下腰椎爆裂骨折的手术治疗

Surgical treatment for lower lumbar burst fractures

中文关键词:  爆裂骨折  下腰椎  手术治疗

英文关键词:Burst fractures  Low lumbar spine  Surgical treatment

中文摘要:

  【摘要】 目的：探讨手术治疗下腰椎（L3~L5）爆裂骨折患者的临床疗效。方法：1996年1月~2006年10月在我科接受手术治疗的下腰椎爆裂骨折患者14例，男12例，女2例，年龄18～63岁，平均32.7岁。入院时1例无神经损伤，4例根性损伤，1例圆锥损伤，8例马尾神经损伤（按ASIA分级A级2例、B级1例、C级3例、D级2例）。L3骨折7例，L4 5例，L5 2例，矢状位Cobb角-20°～12°，平均为-4.1°。8例患者合并多发骨折（其他部位稳定脊柱骨折4例，骨盆骨折1例，股骨粗隆下骨折1例，胫腓骨骨折3例，跟骨骨折2例，肋骨骨折2例）。1例L3爆裂骨折马尾神经C级损伤患者行侧前方入路L3椎体切除、椎间自体髂骨植骨、Kaneda内固定术，其余13例患者均行后路椎板切除、椎弓根螺钉内固定、横突间（12例）或椎体间（1例）植骨融合术。末次随访时进行神经功能、影像学及步行能力评价。结果：手术时间3.5～7h，平均5h。术中出血量600～2200ml，平均1258ml。术后无神经损伤加重。术后出现脑脊液漏2例，无伤口感染、延迟愈合及其他严重并发症。术后2周时Cobb角为-27°～7°，平均-12.4°，与术前比较有显著性差异（P＜0.01）。4例（28.6%）患者行再手术治疗，其中2例因腰背痛于术后2年时取出内固定，术后腰背痛部分缓解；1例初次前路手术后下肢痛明显，半年后再次行后路椎管探查，术后下肢痛部分改善；1例因初次后路手术后骨折复位欠佳，肛周麻、痛，3个月后再次行后路探查、神经根粘连松解，术后症状部分缓解。随访24～42个月，平均34.1个月。末次随访时，根性损伤者肌力均恢复1~2级；圆锥损伤者可实现大小便自控；马尾神经损伤者5例出现1~2个级别的神经功能恢复，3例无变化。末次随访时Cobb角有平均1.7°前凸角度丢失，但与术后2周时比较无显著性差异（P＞0.05）。术后2年13例患者实现骨性融合；1例可疑假关节形成，因无腰背部疼痛未处理。无内固定松动、断裂。所有患者末次随访时在借助/不借助支具的情况下均具有社区内行走功能。结论：下腰椎爆裂骨折的手术治疗以后路手术为主，手术治疗虽可取得较好的矫形效果，但术后腰背部疼痛和下肢及肛周疼痛有可能导致较高的再手术率。

英文摘要:

  【Abstract】 Objective：To investigate the surgical treatment for lower lumbar（L3-L5） burst fractures.Method：The clinical data of 14 patients with lower lumbar burst fractures from January 1996 to October 2006 treated surgically were reviewed retrospectively.There were 12 males and 2 females with the age ranging from 18 to 63 years（mean age，32.7 years）.At time of admission，1 patient had no neurological deficit，4 patients had radiculopathy，1 patient had conus medullaris syndrome and 8 had cauda equina injuries which included grade A in 2，B in 1，C in 3 and D in 2 according to ASIA classification.7 fractures were identified at L3，5 at L4 and 2 at L5.The mean initial Cobb′s angle ranged from -20° to 12°（mean angle，-4.1°，negative value means lordosis）.8 patients were complicated with other injuries which included 4 additional spine stable fractures，1 pelvic fracture，1 subtrochanteric fracture，2 rib fractures，3 tibial and fibular fractures and 2 calcaneus fractures.1 patient with L3 burst fracture and cauda equina injury（ASIA grade C） underwent anterior corpectomy，intervertebral fusion and Kaneda instrumentation.13 patients experienced posterior decompression，pedicle screws instrumentation and posterolateral（12 cases） or intervertebral fusion（1 case）.Neurological function，radiographs and ambulatory status were evaluated at final follow-up.Result：The operation time ranged from 3.5 to 7 hours（average，5 hours） with blood loss ranging from 600ml to 2200ml（average，1258ml）.No patients presented with neurological deterioration regardless of surgical approach.2 patients suffered cerebrospinal fluid leakage.No skin incision infection and other severe complication were noted.At 2 weeks after operation，the Cobb′s angle ranged from -27° to 7°（average，-12.4°），which showed statistical significance compared with preoperation（P＜0.01）.4（28.6%） patients required revision surgery after initial surgical stabilization.2 cases had internal fixation removal due to low back pain.1 patient undergoing anterior surgery initially experienced posterior nerve exploration due to pain in lower extremities.1 patient required posterior exploration and nerve root release because of incorrect reduction and anal pain after initial surgery.All patients had symptoms improved partially after revision surgery.The followed up period ranged from 24 to 42 months（average，34.1 months）.At final follow-up muscle strength in patients with radiculopathy improved one or two grade.Patient with conus medullaris syndrome recovered to routine activity and bladder function.Neurological function of 3 patients with cauda equina injuries remained no change.The other 5 patients had at least one ASIA grade improvement of neurological function.There was 1.7° loss of lordosis at final follow-up，but no statistical significance was noted compared with that at 2 weeks postoperation（P＞0.05）.13 patients got bony union.1 patient suspected to having pseudarthrosis was left alone due to no discomfort.No instrument failure was noted.All patients were able to community ambulation with or without brace at final follow-up.Conclusion：When surgical treatment is indicated for lower lumbar burst fractures，posterior approach should be considered first.Surgical stabilization can ensure good deformity correction，but reoperation can not be avoided due to high rate of low back pain and low extremity and anal pain.