胸腰椎爆裂性骨折中椎间盘完整性对手术疗效的影响
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摘要
目的 :探讨在采用后路伤椎置钉短节段固定融合或非融合手术治疗胸腰椎爆裂骨折时椎间盘的完整性对临床疗效的影响。方法:回顾性分析2009年2月~2012年5月间我科收治的85例接受后路伤椎置钉短节段固定术的胸腰椎爆裂骨折患者的资料,根据椎间盘是否损伤及是否采用椎间融合术将患者分为4组:椎间盘完整未融合组(A1组)、椎间盘完整融合组(A2组)、椎间盘破坏未融合组(B1组)、椎间盘破坏融合组(B2组)。统计各组患者手术前后的上下邻椎间Cobb角、伤椎椎体前缘高度、伤椎上下相邻椎间隙高度、ODI评分、VAS评分及Denis腰痛分级等指标。结果:患者平均随访时间62.9±12.4个月(43~82个月)。4组患者年龄、性别、损伤节段经统计学比较,差异无统计学意义(P>0.05)。4组患者术后均能有效地矫正Cobb角及椎体前缘高度,各组间差异无统计学意义(P>0.05)。至末次随访时,A1组患者Cobb角丢失率为(1.5±2.4)%,椎体前缘高度丢失率为(4.9±3.8)%,ODI为9.1±3.6,VAS为0.87±0.50分;A2组分别为(2.1±2.2)%、(4.2±3.4)%、8.4±3.3和0.56±0.76分;B1组分别为(3.6±2.3)%、(7.6±3.1)%、15±4.2和1.64±1.10分;B2组分别为(2.8±1.8)%、(5.8±3.7)%、10.0±3.5和1.16±0.48分。A组内比较:A1与A2组Cobb角、椎体前缘高度丢失率、VAS评分、ODI评分差异无统计学意义(P>0.05);B组内比较:B1组Cobb角、椎体前缘高度丢失率、ODI评分值高于B2组,差异有统计学意义(P<0.05),B组与A组比较,B1组末次随访时的Cobb角、椎体前缘高度丢失率、ODI评分高于A1组,差异有统计学意义(P<0.05);B2组Cobb角丢失度大于A2组,差异有统计学意义(P<0.05),其他指标与A2组比较差异无统计学意义(P>0.05)。各组间椎间高度丢失的差异无统计学意义(P>0.05)。结论:胸腰椎爆裂骨折患者椎间盘的完整性影响手术的临床疗效,对于椎间盘有明显撕裂损伤的患者,需切除受损椎间盘并进行椎间植骨融合。
Objectives: To investigate the influence of the integrity of preoperative intervertebral disc and fusion or not on surgical outcome. Methods: 85 patients suffering from thoracolumbar burst fracture and receiving posterior short-segment fixation with instrumentation on injured vertebra from February 2009 to May2012 were divided into 4 groups: integrity of intervertebral disc and nonfusion group(group A1); integrity of intervertebral disc and fusion group(group A2); damaged disc and nonfusion group(group B1); damaged disc and fusion group(group B2). These indexes before and after surgery were compared between each two groups,such as Cobb angle, anterior vertebral height, adjacent interverbral disc height, Oswetry disability index(ODI),visual analogue score(VAS) and Denis low back pain grade. Results: The mean follow-up of all patients was62.9 ±12.4 months(43-82 months). There was no statistical significance in terms of the age, gender and damage segments among these groups(P>0.05). At the final follow-up, in group A1, the Cobb angle loss rate was(1.5±2.4)%, the anterior vertebral height loss rate was(4.9±3.8)%, the ODI score was 9.1±3.6, the VASscore was 0.87 ±0.50; in group A2, it was(2.1 ±2.2)%,(4.2 ±3.4)%, 8.4 ±3.3 and 0.56 ±0.76 respectively; in group B1, it was(3.6 ±2.3)%,(7.6 ±3.1)%, 15.0 ±4.2 and 1.64 ±1.10 respectively; in group B2, it was(2.8 ±1.8)%,(5.8±3.7)%, 10.0±3.5 and 1.16±0.48 respectively. There was no significant difference in Cobb angle loss rate, anterior vertebral height loss rate or ODI score between group A1 and A2(P>0.05). Cobb angle loss rate, anterior vertebral height loss rate and ODI score in group B1 were all higher than those in group B2(P<0.05). Cobb angle loss rate, anterior vertebral height loss rate and ODI score in group B1 were higher than those in group A1. Cobb angle loss rate in group B2 was higher than that in group A2(P<0.05), while there were no significant difference in other indexes between group A2 and B2(P >0.05). The intervertebral disc height showed no significant difference between every two groups(P >0.05). Conclusions: The integrity of intervertebral disc has a certain impact on the surgery clinical curative effect for the thoracolumbar burst fracture patients. For the patients who have intervertebral disc obvious tearing damage, removing the damaged intervertebral disc and proceeding intervertebral bone graft fusion is necessary.
Objectives: To investigate the influence of the integrity of preoperative intervertebral disc and fusion or not on surgical outcome. Methods: 85 patients suffering from thoracolumbar burst fracture and receiving posterior short-segment fixation with instrumentation on injured vertebra from February 2009 to May2012 were divided into 4 groups: integrity of intervertebral disc and nonfusion group(group A1); integrity of intervertebral disc and fusion group(group A2); damaged disc and nonfusion group(group B1); damaged disc and fusion group(group B2). These indexes before and after surgery were compared between each two groups,such as Cobb angle, anterior vertebral height, adjacent interverbral disc height, Oswetry disability index(ODI),visual analogue score(VAS) and Denis low back pain grade. Results: The mean follow-up of all patients was62.9 ±12.4 months(43-82 months). There was no statistical significance in terms of the age, gender and damage segments among these groups(P>0.05). At the final follow-up, in group A1, the Cobb angle loss rate was(1.5±2.4)%, the anterior vertebral height loss rate was(4.9±3.8)%, the ODI score was 9.1±3.6, the VASscore was 0.87 ±0.50; in group A2, it was(2.1 ±2.2)%,(4.2 ±3.4)%, 8.4 ±3.3 and 0.56 ±0.76 respectively; in group B1, it was(3.6 ±2.3)%,(7.6 ±3.1)%, 15.0 ±4.2 and 1.64 ±1.10 respectively; in group B2, it was(2.8 ±1.8)%,(5.8±3.7)%, 10.0±3.5 and 1.16±0.48 respectively. There was no significant difference in Cobb angle loss rate, anterior vertebral height loss rate or ODI score between group A1 and A2(P>0.05). Cobb angle loss rate, anterior vertebral height loss rate and ODI score in group B1 were all higher than those in group B2(P<0.05). Cobb angle loss rate, anterior vertebral height loss rate and ODI score in group B1 were higher than those in group A1. Cobb angle loss rate in group B2 was higher than that in group A2(P<0.05), while there were no significant difference in other indexes between group A2 and B2(P >0.05). The intervertebral disc height showed no significant difference between every two groups(P >0.05). Conclusions: The integrity of intervertebral disc has a certain impact on the surgery clinical curative effect for the thoracolumbar burst fracture patients. For the patients who have intervertebral disc obvious tearing damage, removing the damaged intervertebral disc and proceeding intervertebral bone graft fusion is necessary.
引文
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8 .Liu C,Wang L,Tian JW.Short-segment fixation of thoracolumbar burst fractures using pedicle fixation at the level of fracture in patients with osteoporosis[J].Zhonghua Yixue Zazhi,2013,93(25):1993-1996.
9 .Leferink VJ,Zimmerman KW,Veldhuis EF,et al.Thoracolumbar spinal fractures:radiological results of transpedicular fixation combined with transpedicular cancellous bone graft and posterior fusion in 183 patients[J].Eur Spine J,2001,10(6):517-523.
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12 .Cengiz SL,Kalkan E,Bayir A,et al.Timing of thoracolomber spine stabilization in trauma patients;impact on neurological outcome and clinical course:a real prospective(rct)randomized controlled study[J].Arch Orthop Trauma Surg,2008,128(9):959-966.
13 .Oner FC,Wood KB,Smith JS,et al.Therapeutic decision making in thoracolumbar spine trauma[J].Spine,2010,35(21Suppl):S235-244.
14 .Verlaan JJ,Diekerhof CH,Buskens E,et al.Surgical treatment of traumatic fractures of the thoracic and lumbar spine:a systematic review of the literature on techniques,complications,and outcome[J].Spine,2004,29(7):803-814.
15 .印飞,张绍东,吴小涛,等.短节段椎弓根螺钉复位固定伤椎内植骨治疗Denis B型胸腰椎骨折的影像学观察[J].中国脊柱脊髓杂志,2013,23(4):341-346.
16 .Chen BL,Wei FX,Ueyama K,et al.Adjacent segment degeneration after single-segment PLIF:the risk factor for degeneration and its impact on clinical outcomes[J].Eur Spine J,2011,20(11):1946-1950.
17 .Denis F.Spinal instability as defined by the three-column spine concept in acute spinal trauma[J].Clin Orthop Relat Res,1984,189:65-76.
18 .郝勇,周跃,任先军,等.严重胸腰椎骨折合并椎间盘损伤的手术治疗[J].骨与关节损伤杂志,2003,18(1):14-17.
19 .丁建林,梁立华,王毓佳.脊柱爆裂性骨折的影像学评价[J].影像诊断与介入放射学,2006,15(1):25-28.
20 .王前,田纪伟.胸腰椎骨折伴发椎间盘损伤的研究进展[J].中国骨与关节外科,2014,20(3):262-265.
21 .Furderer S,Wenda K,Thiem N,et al.Traumatic intervertebral disc lesion:magnetic resonance imaging as a criterion for or against intervertebral fusion[J].Eur Spine J,2001,10(2):154-163.
22 .Kaufer H,Hayes JT.Lumbar fracture-dislocation.A study of twenty-one cases[J].J Bone Joint Surg Am,1966,48(4):712-730.
23 .Korovessis PG.Re:Mahar A,Kim C,Wedemeyer M,et al.Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture.Spine,2007,32:1503-1507[J].Spine,2007,32(23):2638-2639.
24 .Wang ST,Ma HL,Liu CL,et al.Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine:a prospective,randomized study[J].Spine,2006,31(23):2646-2653.
25 .Qian BP,Qiu Y,Wang B,et al.Effect of posterolateral fusion on thoracolumbar burst fractures[J].Chin J Traumatol,2006,9(6):349-355.
26 .Dai LY,Jiang LS,Jiang SD.Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures:a five to seven-year prospective randomized study[J].J Bone Joint Surg Am,2009,91(5):1033-1041.
27 .Lin RM,Panjabi MM,Oxland TR.Functional radiographs of acute thoracolumbar burst fractures:a biomechanical study[J].Spine,1993,18(16):2431-2437.
2 .Benson DR,Burkus JK,Montesano PX,et al.Unstable thoracolumbar and lumbar burst fractures treated with the AO fixateur interne[J].J Spinal Disord,1992,5(3):335-343.
3 .Eleraky MA,Duong HT,Esp E,et al.Expandable versus nonexpandable cages for thoracolumbar burst fracture[J].World Neurosurg,2011,75(1):149-154.
4 .Shen WJ,Liu TJ,Shen YS.Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit[J].Spine,2001,26(9):1038-1045.
5 .Dick JC,Jones MP,Zdeblick TA,et al.A biomechanical comparison evaluating the use of intermediate screws and cross-linkage in lumbar pedicle fixation[J].J Spinal Disord,1994,7(5):402-407.
6 .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,2007,32(14):1503-1507.
7 .Proietti L,Scaramuzzo L,SchiròGR,et al.Posterior percutaneous reduction and fixation of thoraco-lumbar burst fractures[J].Orthop Traumatol Surg Res,2014,100(5):455-460.
8 .Liu C,Wang L,Tian JW.Short-segment fixation of thoracolumbar burst fractures using pedicle fixation at the level of fracture in patients with osteoporosis[J].Zhonghua Yixue Zazhi,2013,93(25):1993-1996.
9 .Leferink VJ,Zimmerman KW,Veldhuis EF,et al.Thoracolumbar spinal fractures:radiological results of transpedicular fixation combined with transpedicular cancellous bone graft and posterior fusion in 183 patients[J].Eur Spine J,2001,10(6):517-523.
10 .Rath SA,Kahamba JF,Kretschmer T,et al.Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization[J].Neurosurg Rev,2005,28(1):44-52.
11 .Vaccaro AR,Lim MR,Hurlbert RJ,et al.Surgical decision making for unstable thoracolumbar spine injuries:results of a consensus panel review by the Spine Trauma Study Group[J].J Spinal Disord Tech,2006,19(1):1-10.
12 .Cengiz SL,Kalkan E,Bayir A,et al.Timing of thoracolomber spine stabilization in trauma patients;impact on neurological outcome and clinical course:a real prospective(rct)randomized controlled study[J].Arch Orthop Trauma Surg,2008,128(9):959-966.
13 .Oner FC,Wood KB,Smith JS,et al.Therapeutic decision making in thoracolumbar spine trauma[J].Spine,2010,35(21Suppl):S235-244.
14 .Verlaan JJ,Diekerhof CH,Buskens E,et al.Surgical treatment of traumatic fractures of the thoracic and lumbar spine:a systematic review of the literature on techniques,complications,and outcome[J].Spine,2004,29(7):803-814.
15 .印飞,张绍东,吴小涛,等.短节段椎弓根螺钉复位固定伤椎内植骨治疗Denis B型胸腰椎骨折的影像学观察[J].中国脊柱脊髓杂志,2013,23(4):341-346.
16 .Chen BL,Wei FX,Ueyama K,et al.Adjacent segment degeneration after single-segment PLIF:the risk factor for degeneration and its impact on clinical outcomes[J].Eur Spine J,2011,20(11):1946-1950.
17 .Denis F.Spinal instability as defined by the three-column spine concept in acute spinal trauma[J].Clin Orthop Relat Res,1984,189:65-76.
18 .郝勇,周跃,任先军,等.严重胸腰椎骨折合并椎间盘损伤的手术治疗[J].骨与关节损伤杂志,2003,18(1):14-17.
19 .丁建林,梁立华,王毓佳.脊柱爆裂性骨折的影像学评价[J].影像诊断与介入放射学,2006,15(1):25-28.
20 .王前,田纪伟.胸腰椎骨折伴发椎间盘损伤的研究进展[J].中国骨与关节外科,2014,20(3):262-265.
21 .Furderer S,Wenda K,Thiem N,et al.Traumatic intervertebral disc lesion:magnetic resonance imaging as a criterion for or against intervertebral fusion[J].Eur Spine J,2001,10(2):154-163.
22 .Kaufer H,Hayes JT.Lumbar fracture-dislocation.A study of twenty-one cases[J].J Bone Joint Surg Am,1966,48(4):712-730.
23 .Korovessis PG.Re:Mahar A,Kim C,Wedemeyer M,et al.Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture.Spine,2007,32:1503-1507[J].Spine,2007,32(23):2638-2639.
24 .Wang ST,Ma HL,Liu CL,et al.Is fusion necessary for surgically treated burst fractures of the thoracolumbar and lumbar spine:a prospective,randomized study[J].Spine,2006,31(23):2646-2653.
25 .Qian BP,Qiu Y,Wang B,et al.Effect of posterolateral fusion on thoracolumbar burst fractures[J].Chin J Traumatol,2006,9(6):349-355.
26 .Dai LY,Jiang LS,Jiang SD.Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures:a five to seven-year prospective randomized study[J].J Bone Joint Surg Am,2009,91(5):1033-1041.
27 .Lin RM,Panjabi MM,Oxland TR.Functional radiographs of acute thoracolumbar burst fractures:a biomechanical study[J].Spine,1993,18(16):2431-2437.