完全性胸腰椎骨折脱位行后路减压椎间融合内固定手术的可行性分析

·临床研究·收稿日期：2018-05-23；修订日期：2018-07-12作者简介：张志祥（1984-），男，河南籍，主治医师，硕士研究方向：脊柱电子邮箱：969968033@完全性胸腰椎骨折脱位行后路减压椎间融合内固定手术的可行性分析张志祥1，吴学建2，冷华平1，韩国瑞1（1.郑州颐和医院，河南郑州450000；2.郑州大学第一附属医院骨科，河南郑州450000）摘要：目的探讨完全性胸腰段椎体骨折脱位的特点及后路减压复位椎间植骨融合内固定治疗的可行性。

方法选取20例完全性胸腰段椎体骨折脱位患者，损伤节段分别为8例T 10-T 11、7例T 11-T 12、2例T 12-L 1、3例L 1-L 2；其中单纯脱位者8例，合并四肢骨折12例、肺挫伤10例、腹腔脏器损伤7例、失血或创伤性休克7例、颅脑损伤5例；术前MMT 肌力分级0级9例，Ⅰ级11例。

20例患者均在合并症处理稳定的基础上，予以后路减压复位椎间植骨融合内固定手术治疗。

结果20例患者手术均顺利完成，脱位椎体完全复位率为85.00%，另3例双侧关节突交锁严重导致复位仍不完全。

术后4例患者发生脑脊液漏，经局部缝合、加压包扎后康复；1例切口感染，经对症处置后得以痊愈。

20例术后7d 、12个月的矢状面Cobb 角均较术前明显改善（P <0.05）。

9例MMT 肌力分级为0级者，术后均未恢复；11例Ⅰ级者，1例术后恢复至Ⅱ级，5例恢复至Ⅲ级，5例未恢复。

9例ASIA分级为A 级者术后均未改善；11例B 级者，5例术后恢复至C 级，6例未恢复。

所有患者骨折均在术后12个月内达到骨性融合，无固定松动或断裂情况。

结论完全性胸腰段椎体骨折脱位患者损伤严重，且多伴有复合伤；经后路减压复位植骨融合内固定术治疗，其操作简便，术后恢复较为理想。

关键词：完全性胸腰椎骨折脱位；后路减压复位；椎弓根钉棒；内固定手术；椎间融合中图分类号：R687.3文献标识码：B文章编号：1005-7234（2019）02-0201-04DOI ：10.3969/j.issn.1005-7234.2019.02.018Characteristics of complete thoracolumbar fracture and dislocation and the feasibility of posterior decompression and reduction with interbody fusion and internal fixationZHANG Zhi-xiang 1,WU Xue-jian 2,LENG Hua-ping 1,HAN Guo-rui 1.(1.Zhengzhou Yihe Hospital,Zhengzhou,Henan,450000;2.Department of Orthopaedics,First Affiliated Hospital of ZhengzhouUniversity,Zhengzhou,Henan,450000,China.)Abstract:Objective To investigate the characteristics of complete thoracolumbar vertebral fracture and dislocation and thefeasibility of posterior decompression,reduction,interbody fusion and internal fixation.Methods 20cases of thoracolumbar vertebralfractures and dislocations were selected as the research object.The injured segments were 8cases of T 10-T 11,7cases of T 11-T 12,2cases of T 12-L 1,3cases of L 1-L 2.There were 8cases of simple dislocation,12cases of limb fracture,10cases of pulmonary contusion,7casesof abdominal organ injury,7cases of hemorrhage or traumatic shock,5cases of craniocerebral injury,9cases of preoperative MMT muscle strength grade 0,11cases of grade I.All patients underwent posterior decompression,reduction,fusion and internal fixation.Results All the operations were successfully completed.The complete reduction rate of dislocated vertebrae was 85.00%.The other 3cases were still incomplete due to severe bilateral facet strands.Four patients had cerebrospinal fluid leakage and recovered after local suture and compression bandage.One case of incision infection was cured after symptomatic treatment.The Cobb angle of sagittal plane was significantly improved in 20cases at 7days and 12months after operation (P <0.05).Nine patients with MMT muscle strengthgrading 0did not recover after operation,11patients with MMT muscle strength grading I,1patient recovered to grade II,5patients recovered to grade III and 5patients did not recover.Nine patients with ASIA grade A did not improve after operation,11patients with grade B,5patients with ASIA grade C and 6patients with ASIA grade A did not recover after operation.All patients achieved bony fusion within 12months after operation,without any loosening or breakage.Conclusion Complete thoracolumbar vertebral fracture and dislocation patients with serious injury,and more complicated injuries;posterior decompression reduction,bone graft fusion and internalfixation,its operation is simple,postoperative recovery is ideal.Key words:complete thoracolumbar fracture and dislocation;posterior decompression and reduction;pedicle screw rod;Internalfixation;intervertebral fusion胸腰椎骨折脱位是指由于外力造成胸腰椎骨质连续性的破坏[1]，常引起神经功能损伤，尤其是完全性骨折脱位是在椎体骨折基础上合并严重的前方、后方以及侧方旋转、移位，多合并各种严重并发症[2]，给手术复位以及固定等环节带来了极大的困难和挑战，手术方式主要为前后路联合手术，但是手术时间较长、创伤较大，效果不甚理想[3]。

本院自2013-05-2016-05，采用后路减压复位椎间植骨融合内固定手术治疗20例此类患者，获得较满意的疗效。

1资料与方法1.1一般资料选取我院2013-05-2016-05，收治的20例完全性胸腰段椎体骨折脱位患者，男性15例，女5例，年龄20~50岁，平均（34.90±4.41）岁；受伤至入院时间1~9h，平均（3.51±0.60）h，致伤原因：交通事故6例，高空坠落7例，重物砸伤7例；美国脊柱损伤协会（ASIA）分级：A级9例，B级11例；损伤节段：T10-11者8例，T11-12者7例、T12L1者2例、L1-2者3例。

X线片提示患者脱位上位椎体位于下位椎体前方，矢状面后凸cobb角-20.05~2.46°，平均（-13.41±6.45）°；CT三维重建提示患者胸腰段椎体完全脱位，MRI检查提示多数患者脊髓及椎间盘受损，其中单纯脱位者8例，合并四肢骨折12例、肺挫伤10例、腹腔脏器损伤7例、失血或创伤性休克7例、颅脑损伤5例；术前MMT肌力分级0级9例，Ⅰ级11例。

1.2手术方法1.2.1术前合并症处理所有患者确诊入院后首先对合并伤进行处理，特别是对可能危及患者生命安全的失血、休克、血气胸、颅脑损伤、腹腔脏器损伤等进行优先治疗，待病情稳定后再行脊柱手术。

脊柱手术的前提满足条件：（1）失血量大于20%者第一时间输血以补充血容量，直至患者收缩压恢复至90mmHg以上，脉搏降为100次/min以下；（2）合并多发肋骨骨折并伴血气胸者，采用多头胸带给予固定，请院胸外科医师协助会诊，肺萎缩大于30%者及时行胸腔闭合引流术，对连枷胸患者同步对其肋骨予以固定，术后积极预防肺部感染，待患者日引流量小于0.5L、血气各项指标基本稳定或肺通气测试为中轻度阻塞性通气障碍以上为止；（3）合并严重颅脑损伤患者，请神经外科协助诊治，待患者意识恢复、颅脑CT检查提示无活动性出血为止；（4）合并腹腔脏器损伤者及时请普外科会诊，行急诊腹腔脏器修补术治疗，术后7d待患者生命体征及病情稳定为止；（5）另合并四肢骨折但未见明显或严重神经损伤者，采用石膏或支具先行固定处理。