多节段非相邻型脊柱骨折的诊断与治疗

Diagnosis and treatment of multiple level and noncontiguous spinal fractures

中文关键词:  脊柱骨折  多节段  非相邻  诊断  治疗

英文关键词:Spine fractures  Multiple-level  Noncontiguous  Diagnosis  Treatment

中文摘要:

  【摘要】 目的：探讨多节段非相邻型脊柱骨折（MNSF）的诊断和治疗。方法：2007年1月～2010年12月收治MNSF患者30例，男26例，女4例，年龄16～64岁。均有外伤史，受伤至入院时间为2h～3d。均急诊行全脊柱正侧位X线片和CT平扫+冠矢状位重建，1例患者合并脑疝于入院当日死亡，其余患者在入院后4d内行全脊柱MRI检查。骨折节段：2个节段14例，3个节段11例，4个节段3例，5个节段2例，共83个节段。有6例7个节段出现延迟诊断，延迟诊断时间为2~4d，均在入院后通过全脊柱MRI检查发现。脊髓功能按ASIA分级：A级5例，B级2例，C级7例，D级4例，E级11例。合并脑外伤8例，肋骨骨折4例，血气胸3例，肺挫伤4例，脾破裂2例，肾挫伤1例，四肢骨折10例，骨盆骨折2例。14例有神经症状和有中柱损伤的爆裂骨折者行手术治疗，手术部位为引起神经受压症状的节段和有中柱损伤的爆裂骨折节段，受伤至手术时间为4～9d，平均6.2d；10例椎体高度丢失小于1/3且无神经症状的单纯压缩骨折患者行保守治疗；5例放弃治疗。结果：1例保守治疗患者入院后6d因肺栓塞死亡，其余23例接受治疗者随访10~44个月，平均28个月。14例手术治疗者，手术节段矢状面Cobb角从术前平均20.8°（16.6°～22.3°）恢复到术后平均6.1°（4.7°～7.4°），末次随访平均6.7°（4.6°～7.7°），末次随访椎体高度无明显丢失，伤椎愈合良好；其中12例有神经症状者末次随访8例ASIA分级改善1~2级，4例无变化（A级3例，B级1例）；无内固定失败、植骨不融合、神经症状加重。9例保守治疗者，末次随访骨折愈合，伤椎高度无明显丢失，未出现迟发性神经损伤。结论：MNSF易漏诊，对多发伤患者应常规行全脊柱X线片和CT三维重建，必要时应行MRI检查。对不稳定骨折和脊髓有损伤者尽早手术，可取得较好疗效。

英文摘要:

  【Abstract】 Objective：To investigate the diagnosis and treatment of multiple level and noncontiguous spinal fractures.Method：30 cases suffering ｆｒｏｍ　multiple level and noncontiguous spinal fractures were admitted to our institute from January 2007 to December 2010.There were 26 males and 4 females with the age ranging from 16 to 64 years.All the cases had a natural history of trauma.The duration from injury to admission was from 2 hours to 3 days.Total spine X-ray radiographic survey and three-dimensional CT scan were accomplished in the emergency room.One case died of cerebral hernia at the day of admission，and others underwent total spine MRI within 4 days after admission.14 cases suffered with 2 segments fractures，11 cases with 3 segments fractures，3 cases with 4 segments fractures and 2 cases with 5 segments fractures.A total of 83 segments were involved.Diagnosis was postponed in 6 cases（7 segments） with delayed time of 2 to 4 days.All delayed-diagnosed　ｃａｓｅｓ were determined by total spine MRI.According to ASIA grading system，there were 5 grade A，2 grade B，7 grade C，4 grade D and 11 grade E.8 cases were ａｃｃｏｍｐａｎｉｅｄ by cerebral trauma，4 ｂｙ　rib fracture，3　ｂｙ hemopneumothorax，4 ｂｙ　pulmonary contusion，2 ｂｙ　rupture of the spleen，1 ｂｙ　kidney contusion，10 ｂｙ　limb fracture and 2 ｂｙ　pelvic fracture.14 cases suffering ｆｒｏｍ　burst fractures ｗｅｒｅ　complicated with spinal cord injury underwent surgery.The average time from injury to surgery is 6.2 day（4-9 days）.10 simple compression fractures with the loss of vertebraｌ height less than 1/3 and no neurological deficit were treated conservatively.5 cases abandoned treatment.Result：23 patients were followed up for 10 months to 44 months with a mean time of 28 months，ｗｈｉｌｅ　1 case undergoing conservative treatment died of pulmonary embolism 6 days after admission.14 cases treated surgically had the average Cobb′s angle improved from 20.8°（range，16.6°-22.3°） of preoperation to 6.1°（range，4.7°-7.4°） of postoperation，and 6.7°（range，4.6°-7.7°） at final follow-up.No loss of vertebral height was noted，and all fractureｄ vertebrｅ healed at final follow-up.Among 12 patients with neurological deficit before operation，8 cases had ASIA grade improved 1-2 grade，ａｎｄ　4 cases remained unchanged（3 grade A and 1 grade B） at final follow-up.No implant failure，nonunion ｏｒ　neurological deterioration were noted during followｉｎｇ up.9 cases undergoing conservative treatment had bony-union and no loss of vertebral height，and no neurological deterioration was noted either.Conclusion：Missed diagnosis in multiple level ａｎｄ　noncontiguous spinal fractures ｉｓ usually encountered.It ｉｓ recommended that total spine X-ray radiographic survey and three-dimensional CT should be accomplished routinely to the cases with multiple trauma.The spine MRI ｉｓ performed if necessary.If the fractures are unstable or combined with spinal cord deficit，surgical treatment is suggested as soon as possible for better healing effect.