后路椎弓根钉固定结合后外侧植骨融合术选择性治疗胸腰段脊柱爆裂性骨折的临床研究
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摘要
目的：评价后路椎弓根钉系统内固定并结合后外侧植入自体髂骨治疗胸腰段脊柱爆裂性骨折的临床疗效。
方法：依据随机分配原则,将60例胸腰段脊柱爆裂性骨折病例随机分为两组(单纯应用后路椎弓根钉组、椎弓根钉结合后外侧植骨组)进行治疗。通过观察和测量术前、术后及随访时伤椎后凸畸形角(Cobb角)、患椎楔变角(anterior welded angel, AWA)、伤椎前缘高度百分比(Anterior Vertebral Height, AVH)、ODI评分的变化,结合术后融合率及中晚期并发症,对两组疗效进行评估。
结果：
(1)两组手术时间及术中出血量在统计学上有非常显著性差异(p<0.01),A组比B组手术时间短,术中出血少；
(2)A组：AVH、Cobb角、AWA在手术前后、术前和随访时在统计学上均有非常显著性差异(P<0.01)；术后即刻和内固定物取出前时比较无统计学意义(P>0.05)。术后即刻与末次随访时、内固定取出前和末次随访时比较,有显著性差异(P<0.05)。A组融合2例,融合率为6.67%；ODI评分：术前和术后、末次随访时比较,在统计学上有非常显著性差异(P<0.01)；术后与末次随访时比较,统计学上有显著性差异(P<0.05)。
(3)B组：AVH、Cobb角、AWA、ODI评分在手术前后、术前和随访时在统计学上均有非常显著性差异(P<0.01);术后和随访时比较,在统计学上无统计学意义(P>0.05)。B组融合30例,融合率为100%；
(4)两组间比较,Cobb角、AWA、AVH术前、术后即刻、内固定取出前在统计学上均无统计学意义(P>0.05),末次随访时有显著性差异(P<0.05)。两组末次随访时ODI评分在统计学上有显著性差异(P<0.05)。
结论：
1、后路椎弓根螺钉内固定系统是一种治疗急性胸腰段脊柱爆裂骨折行之有效的方法；
2、结合后外侧植骨融合可恢复骨折椎体处的力线传导,能够有效的降低后路手术后远期矫正度丢失及术后并发症的发生。
Objective:To investigate the clinical effect of Thoracolumbar Burst Fractures by selective treatment of Pedicle Screw Internal Fixation combined with Posterlateral Fusion.
Methods:Under the principle of random contrast,60 cases of Thoracolumbar Burst Fractures were randomly divided into two groups according to their treatents:group A were only treated with Pedicle Screw Internal Fixation while group B were treated with Pedicle Serew Internal Fixation combined with Posterlateral Fusion. Then the clinical effects of the two groups were observed, compared and assessed according to the changes of the cobb angle, the anterior welded angel(AWA), the anterior vertebral hight(AVH) and ODI at the preoperative, postoperative and follow-up stages, the postoperative fusion rate and the complications happened during and after the treatments.
Results:
(1)There is a distinctive difference between the two groups on poerttion time and the amount of bleeding:the poerttion time of A group is shorter and and the bleeding of A group is less than B group.
(2)A group:there are very significant statistic differences of AVH, the cobb angle, and AWA (P <0.01) between the preoperative stage and the postoperative and follow-up stages. There is no statistic significance (P>0.05) between the postoperative stage and before taking-fixation. But all guide lines show statistic differences(P<0.05) between the final follow-up and the postoperative and before taking-fixation.There are two cases fusioned in A group. The fusion rate is 6.67%. The ODI rating shows significant differences between the preoperative, the postoperative and the final follow-up stage(P< 0.01).The differences between the postoperative and the final follow-up stage are significant.
(3)B group:there are significant differences of AVH, the cobb angle, AWA and ODI(P<0.01). between the preoperative and the postoperative stages, before taking-fixation and the final follow-up. There is no statistic significance (P>0.05) between the postoperative stage and the follow-up stage. There are 30 cases fusioned in B group. The fusion rate is 100%.
(4) The cobb angle, AVH and AWA show no statistic differences between the preoperative, the postoperative and before taking-fixation. But all guide lines have statistic difference at final follow-up stage (P<0.05). The ODI rating has statistic difference at the final follow-up (P< 0.05).
Conclusion:
1. Pedicle Screw Inernal Fixation is effective on Thoracolumbar Burst Fractures.
2. Pedicle Serew Interanl Fixation combined with Posterlateral Fusion on Thoracolumbar Burst Fractures can lower the probality of complications and the loss of Correction Degree after the operation.
方法：依据随机分配原则,将60例胸腰段脊柱爆裂性骨折病例随机分为两组(单纯应用后路椎弓根钉组、椎弓根钉结合后外侧植骨组)进行治疗。通过观察和测量术前、术后及随访时伤椎后凸畸形角(Cobb角)、患椎楔变角(anterior welded angel, AWA)、伤椎前缘高度百分比(Anterior Vertebral Height, AVH)、ODI评分的变化,结合术后融合率及中晚期并发症,对两组疗效进行评估。
结果：
(1)两组手术时间及术中出血量在统计学上有非常显著性差异(p<0.01),A组比B组手术时间短,术中出血少；
(2)A组：AVH、Cobb角、AWA在手术前后、术前和随访时在统计学上均有非常显著性差异(P<0.01)；术后即刻和内固定物取出前时比较无统计学意义(P>0.05)。术后即刻与末次随访时、内固定取出前和末次随访时比较,有显著性差异(P<0.05)。A组融合2例,融合率为6.67%；ODI评分：术前和术后、末次随访时比较,在统计学上有非常显著性差异(P<0.01)；术后与末次随访时比较,统计学上有显著性差异(P<0.05)。
(3)B组：AVH、Cobb角、AWA、ODI评分在手术前后、术前和随访时在统计学上均有非常显著性差异(P<0.01);术后和随访时比较,在统计学上无统计学意义(P>0.05)。B组融合30例,融合率为100%；
(4)两组间比较,Cobb角、AWA、AVH术前、术后即刻、内固定取出前在统计学上均无统计学意义(P>0.05),末次随访时有显著性差异(P<0.05)。两组末次随访时ODI评分在统计学上有显著性差异(P<0.05)。
结论：
1、后路椎弓根螺钉内固定系统是一种治疗急性胸腰段脊柱爆裂骨折行之有效的方法；
2、结合后外侧植骨融合可恢复骨折椎体处的力线传导,能够有效的降低后路手术后远期矫正度丢失及术后并发症的发生。
Objective:To investigate the clinical effect of Thoracolumbar Burst Fractures by selective treatment of Pedicle Screw Internal Fixation combined with Posterlateral Fusion.
Methods:Under the principle of random contrast,60 cases of Thoracolumbar Burst Fractures were randomly divided into two groups according to their treatents:group A were only treated with Pedicle Screw Internal Fixation while group B were treated with Pedicle Serew Internal Fixation combined with Posterlateral Fusion. Then the clinical effects of the two groups were observed, compared and assessed according to the changes of the cobb angle, the anterior welded angel(AWA), the anterior vertebral hight(AVH) and ODI at the preoperative, postoperative and follow-up stages, the postoperative fusion rate and the complications happened during and after the treatments.
Results:
(1)There is a distinctive difference between the two groups on poerttion time and the amount of bleeding:the poerttion time of A group is shorter and and the bleeding of A group is less than B group.
(2)A group:there are very significant statistic differences of AVH, the cobb angle, and AWA (P <0.01) between the preoperative stage and the postoperative and follow-up stages. There is no statistic significance (P>0.05) between the postoperative stage and before taking-fixation. But all guide lines show statistic differences(P<0.05) between the final follow-up and the postoperative and before taking-fixation.There are two cases fusioned in A group. The fusion rate is 6.67%. The ODI rating shows significant differences between the preoperative, the postoperative and the final follow-up stage(P< 0.01).The differences between the postoperative and the final follow-up stage are significant.
(3)B group:there are significant differences of AVH, the cobb angle, AWA and ODI(P<0.01). between the preoperative and the postoperative stages, before taking-fixation and the final follow-up. There is no statistic significance (P>0.05) between the postoperative stage and the follow-up stage. There are 30 cases fusioned in B group. The fusion rate is 100%.
(4) The cobb angle, AVH and AWA show no statistic differences between the preoperative, the postoperative and before taking-fixation. But all guide lines have statistic difference at final follow-up stage (P<0.05). The ODI rating has statistic difference at the final follow-up (P< 0.05).
Conclusion:
1. Pedicle Screw Inernal Fixation is effective on Thoracolumbar Burst Fractures.
2. Pedicle Serew Interanl Fixation combined with Posterlateral Fusion on Thoracolumbar Burst Fractures can lower the probality of complications and the loss of Correction Degree after the operation.
引文
[1]Mcafee PC, Boden SD, Brantigan JW, et al. Symposium:a critical discrepancy-a criteria of successful arthrodesis following interbody spinal fusion[J]. Spine,2001,26(3):320-334
[2]Roy-Camille R,Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop,1986,203(1):7-17
[3]Skinner L,Maybee J,Transfeldt Z.Experimental pullout testing and comparison of variables in transpedicular screw fixation[J]. Spine 1990,15:195
[4]Shen WJ,Liu TJ,Shen YS.Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures with outneurologic deficit.Spine,2001;26:1038-1045.
[5]Denis F,Armstrong GW, et al.Acute thoracolumbar burst fractures in the absence of neurologic deficit.A comparison between operative and nonoperative treatment.Clin Orthop,1984; 189:142-149.
[6]Mumford J,Weinstein JN,Spratt KF,Goel VK.Thoracolumbar burst fractures.The clinical efficacy and outcome of nonoperative management. Spine,1993; 18:955-970.
[7]Wood K,Butterman G,et al.Operative Compared with Nonoperative Treatment of A Thoracolumbar Burst Fracture Without Neurological Deficit:Aprospective,Randomized study.Journal of Bone&Joint Surgery-American Volume.2003,85:773-781.
[8]Hitchon PW,Torner JC,et al.Management options in thoracolumbar burst fractures.Surg Neurol, 1998,49:619-627.
[9]贾连顺,李家顺,主编.脊柱创伤外科学[M].第1版.上海：上海远东出版社,2000,284-291.
[10]Gertzbein S D.Scolliosis Research Society.Multicenter spine fracture study. Spine,1992; 17:528-540.
[11]Alexander R,Richard S,et al.The Significance of Thoracolumbar Spinal Canal Size in Spinal Cord Injury Patients.Spine,2001,26(4):371-376.
[12]候树勋,史亚民.胸腰椎骨折手术适应症及其远期疗效观察[J].中华创伤杂志,2002；18(1)：14-16.
[13]Wbod KB,Bohn D,Mehbod A.Anterior versus Posterior treatment of stable thoracolumbar burst fraetures without neurologic defieit.J Spinal Disord Tech,2005,18:515-523.
[14]SassoR C,Renkens K,Hanson D,et al.Unstable thoraeolumbar burst fraetures:anteriorouly versus short-segment Posterior fixation.J Spinal Disord Tech.2006,19:242-248.
[15]邹德威,马华松,海涌.胸腰段脊柱骨折治疗方法的选择及手术指征[J].中华外科杂志,1995：33(12)：731-733.。
[16]单方军,王春.后路植骨在胸腰椎爆裂骨折中的应用和发展[J].生物骨科材料与临床研究,2007,4(5)：33-35.
[17]王大伟,韩士章,张佐伦.腰椎后外侧融合术[J].中国矫形外科杂志,2004,12(5)：374-376.
[18]万军,张学利,田融,等.后外侧减压植骨融合内固定治疗胸腰段爆裂骨折[J].实用骨科杂志,2009,15(2)：81-83.
[19]滕云升,郭永明,张朝,等.椎弓根螺钉内固定加后外侧植骨融合治疗胸腰段脊柱骨折[J].美中国际创伤杂志,2006,5(4)：56-58.
[20]Sanderson PL,Fraser RD,Hall DJ,et al.Short segment fixation of thoracolumbar burst fractures without fusion[J].Eur Spine,1999,8:495-500.
[21]Shirado O,Zeblick TA,Mcafee PC.Biomechanical evaluation of methods of posterior stabilization of the spine and posterior lumbar interbody arthrodesis for lumbosacral isthmus spondylisthesis[J].BoneSurg,1991,73A:518-522.
[22]徐宝山,唐大驹,杨惠林.经后路短节段推弓根内固定治疗胸腰推爆裂性骨折的远期疗效.中华骨科杂志,2002,22(11)：641-647.
[23]Verlaan JJ,Diekerhof CH,Buskens E,et al.Sugical treatment of traumatic fractures of the thoracicand lumbar spine:a systematic review of the literature on techniques complications and outcome.Spine,2004,29:803-814.
[24]Paker JW,Lane GR,Karaikovic EE,et al. Successful Short-segment instrumentation and fusion for thoracolumbar spine fractures:A consecutive 41/2year series[J].Spine,2000,25(9):1157-1170
[25].Oner F,Gils A,Faber J,et al.Some complications of common treatment schemes of thoracolumbar spine fractures can be predicted with magnetic resonance imaging:Prospective study of 53 patients with 71 fractures. Spine,2002,27(6):629-636.
[26]Roberson PA,Wray AC.Natural history of posterior iliac crest bone graft donation for spinal surgery:a prospective analysis of morbidity.Spine.2001;26:1473-1476
[1]张贵林.脊柱胸腰段骨折术后维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.
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[11]滕云升,郭永明,张朝,等.椎弓根螺钉内固定加后外侧植骨融合治疗胸腰段脊柱骨折[J].美中国际创伤杂志,2006,5(4)：56-58.
[12]王春萍,翟明玉,陈金华,等.AF钉治疗胸腰椎骨折132例报告[J].中医正骨,2004,1(65)：920.
[13]陆耀刚,王子平,王秀会,等.胸腰椎骨折小关节突间植骨临床应用价值[J].中国骨与关节损伤杂志,2006,2(12)：109-110.
[14]王大伟,韩士章,张佐伦.腰椎后外侧融合术[J].中国矫形外科杂志,2004,12(5)：374-376.
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[2]Roy-Camille R,Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop,1986,203(1):7-17
[3]Skinner L,Maybee J,Transfeldt Z.Experimental pullout testing and comparison of variables in transpedicular screw fixation[J]. Spine 1990,15:195
[4]Shen WJ,Liu TJ,Shen YS.Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures with outneurologic deficit.Spine,2001;26:1038-1045.
[5]Denis F,Armstrong GW, et al.Acute thoracolumbar burst fractures in the absence of neurologic deficit.A comparison between operative and nonoperative treatment.Clin Orthop,1984; 189:142-149.
[6]Mumford J,Weinstein JN,Spratt KF,Goel VK.Thoracolumbar burst fractures.The clinical efficacy and outcome of nonoperative management. Spine,1993; 18:955-970.
[7]Wood K,Butterman G,et al.Operative Compared with Nonoperative Treatment of A Thoracolumbar Burst Fracture Without Neurological Deficit:Aprospective,Randomized study.Journal of Bone&Joint Surgery-American Volume.2003,85:773-781.
[8]Hitchon PW,Torner JC,et al.Management options in thoracolumbar burst fractures.Surg Neurol, 1998,49:619-627.
[9]贾连顺,李家顺,主编.脊柱创伤外科学[M].第1版.上海：上海远东出版社,2000,284-291.
[10]Gertzbein S D.Scolliosis Research Society.Multicenter spine fracture study. Spine,1992; 17:528-540.
[11]Alexander R,Richard S,et al.The Significance of Thoracolumbar Spinal Canal Size in Spinal Cord Injury Patients.Spine,2001,26(4):371-376.
[12]候树勋,史亚民.胸腰椎骨折手术适应症及其远期疗效观察[J].中华创伤杂志,2002；18(1)：14-16.
[13]Wbod KB,Bohn D,Mehbod A.Anterior versus Posterior treatment of stable thoracolumbar burst fraetures without neurologic defieit.J Spinal Disord Tech,2005,18:515-523.
[14]SassoR C,Renkens K,Hanson D,et al.Unstable thoraeolumbar burst fraetures:anteriorouly versus short-segment Posterior fixation.J Spinal Disord Tech.2006,19:242-248.
[15]邹德威,马华松,海涌.胸腰段脊柱骨折治疗方法的选择及手术指征[J].中华外科杂志,1995：33(12)：731-733.。
[16]单方军,王春.后路植骨在胸腰椎爆裂骨折中的应用和发展[J].生物骨科材料与临床研究,2007,4(5)：33-35.
[17]王大伟,韩士章,张佐伦.腰椎后外侧融合术[J].中国矫形外科杂志,2004,12(5)：374-376.
[18]万军,张学利,田融,等.后外侧减压植骨融合内固定治疗胸腰段爆裂骨折[J].实用骨科杂志,2009,15(2)：81-83.
[19]滕云升,郭永明,张朝,等.椎弓根螺钉内固定加后外侧植骨融合治疗胸腰段脊柱骨折[J].美中国际创伤杂志,2006,5(4)：56-58.
[20]Sanderson PL,Fraser RD,Hall DJ,et al.Short segment fixation of thoracolumbar burst fractures without fusion[J].Eur Spine,1999,8:495-500.
[21]Shirado O,Zeblick TA,Mcafee PC.Biomechanical evaluation of methods of posterior stabilization of the spine and posterior lumbar interbody arthrodesis for lumbosacral isthmus spondylisthesis[J].BoneSurg,1991,73A:518-522.
[22]徐宝山,唐大驹,杨惠林.经后路短节段推弓根内固定治疗胸腰推爆裂性骨折的远期疗效.中华骨科杂志,2002,22(11)：641-647.
[23]Verlaan JJ,Diekerhof CH,Buskens E,et al.Sugical treatment of traumatic fractures of the thoracicand lumbar spine:a systematic review of the literature on techniques complications and outcome.Spine,2004,29:803-814.
[24]Paker JW,Lane GR,Karaikovic EE,et al. Successful Short-segment instrumentation and fusion for thoracolumbar spine fractures:A consecutive 41/2year series[J].Spine,2000,25(9):1157-1170
[25].Oner F,Gils A,Faber J,et al.Some complications of common treatment schemes of thoracolumbar spine fractures can be predicted with magnetic resonance imaging:Prospective study of 53 patients with 71 fractures. Spine,2002,27(6):629-636.
[26]Roberson PA,Wray AC.Natural history of posterior iliac crest bone graft donation for spinal surgery:a prospective analysis of morbidity.Spine.2001;26:1473-1476
[1]张贵林.脊柱胸腰段骨折术后维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.
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