椎弓根钉内固定治疗胸腰椎临床疗效分析
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摘要
目的：评价椎弓根螺钉内固定系统治疗胸腰椎骨折的临床效果，分别比较椎弓根钉内固定后植骨与不植骨及Dick、Steffee、AF三种椎弓根钉系统治疗胸腰椎骨折的效果。
材料与方法：1994年11月至2002年1月经随访胸腰段骨折手术病例64例，应用椎弓根内固定系统治疗的胸腰段骨折患者术前、术后和随诊时的临床表现、X线片和CT、MRI检查。随访时间至少1年，平均40个月。
结果：64例患者总的伤椎后凸畸形术前(21.6±8.6)°，术后(6.4±4.9)°，随访(12.2±4.9)°。椎体压缩术前平均48.5％，术后15.8％，随诊24.7％。术前和术后、术前和随访统计学上均有显著性差异。但在术后随访时伤椎椎体高度及矫正角均有不同程度的丢失。
植骨组伤椎后凸畸形术前(22.6±9.0)°，术后(4.9±4.1)°，随访植骨组矫正度丢失(6.0±2.2)°；非植骨组术前(21.1±8.4)°，术后(5.6±4.9)°，随访矫正度丢失(5.0±2.7)°。植骨组与非植骨组相比，二组间伤椎后凸畸形、椎体压缩在术前、术后和随诊均无明显统计学差异。疼痛及工作情况根据Denis疼痛及工作级数，植骨组P1P2占83％，P4P5占9％，植骨组P1P2占76％，P4P5占14％。植骨组W1W2占52％，W4W5占39％，植骨组W1W2占46％，W4W5占41％。非植骨组严重疼痛较植骨组多，但经非参数检验两组间疼痛及工作级数无统计学差异。
64例胸腰段骨折患者中，Dick11例，AF18例，Steffee24例。Dick组手术前后后凸畸形角分别是(20.9±12.4)°和(9.4±4.5)°；Steffee组(21.0±6.0)°和(8.1±4.5)°；AF组(24.0±10.5)°和(4.1±3.4)°。三组手术前后差异均有显著意义(P＜0.01)。Dick钉系统对脊柱骨折后凸畸形的矫正度是(11.5±10.0)°，Steffee(12.9±5.5)°，AF(19.9±10.3)°。AF组明显大于Dick组和Steffee组，差异有显著意义(P＜0.01)，而Dick组和Steffee组对后凸畸形的矫正度相差不明显。椎体高度恢复Dick组平均21.0％，Steffee组平均28.2％，AF组平均43.6％。Dick组和Steffee组相差不大。AF组椎
体高度恢复明显好于Dick组和steffee组，P植分别是0.003和0.007。
Dick组术后丢失角度平均(6.7士3.8)0，steffee组(6.9士2.3)0，AF组(4.6
士1.4)”。oick组和steffee组丢失角度大于AF组，和AF组相比，P
值分别为0.04和小于0.01，有统计学差异。椎体高度丢失Dick组平均
值为9.5士3.0，Steffec组平均值为10.0士10.3，AF组平均值为8.7士1.2。
三组椎体高度丢失相差不大，P值大于0.05。三组神经功能恢复情况经
秩和检验分析，差异无显著性意义
结论:椎弓根内固定系统是治疗胸腰段骨折的有效方法，但术后伤
椎矫正角及椎体高度均有一定丢失。虽然胸腰椎骨折行椎弓根钉内固定
配合植骨增加了脊柱的稳定性，并不能防止矫正角的丢失，和椎弓根钉
内固定未行植骨相比无显著差别。由于Dick、steffee、AF椎弓根钉系统
的结构和作用机制不同，临床效果不尽相同，从脊柱骨折的复位程度和
术后后期后凸畸形矫正度丢失等方面分析，AF椎弓根钉系统优于Dick
钉系统和steffee钢板。
Study design. A retrospective clinical study was performed.
Objective. To determine the clinical, radiologic, and functional status of patients who underwent pedicle-screw fixation of thoracolumbar fractures, to compare the results of pedicle-screw fixation with and without fusion and to evaluate the effect of three types of pedicle-screw fixators(Dick internal fixator, Steffee variable screw placement system,and atlas fixation systerm).
Methods. Sixty four patients with unstable thoracolumbar fractures were included in the study. The inclusion criteria was the presence of fractures through the T11-L4 vertebrae with or without neurologic compromise. Multi-segment fractures were excluded from the study. Part one: The patients were randomized into two groups. Group 1 patients were treated using pedicle-screw fixation with fusion(n = 23), and Group 2 patients were treated using pedicle-screw fixation without fusion(n = 41). Part two: The patients were into three groups. Group 1 patients were treated using Dick internal fixator (n = 11), Group 2 using Steffee variable screw placement system (n = 24), and Group 3 using atlas fixation systerm (AF) (n =18). All patients were evaluated clinically, radiographically, and functionally for a minimum of 1 years (mean 40 months). Clinical (Frankel/ASIA grade and Denis' pain and word scales) and radiologic (local kyphosis, percentage of anterior boby height compression) outcomes were analyzed.
Results. Before surgey, vertebral kyphosis of all cases averaged 21.6° improved to 6.4° with reduction, and reached 12.2?at final follow -up. percentage of anterior boby height compression initially averaged 48.5% but was reduced to 15.8% with surgey and 24.7% at final follow-up.Both the kyphosis angle and boby height compression were improved after operation, but were losed in some degrees. The patients with incomplete spinal cord injury showed significant functional improvement.
The two groups (with grafting and without grafting) were similar in age,
follow-up period, and severity of the deformity and fracture. The postoperative and follow-up kyphosis angle, percentage of anterior boby height compression,and average correction loss in kyphosis angle and vertebral height in both groups were not significantly different. In grafting group, 83% of patients had little or no pain (P1P2) and 52% of patients had returned previous work (W1W2). In no grafting group, 76% of patients was rated P1P2 and 46% of patients was rated WlW2.The number of patients with serious pain in no grafting group was larger than grafting group, but there was no significant difference.
Among the sixty four patients, Dick internal fixator, Steffee variable screw placement system,and atlas fixation systerm were used in 11, 18, and 24 cases respectively. In the dick group, the kyphosis angle was improved initially by 12.9°, and this was lost by 6.9° at follow-up. In the Steffee group, the kyphosis angle was improved initially by 11.5°, which was lost by 6.7° at follow-up. In the AF group, the kyphosis angle was improved initially by 19.9°, which was lost by 4.6?at follow-up. The correction loss of kyphosis angle in the AF group was smaller than that in the dick group and in the steffee group. The boby height loss were no significantly different in both groups.
Conclusions. The pedicle screw instrumentation is one of effective devices for the treatment of thoracolumbar fracrures.but there are certain degree loss of the rate of compressed vertebral body height and correction loss in kyphosis angle at follw-up. Although pedicle-screw fixation by additional posterior grafting adds spine stability, it cannot prevent correction loss in kyphosis angle. There was no significant difference of correction loss in kyphosis angle and body height loss in the grafting group and in the no grafting group. According reduction degree and correction loss at follow-up, AF system is better than Dick internal fixator and Steffee variable screw placement system.
材料与方法：1994年11月至2002年1月经随访胸腰段骨折手术病例64例，应用椎弓根内固定系统治疗的胸腰段骨折患者术前、术后和随诊时的临床表现、X线片和CT、MRI检查。随访时间至少1年，平均40个月。
结果：64例患者总的伤椎后凸畸形术前(21.6±8.6)°，术后(6.4±4.9)°，随访(12.2±4.9)°。椎体压缩术前平均48.5％，术后15.8％，随诊24.7％。术前和术后、术前和随访统计学上均有显著性差异。但在术后随访时伤椎椎体高度及矫正角均有不同程度的丢失。
植骨组伤椎后凸畸形术前(22.6±9.0)°，术后(4.9±4.1)°，随访植骨组矫正度丢失(6.0±2.2)°；非植骨组术前(21.1±8.4)°，术后(5.6±4.9)°，随访矫正度丢失(5.0±2.7)°。植骨组与非植骨组相比，二组间伤椎后凸畸形、椎体压缩在术前、术后和随诊均无明显统计学差异。疼痛及工作情况根据Denis疼痛及工作级数，植骨组P1P2占83％，P4P5占9％，植骨组P1P2占76％，P4P5占14％。植骨组W1W2占52％，W4W5占39％，植骨组W1W2占46％，W4W5占41％。非植骨组严重疼痛较植骨组多，但经非参数检验两组间疼痛及工作级数无统计学差异。
64例胸腰段骨折患者中，Dick11例，AF18例，Steffee24例。Dick组手术前后后凸畸形角分别是(20.9±12.4)°和(9.4±4.5)°；Steffee组(21.0±6.0)°和(8.1±4.5)°；AF组(24.0±10.5)°和(4.1±3.4)°。三组手术前后差异均有显著意义(P＜0.01)。Dick钉系统对脊柱骨折后凸畸形的矫正度是(11.5±10.0)°，Steffee(12.9±5.5)°，AF(19.9±10.3)°。AF组明显大于Dick组和Steffee组，差异有显著意义(P＜0.01)，而Dick组和Steffee组对后凸畸形的矫正度相差不明显。椎体高度恢复Dick组平均21.0％，Steffee组平均28.2％，AF组平均43.6％。Dick组和Steffee组相差不大。AF组椎
体高度恢复明显好于Dick组和steffee组，P植分别是0.003和0.007。
Dick组术后丢失角度平均(6.7士3.8)0，steffee组(6.9士2.3)0，AF组(4.6
士1.4)”。oick组和steffee组丢失角度大于AF组，和AF组相比，P
值分别为0.04和小于0.01，有统计学差异。椎体高度丢失Dick组平均
值为9.5士3.0，Steffec组平均值为10.0士10.3，AF组平均值为8.7士1.2。
三组椎体高度丢失相差不大，P值大于0.05。三组神经功能恢复情况经
秩和检验分析，差异无显著性意义
结论:椎弓根内固定系统是治疗胸腰段骨折的有效方法，但术后伤
椎矫正角及椎体高度均有一定丢失。虽然胸腰椎骨折行椎弓根钉内固定
配合植骨增加了脊柱的稳定性，并不能防止矫正角的丢失，和椎弓根钉
内固定未行植骨相比无显著差别。由于Dick、steffee、AF椎弓根钉系统
的结构和作用机制不同，临床效果不尽相同，从脊柱骨折的复位程度和
术后后期后凸畸形矫正度丢失等方面分析，AF椎弓根钉系统优于Dick
钉系统和steffee钢板。
Study design. A retrospective clinical study was performed.
Objective. To determine the clinical, radiologic, and functional status of patients who underwent pedicle-screw fixation of thoracolumbar fractures, to compare the results of pedicle-screw fixation with and without fusion and to evaluate the effect of three types of pedicle-screw fixators(Dick internal fixator, Steffee variable screw placement system,and atlas fixation systerm).
Methods. Sixty four patients with unstable thoracolumbar fractures were included in the study. The inclusion criteria was the presence of fractures through the T11-L4 vertebrae with or without neurologic compromise. Multi-segment fractures were excluded from the study. Part one: The patients were randomized into two groups. Group 1 patients were treated using pedicle-screw fixation with fusion(n = 23), and Group 2 patients were treated using pedicle-screw fixation without fusion(n = 41). Part two: The patients were into three groups. Group 1 patients were treated using Dick internal fixator (n = 11), Group 2 using Steffee variable screw placement system (n = 24), and Group 3 using atlas fixation systerm (AF) (n =18). All patients were evaluated clinically, radiographically, and functionally for a minimum of 1 years (mean 40 months). Clinical (Frankel/ASIA grade and Denis' pain and word scales) and radiologic (local kyphosis, percentage of anterior boby height compression) outcomes were analyzed.
Results. Before surgey, vertebral kyphosis of all cases averaged 21.6° improved to 6.4° with reduction, and reached 12.2?at final follow -up. percentage of anterior boby height compression initially averaged 48.5% but was reduced to 15.8% with surgey and 24.7% at final follow-up.Both the kyphosis angle and boby height compression were improved after operation, but were losed in some degrees. The patients with incomplete spinal cord injury showed significant functional improvement.
The two groups (with grafting and without grafting) were similar in age,
follow-up period, and severity of the deformity and fracture. The postoperative and follow-up kyphosis angle, percentage of anterior boby height compression,and average correction loss in kyphosis angle and vertebral height in both groups were not significantly different. In grafting group, 83% of patients had little or no pain (P1P2) and 52% of patients had returned previous work (W1W2). In no grafting group, 76% of patients was rated P1P2 and 46% of patients was rated WlW2.The number of patients with serious pain in no grafting group was larger than grafting group, but there was no significant difference.
Among the sixty four patients, Dick internal fixator, Steffee variable screw placement system,and atlas fixation systerm were used in 11, 18, and 24 cases respectively. In the dick group, the kyphosis angle was improved initially by 12.9°, and this was lost by 6.9° at follow-up. In the Steffee group, the kyphosis angle was improved initially by 11.5°, which was lost by 6.7° at follow-up. In the AF group, the kyphosis angle was improved initially by 19.9°, which was lost by 4.6?at follow-up. The correction loss of kyphosis angle in the AF group was smaller than that in the dick group and in the steffee group. The boby height loss were no significantly different in both groups.
Conclusions. The pedicle screw instrumentation is one of effective devices for the treatment of thoracolumbar fracrures.but there are certain degree loss of the rate of compressed vertebral body height and correction loss in kyphosis angle at follw-up. Although pedicle-screw fixation by additional posterior grafting adds spine stability, it cannot prevent correction loss in kyphosis angle. There was no significant difference of correction loss in kyphosis angle and body height loss in the grafting group and in the no grafting group. According reduction degree and correction loss at follow-up, AF system is better than Dick internal fixator and Steffee variable screw placement system.
引文
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2． Lund T, Oxland TR, Jost B, et al . Interbody cage stabilization in the lumbar spine: biomechanical evaluation of cage desing, posterior instrumentation and bone density. J Bone Joint Surg Br, 1998, 80:351-359．
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4． Sanderson PL, Fraser RD, Hall DJ, et al. Short segment fixation of thoracolumbar burst fractures without fusion. Eur Spine J. 1999, 8(6) : 495-500．
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2． Lund T, Oxland TR, Jost B, et al . Interbody cage stabilization in the lumbar spine: biomechanical evaluation of cage desing, posterior instrumentation and bone density. J Bone Joint Surg Br, 1998, 80:351-359．
3． Sjostrom L, Karlstrom G, Pech P et al. Indirect spinal canal decompression in burst fractures treated with pedicle screw instrumentation. Spine, 1996,21:113-123．
4． Sanderson PL, Fraser RD, Hall DJ, et al. Short segment fixation of thoracolumbar burst fractures without fusion. Eur Spine J. 1999, 8(6) : 495-500．
5． Louis CA, Gauthier VY, Louis RP. Posterior approach with Louis plates for fractures of the thoracolumbar and lumbar spine with and without neurologic deficits. Spine. 1998, 23(18) : 2030-9．
6． Daanisa OA, Shaffrey CI, Jane JA, et al. Surgical approaches for the correction of unstable thoracolumbar burst fractures: A retrospective analysis of treatment outcomes. J Neurosurg 1995, 83:977-83．
7． McLain RF, Sparlin E, Benson DR. Eearly failure of short segment pedicle instrumentation for thoracolumbar fractures: A preliminary report. J Bone Joint Surg Aml993, 75:162-7．
8． Denis F, Armstrong GW, Searls K et al. Acute thoracolumbar burst fractures in the absence of neurologic deficit. A comparison between operative and nonoperative treatment. Clin Orthop. 1984, (189) : 142-9．
9． Knop C, Fabian HF, Bastian L, Blauth M, Late results of thoracolumbar fractures after posterior instrumentation and transpedicular bone grafting. Spine. 2001,26(1) : 88-99．
10． Lindsey RW, Dick W. The fixateur interne in the reduction and stabilization of thoracolumbar spine fractures in patients with neurologic deficit. Spine. 1991, 16(3 Suppl): S140-5．
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