胸腰段骨折后路手术失败原因分析及翻修策略
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摘要
目的探讨胸腰段骨折单纯行后路内固定手术失败的原因及翻修策略。方法回顾性分析2008年3月至2014年12月在我院脊柱外科接受胸腰段(T11~L2)翻修手术的31例患者,其中28例患者从基层转入,3例患者来自本院。男19例,女12例;年龄19~57岁,平均(35.4±3.6)岁。分析患者初次手术时影像学资料,根据AO胸腰椎损伤分类系统分类,A3型4例,B1型2例,B2型5例,B3型7例,C型13例。均行单纯后路内固定。失败原因:内固定物断裂26例,椎弓根螺钉或连接棒断裂并出现不同程度的后凸畸形;后路椎弓根螺钉误置3例;后路手术减压不彻底1例;取内固定后出现侧凸畸形1例。首次术后症状无改善者2例,内固定断裂后神经功能损害进行性加重26例,所有患者均有腰背部疼痛不适。根据实际情况分别行前路骨折椎体切除、髂骨或钛网重建固定融合术;后路内固定重置长节段固定并行相应节段的椎管减压;后路经椎弓根楔形截骨矫形术。结果 AO分型中A型占翻修率的12.9%,B型45.16%,C型41.93%。所有患者随访12~24个月,未见再次内固定失败的病例,术后10~12个月随访时均获得骨性融合。Frankel分级上升0~2级,平均上升(1.3±0.79)级。末次随访时视觉模拟评分(visual analogue scale,VAS)由术前平均6.9分降至2.4分,Oswestry功能障碍指数(Oswestry disability index,ODI)由46.3%降至12.4%。26例合并后凸畸形的患者术前后凸角10°~58°,平均(40.5±15.3)°;术后矫正至-3°~7°,平均(2.3±3.7)°;末次随访时角度丢失0°~1.3°,平均(0.6±0.2)°;最终后凸矫正率为91.8%。结论胸腰段骨折后路手术失败,其主要原因是初次手术基层医院未重视骨折损伤分型,B型、C型骨折单纯行后路内固定手术的失败率最高,翻修以重建脊柱前中柱、防止内固定再次失败为关键,并对初次手术失败所引发的疼痛及畸形予以处理,可获得较好的治疗效果。
Objective To explore the failure reason and revision strategy of posterior internal fixation surgery alone for thoracolumbar fracture.Methods From March 2008 to December 2014,12 thoracolumbar fracture(T11 ~L2)patients have had revision surgery in Spine Surgery Department of our hospital.Among them,28 was transferred from primary hospital.Reasons for revision surgery were fracture of internal fixation including pedicle screw and connecting rods combined with kyphosis.We analyzed the imaging data of primary operation and classifying it by AO classification system for thoracolumbar injuries.According to AO classification,the fractures were A3 in 4 cases,B1 in 2 cases,B2 in 5 cases,B3 in 7 cases,C in 13 cases.All patients underwent posterior internal fixation alone.The reasons of revision were misplacement of posterior pedicle screw in 3 cases,incompletely posterior decompression in 1 case,the scoliosis after removal of the internal fixation in 1 case and unimproved symptoms after primary surgery in 2 cases.Neurological deficits were progressively aggravated after fracture of the internal fixation in 26 cases.All these patients had back pain.The anterior vertebral resection,reconstruction and fusion by Iliac bone or titanium mesh,posterior internal fixation for long segment and decompression of vertebral canal with corresponding segments,posterior transpedicular wedge osteotomy were performed according to the actual situation.Results According to AO classification system,revision rates were 12.9%in type A,45.16%in type B and 41.93%in type C.No case of internal fixation failure had been found again during 12~24 months follow-up,and all patients had obtained bony fusion after 10~12 months follow-up.Frankel classification improved 0~2(1.3±0.79)level,Visual analog scale(VAS)decreased from 6.9 preoperationally to 2.4 during last follow-up,oswestry disability index(ODI)decreased from 46.3 to 12.4.Kyphosis angle improved in 26 patients from 10°~58°(40.5±15.3)°preoperationally to-3~7°(2.3±3.7)°postoperationally which only losses 0°~1.3°(0.6±0.2)during last follow-up,and the final correction rate was 91.8%.Conclusion Main reason for the failure of thoracolumbar fracture posterior surgery is that primary hospital did not pay enough attention to fracture classification before surgery.For type B and type C patient posterior internal fixation alone often leads to failure.Revision surgery to reconstruct anterior and middle column of fracture is the key to prevent the internal fixation from failing again,by the side,it had definite curative effect on the pain and deformity caused by the failure of the primary operation.
Objective To explore the failure reason and revision strategy of posterior internal fixation surgery alone for thoracolumbar fracture.Methods From March 2008 to December 2014,12 thoracolumbar fracture(T11 ~L2)patients have had revision surgery in Spine Surgery Department of our hospital.Among them,28 was transferred from primary hospital.Reasons for revision surgery were fracture of internal fixation including pedicle screw and connecting rods combined with kyphosis.We analyzed the imaging data of primary operation and classifying it by AO classification system for thoracolumbar injuries.According to AO classification,the fractures were A3 in 4 cases,B1 in 2 cases,B2 in 5 cases,B3 in 7 cases,C in 13 cases.All patients underwent posterior internal fixation alone.The reasons of revision were misplacement of posterior pedicle screw in 3 cases,incompletely posterior decompression in 1 case,the scoliosis after removal of the internal fixation in 1 case and unimproved symptoms after primary surgery in 2 cases.Neurological deficits were progressively aggravated after fracture of the internal fixation in 26 cases.All these patients had back pain.The anterior vertebral resection,reconstruction and fusion by Iliac bone or titanium mesh,posterior internal fixation for long segment and decompression of vertebral canal with corresponding segments,posterior transpedicular wedge osteotomy were performed according to the actual situation.Results According to AO classification system,revision rates were 12.9%in type A,45.16%in type B and 41.93%in type C.No case of internal fixation failure had been found again during 12~24 months follow-up,and all patients had obtained bony fusion after 10~12 months follow-up.Frankel classification improved 0~2(1.3±0.79)level,Visual analog scale(VAS)decreased from 6.9 preoperationally to 2.4 during last follow-up,oswestry disability index(ODI)decreased from 46.3 to 12.4.Kyphosis angle improved in 26 patients from 10°~58°(40.5±15.3)°preoperationally to-3~7°(2.3±3.7)°postoperationally which only losses 0°~1.3°(0.6±0.2)during last follow-up,and the final correction rate was 91.8%.Conclusion Main reason for the failure of thoracolumbar fracture posterior surgery is that primary hospital did not pay enough attention to fracture classification before surgery.For type B and type C patient posterior internal fixation alone often leads to failure.Revision surgery to reconstruct anterior and middle column of fracture is the key to prevent the internal fixation from failing again,by the side,it had definite curative effect on the pain and deformity caused by the failure of the primary operation.
引文
[1]Rajasekaran S,Kanna RM,Shetty AP.Management of thoracolumbar spine trauma:an overview[J].Indian J Orthop,2015,49(1):72-82.
[2]Reinhold M,Audige L,Schnake KJ,et al.AO spine injury classification system:a revision proposal for the thoracic and lumbar spine[J].Eur Spine J,2013,22(10):2184-2201.
[3]McCormack T,Karaikovic E,Gaines RW.The load sharing classification of spine fractures[J].Spine,1994,19(15):1741-1744.
[4]Frankel HL,Hancock DO,Hyslop G,et al.The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia[J].Paraplegia,1969,7(3):179-192.
[5]Lee CK,Vessa P,Lee JK.Chronic disabling low back pain syndrome caused by internal disc derangements.The results of disc excision and posterior lumbar interbody fusion[J].Spine 1995,20(3):356-361.
[6]Aebi M.Classification of thoracolumbar fractures and dislocations[J].Eur Spine J,2010,19(Suppl 1):S2-7.
[7]Brantigan JW,Steffee AD.A carbon fiber implant to aid interbody lumbar fusion.Two-year clinical results in the first 26patients[J].Spine(Phila Pa 1976),1993,18(14):2106-2107.
[8]Dai LY,Jiang SD,Wang XY,et al.A review of the management of thoracolumbar burst fractures[J].SurgNeurol,2007,67(3):221-231.
[9]Alpantaki K,Bano A,Pasku D,et al.Thoracolumbar burst fractures:a systematic review of management[J].Orthopedics,2010,33(6):422-429.
[10]胡临,田伟,刘波,等.陈旧性胸腰椎骨折的术式选择——前路固定与后路椎体截骨术的比较[J].中华创伤骨科杂志,2004,6(11):1223-1225.
[11]Butt MF,Farooq M,Mir B,et al.Management of unstable thoracolumbar spinal injuries by posterior short segment spinal fixation[J].Int Orthop,2007,31(2):259-264.
[12]Gnanenthiran SR,Adie S,Harris IA.Nonoperative versus operative treatment for thoracolumbar burst fracture swithoutneurologic deficit:a meta-analysis[J].Clin Orthop Relat Res,2012,470(2):567-577.
[13]Cho DY,Lee WY,Sheu PC.Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short-segment pedicle screw fixation[J].Neurosurgery,2003,53(6):1354-1360.
[14]Marco RA,Meyer BC,Kushwaha VP.Thoracolumbar burst fractures treated with posterior decompression and pedicle screw instrumentation supplemented with balloon-assisted vertebroplasty and calcium phosphate reconstruction Surgical technique[J].J Bone Joint Surg(Am),2010,92(1):67-76.
[15]Hao D,Wang W,Duan K,et al.Two-year follow-up evaluation of surgical treatment for thoracolumbar fracture-dislocation[J].Spine(Phila Pa 1976),2014,39(21):1284-1290.
[16]Hicks JM,Singla A,Shen FH,et al.Complications of pedicle screw fixation in scoliosis surgery:a systematic review[J].Spine,2010,35(11):465-470.
[17]张贵林,荣国威.脊柱胸腰段骨折术后椎弓根螺钉断裂及弯曲松动的原因分析[J].中华骨科杂志,2000,20(8):470-472.
[18]Vaccaro AR,Silber JS.Post-traumatic spinal deformity[J].Spine,2001,26(24Suppl):111-118.
[19]Benli IT,Kaya A,Uruc V,et al.Minimum 5-year follow-up surgical results of post-traumatic thoracic and lumbar kyphosis treated with anterior instrumentation:comparison of anterior plate and dual rod systems[J].Spine,2007,32(9):986-994.
[20]Chou D,Wang VY,Storm PB.Pedicle subtraction osteotomies for the correction of post-traumatic thoracolumbar kyphosis[J].J Clin Neurosci,2010,17(1):113-117.
[21]Suk SI,Kim JH,Lee SM,et al.Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture[J].Spine,2003,28(18):2170-2175.
[22]Elsharkawi MM,Koptan WM,Elmiligui YH,et al.Comparison between pedicle subtraction osteotomy and anterior corpectomy and plating for correcting post-traumatic kyphosis:a multicenter study[J].Eur Spine J,2011,20(9):1434-1440.
[23]夏群,徐宝山,张继东,等.胸腰椎爆裂骨折手术入路的选择[J].中华骨科杂志,2004,24(12):718-722.
[2]Reinhold M,Audige L,Schnake KJ,et al.AO spine injury classification system:a revision proposal for the thoracic and lumbar spine[J].Eur Spine J,2013,22(10):2184-2201.
[3]McCormack T,Karaikovic E,Gaines RW.The load sharing classification of spine fractures[J].Spine,1994,19(15):1741-1744.
[4]Frankel HL,Hancock DO,Hyslop G,et al.The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia[J].Paraplegia,1969,7(3):179-192.
[5]Lee CK,Vessa P,Lee JK.Chronic disabling low back pain syndrome caused by internal disc derangements.The results of disc excision and posterior lumbar interbody fusion[J].Spine 1995,20(3):356-361.
[6]Aebi M.Classification of thoracolumbar fractures and dislocations[J].Eur Spine J,2010,19(Suppl 1):S2-7.
[7]Brantigan JW,Steffee AD.A carbon fiber implant to aid interbody lumbar fusion.Two-year clinical results in the first 26patients[J].Spine(Phila Pa 1976),1993,18(14):2106-2107.
[8]Dai LY,Jiang SD,Wang XY,et al.A review of the management of thoracolumbar burst fractures[J].SurgNeurol,2007,67(3):221-231.
[9]Alpantaki K,Bano A,Pasku D,et al.Thoracolumbar burst fractures:a systematic review of management[J].Orthopedics,2010,33(6):422-429.
[10]胡临,田伟,刘波,等.陈旧性胸腰椎骨折的术式选择——前路固定与后路椎体截骨术的比较[J].中华创伤骨科杂志,2004,6(11):1223-1225.
[11]Butt MF,Farooq M,Mir B,et al.Management of unstable thoracolumbar spinal injuries by posterior short segment spinal fixation[J].Int Orthop,2007,31(2):259-264.
[12]Gnanenthiran SR,Adie S,Harris IA.Nonoperative versus operative treatment for thoracolumbar burst fracture swithoutneurologic deficit:a meta-analysis[J].Clin Orthop Relat Res,2012,470(2):567-577.
[13]Cho DY,Lee WY,Sheu PC.Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short-segment pedicle screw fixation[J].Neurosurgery,2003,53(6):1354-1360.
[14]Marco RA,Meyer BC,Kushwaha VP.Thoracolumbar burst fractures treated with posterior decompression and pedicle screw instrumentation supplemented with balloon-assisted vertebroplasty and calcium phosphate reconstruction Surgical technique[J].J Bone Joint Surg(Am),2010,92(1):67-76.
[15]Hao D,Wang W,Duan K,et al.Two-year follow-up evaluation of surgical treatment for thoracolumbar fracture-dislocation[J].Spine(Phila Pa 1976),2014,39(21):1284-1290.
[16]Hicks JM,Singla A,Shen FH,et al.Complications of pedicle screw fixation in scoliosis surgery:a systematic review[J].Spine,2010,35(11):465-470.
[17]张贵林,荣国威.脊柱胸腰段骨折术后椎弓根螺钉断裂及弯曲松动的原因分析[J].中华骨科杂志,2000,20(8):470-472.
[18]Vaccaro AR,Silber JS.Post-traumatic spinal deformity[J].Spine,2001,26(24Suppl):111-118.
[19]Benli IT,Kaya A,Uruc V,et al.Minimum 5-year follow-up surgical results of post-traumatic thoracic and lumbar kyphosis treated with anterior instrumentation:comparison of anterior plate and dual rod systems[J].Spine,2007,32(9):986-994.
[20]Chou D,Wang VY,Storm PB.Pedicle subtraction osteotomies for the correction of post-traumatic thoracolumbar kyphosis[J].J Clin Neurosci,2010,17(1):113-117.
[21]Suk SI,Kim JH,Lee SM,et al.Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture[J].Spine,2003,28(18):2170-2175.
[22]Elsharkawi MM,Koptan WM,Elmiligui YH,et al.Comparison between pedicle subtraction osteotomy and anterior corpectomy and plating for correcting post-traumatic kyphosis:a multicenter study[J].Eur Spine J,2011,20(9):1434-1440.
[23]夏群,徐宝山,张继东,等.胸腰椎爆裂骨折手术入路的选择[J].中华骨科杂志,2004,24(12):718-722.