneous transpedicular screw and rob to lever reduction and fixation is effective in the treatment of thoracolumbar fractures by local anesthesia.It can restore vertebral height and Cobb’s angle with satisfactory clinical results,providing references for further clinical promotion.
Objective To evaluate the feasibility and safety of percutaneous transpedicular screw internal fixation and reduction in the treatment of traumatic thoracolumbar fracture by local anesthesia.Methods A retrospective study was made in 26 patients with traumatic fracture of the thoracolumbar spine from June 2013 to March 2015.All patients were treated within 3 days after injury.There were 20 males and 6 females with the average of 45.2 years(range:18-62 years).Fracture locations:T_(10) in 1,T_(11) in 1,T_(12) in 9,L_l in 9,L_2 in 7.Preoperative anteroposterior and lateral radiographs of the fractured spine were made to evaluate the injury severity,spinal canal,disc and ligament as well as CT and MRI.Magerl classification:16 were of type A1 fracture,3 of type A2,5 of type A3,1 of type B1,1 of type B2.Frankel classification:14 were of type E,9 of type D,3 of type C.A series of pedicle screw placement and reduction were performed to correct the kyphotic deformity and decompression of the fracture.Operative time and intraoperative blood loss were recorded to observe clinical results.Results The average operation time was(85.9±12.4)minutes,with a mean intraoperative blood loss of(24.3±10.1)ml.The incision size was(6.3±0.3)cm.The effective rate of intraoperative local anesthesia was 84.6%.Before the operation,the visual analogue(VAS),Sagittal kyphposis Cobb’s angle and anterior height of the fracture vertebral body were(7.2±0.8),(9.4±9.4)°and(74.0±15.3)%,which were improved to(2.1±0.6),(3.0±7.7)°and(101.8±18.5)%respectively after the operation.No neurological deficits or other surgery-related complications were observed.All patients were followed up for 3-15 months(average:13.2 months).Grade 1 neurofunction recovery was observed at final follow-up.No significant vertebral body height loss was observed(P>0.05).VAS was significantly improved(P<0.05).Conclusions Percutaneous transpedicular screw and rob to lever reduction and fixation is effective in the treatment of thoracolumbar fractures by local anesthesia.It can restore vertebral height and Cobb’s angle with satisfactory clinical results,providing references for further clinical promotion.
引文
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[8]靳安民,陈仲,李奇,等.脊神经后支形态特点及其阻滞麻醉下腰椎间盘手术4063例报告[J].中国临床解剖学杂志,2002,20(5):391-393.
[9]王根林,杨惠林,牛国旗,等.椎弓根内固定治疗无神经损伤的胸腰椎骨折[J].中国矫形外科杂志,2004,12(21):1664-1666.
[10]Sun XY,Zhang XN,Hai Y.Percutaneous versus traditional and paraspinal posterior open approaches for treatment of thoracolumbar fractures without neurologic deficit:a metaanalysis[J].Eur Spine J,2017,26(5):1418-1431.
[11]Kim BG,Dan JM,Shin DE.Treatment of thoracolumbar fracture[J].Asian Spine J,2015,9(1):133-146.
[12]Wang H,Zhou Y,Li C,et al.Comparison of open versus percutaneous pedicle screw fixation using the sextant system in the treatment of traumatic thoracolumbar fractures[J].Clin Spine Surg,2017,30(3):E239-246.
[13]Koreckij T,Park DK,Fischgrund J.Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma[J].Neurosurg Focus,2014,37(1):E11.
[14]李长青,罗刚,周跃,等.新型微创经皮椎弓根螺钉内固定治疗胸腰椎骨折[J].中华创伤杂志,2009,25(6):522-525.
[15]Jiang WY,Ma WH,Zhao LJ,et al.Treatment of flexiondistraction thoracolumbar fractures by postural reduction with instrumental reduction[J].Zhongguo Gu Shang,2014,27(2):145-147.
[16]Vanek P,Bradac O,Konopkova R,et al.Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation:prospective comparative study with a minimum 2-year follow-up[J].J Neurosurg Spine,2014,20(2):150-156.
[17]Müller U,Berlemann U,Sledge J,et al.Treatment of thoracolumbar burst fractures without neurologic deficit by indirect reduction and posterior instrumentation:bisegmental stabilization with monosegmental fusion[J].Eur Spine J,1999,8(4):284-289.
[18]Oner FC,van der Rijt RR,Ramos LM,et al.Changes in the disc space after fractures of the thoracolumbar spine[J].J Bone Joint Surg Br,1998,80(5):833-839.
[2]Loibl M,Korsun M,Reiss J,et al.Spinal fracture reduction with a minimal-invasive transpedicular Schanz Screw system:clinical and radiological one-year follow-up[J].Injury,2015,46(Suppl 4):S75-82.
[3]Konstantinidis L,Mayer E,Strohm PC,et al.Early surgeryrelated complications after anteroposterior stabilization of vertebral body fractures in the thoracolumbar region[J].J Orthop Sci,2010,15(2):178-184.
[4]Oppenheimer JH,DeCastro I,McDonnell DE.Minimally invasive spine technology and minimally invasive spine surgery:a historical review[J].Neurosurg Focus,2009,27(3):E9.
[5]Mo bbs RJ,Sivabalan P,Li J.Technique,challenges and indications for percutaneous pedicle screw fixation[J].J Clin Neurosci,2011,18(6):741-749.
[6]Gnanenthiran SR,Adie S,Harris IA.Nonoperative versus operative treatment for thoracolumbar burst fractures without neurologic deficit:a meta-analysis[J].Clin Orthop Relat Res,2012,470(2):567-577.
[7]Hu ZJ,Fang XQ,Zhou ZJ,et al.Effect and possible mechanism of muscle-splitting approach on multifidus muscle injury and atrophy after posterior lumbar spine surgery[J].J Bone Joint Surg Am,2013,95(24):e192(1-9).
[8]靳安民,陈仲,李奇,等.脊神经后支形态特点及其阻滞麻醉下腰椎间盘手术4063例报告[J].中国临床解剖学杂志,2002,20(5):391-393.
[9]王根林,杨惠林,牛国旗,等.椎弓根内固定治疗无神经损伤的胸腰椎骨折[J].中国矫形外科杂志,2004,12(21):1664-1666.
[10]Sun XY,Zhang XN,Hai Y.Percutaneous versus traditional and paraspinal posterior open approaches for treatment of thoracolumbar fractures without neurologic deficit:a metaanalysis[J].Eur Spine J,2017,26(5):1418-1431.
[11]Kim BG,Dan JM,Shin DE.Treatment of thoracolumbar fracture[J].Asian Spine J,2015,9(1):133-146.
[12]Wang H,Zhou Y,Li C,et al.Comparison of open versus percutaneous pedicle screw fixation using the sextant system in the treatment of traumatic thoracolumbar fractures[J].Clin Spine Surg,2017,30(3):E239-246.
[13]Koreckij T,Park DK,Fischgrund J.Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma[J].Neurosurg Focus,2014,37(1):E11.
[14]李长青,罗刚,周跃,等.新型微创经皮椎弓根螺钉内固定治疗胸腰椎骨折[J].中华创伤杂志,2009,25(6):522-525.
[15]Jiang WY,Ma WH,Zhao LJ,et al.Treatment of flexiondistraction thoracolumbar fractures by postural reduction with instrumental reduction[J].Zhongguo Gu Shang,2014,27(2):145-147.
[16]Vanek P,Bradac O,Konopkova R,et al.Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation:prospective comparative study with a minimum 2-year follow-up[J].J Neurosurg Spine,2014,20(2):150-156.
[17]Müller U,Berlemann U,Sledge J,et al.Treatment of thoracolumbar burst fractures without neurologic deficit by indirect reduction and posterior instrumentation:bisegmental stabilization with monosegmental fusion[J].Eur Spine J,1999,8(4):284-289.
[18]Oner FC,van der Rijt RR,Ramos LM,et al.Changes in the disc space after fractures of the thoracolumbar spine[J].J Bone Joint Surg Br,1998,80(5):833-839.