中国修复重建外科杂志

中国修复重建外科杂志

减压和非减压治疗无神经症状椎管内占位胸腰椎骨折的对比研究

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目的 比较后路开窗减压与非减压手术治疗无神经症状椎管内占位胸腰椎骨折的疗效。 方法 回顾分析 2008 年 10 月—2015 年 10 月收治的符合选择标准的 97 例椎管受压占椎管面积1/3~1/2 的无神经症状胸腰椎骨折患者,其中采用后路开窗减压手术 51 例(减压组),采用后路非减压手术 46 例(非减压组)。两组患者性别、年龄、致伤原因、受伤节段、胸腰椎损伤分类及严重程度评分(TLICS)、合并伤、受伤至手术时间以及术前伤椎前缘相对高度、后凸 Cobb 角、椎管受压占椎管面积百分比、疼痛视觉模拟评分(VAS)、Oswestry 功能障碍指数(ODI)、日本骨科协会(JOA)评分等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。记录并比较两组患者手术时间、术中出血量、术后引流量、术后卧床时间、住院时间;术前、术后 3 d 及术后 1 年伤椎前缘相对高度、后凸 Cobb 角、椎管受压占椎管面积百分比及 VAS 评分、ODI、JOA 评分。 结果 非减压组手术时间、术中出血量及术后引流量均明显少于减压组(P<0.05);两组术后卧床时间和住院时间比较差异无统计学意义(P>0.05)。减压组有 4 例发生术后脑脊液漏,经保守治疗后治愈;两组切口均 Ⅰ 期愈合,均未发生神经损伤、切口感染并发症。所有患者均获随访,随访时间 10~18 个月,平均 11.7 个月。两组椎体高度恢复满意,均无继发后凸畸形及继发神经症状加重。两组术后 3 d 及 1 年各影像学指标及疗效评分均较术前显著改善,差异有统计学意义(P<0.05);术后 1 年两组椎管受压占椎管面积百分比、VAS 评分、ODI 均显著低于术后 3 d(P<0.05),JOA 评分均显著高于术后 3 d(P<0.05);术后 1 年伤椎前缘相对高度非减压组显著高于术后 3 d(P<0.05),减压组与术后 3 d 比较差异无统计学意义(P>0.05)。除术后 3 d 非减压组椎管受压占椎管面积百分比及 JOA 评分高于减压组,VAS 评分和 ODI 显著低于减压组,比较差异有统计学意义(P<0.05)外,其余指标组间比较差异无统计学意义(P>0.05)。 结论 与后路开窗减压手术相比,后路非减压手术具有术中出血少、手术创伤小、术后疼痛轻等优点;在严格掌握手术适应证情况下,后路非减压手术是治疗椎管内占位达椎管面积 1/3~1/2 的无神经症状胸腰椎骨折有效方法之一。

Objective To investigate the effectiveness of posterior non-decompression surgery in the treatment of thoracolumbar fractures without spinal symptoms by comparing with the conventional posterior decompression surgery. Methods Between October 2008 and October 2015, a total of 97 patients with thoracolumbar fractures with intraspinal occupying 1/3-1/2 and without neurological symptoms were divided into the decompression surgery group (51 cases) and the non-decompression surgery group (46 cases). There was no significant difference in gender, age, cause of injury, injury segment, the thoracolumbar injury severity score (TLICS), combined injury, disease duration, and preoperative relative anterior vertebral height, kyphosis Cobb angle, intraspinal occupying percentage, visual analogue scale (VAS), Oswestry disability index (ODI), and Japanese Orthopaedic Association (JOA) score between 2 groups (P>0.05). The operation time, intraoperative blood loss volume, and postoperative drainage, bed rest time, hospitalization time, relative anterior vertebral height, kyphosis Cobb angle, intraspinal occupying percentage, and VAS score, ODI, JOA score at preoperative and postoperative 3 days and 1 year were recorded and compared. Results The operation time, intraoperative blood loss volume, and postoperative drainage in non-decompression surgery group were significantly less than those in decompression surgery group (P<0.05). There was no significant difference in the postoperative bed rest time and hospitalization time between 2 groups (P>0.05). In decompression surgery group, 4 cases had cerebrospinal fluid leakage and healed after conservative treatment. All incisions healed by first intention, and no nerve injury or infection of incision occurred. All patients were followed up 10-18 months (mean, 11.7 months). The recovery of vertebral body height was satisfactory in 2 groups, without secondary kyphosis and secondary nerve symptoms. The imaging indexes and effectiveness scores of 2 groups at 3 days and 1 year after operation were significantly improved when compared with preoperative ones (P<0.05). The intraspinal occupying percentage, VAS score, and ODI at 1 year after operation were significantly lower than those at 3 days after operation in 2 groups (P<0.05), and JOA score at 1 year after operation was significantly higher than that at 3 days after operation (P<0.05). Relative anterior vertebral height at 1 year after operation was significantly higher than that at 3 days after operation in non-decompression surgery group (P<0.05); and there was no significant difference in decompression surgery group (P>0.05). At 3 days, the intraspinal occupying percentage and JOA score in non-decompression surgery group were higher than in decompression surgery group (P<0.05), and VAS score and ODI at 3 days in non-decompression surgery group were lower than in decompression surgery group (P<0.05). No significant difference was found in the other indexes between 2 groups at 3 days and 1 year after operation (P>0.05). Conclusion Compared with the posterior decompression surgery, posterior non-decompression surgery has the advantages of less bleeding, less trauma, less postoperative pain, and so on. It is an ideal choice for the treatment of thoracolumbar fractures with intraspinal occupying 1/3-1/2 and without neurological symptoms under the condition of strict indication of operation.

关键词: 胸腰椎骨折; 神经症状; 椎管内占位; 后路减压

Key words: Thoracolumbar fracture; neurological symptom; intraspinal occupying; posterior decompression

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