摘要
目的:比较3种不同手术入路椎弓根钉棒系统内固定治疗胸腰椎骨折的临床疗效及安全性。方法:将135例胸腰椎骨折患者随机分为后正中入路组、经皮入路组及椎旁肌间隙入路组,每组45例。3组患者由同一主刀医生进行手术,术中分别采用不同的手术入路植入椎弓根钉棒系统,复位、固定骨折。记录切口长度、手术时间、术中出血量、住院时间及骨折愈合时间。分别于术前和术后3个月,测量伤椎前后缘高度比和伤椎后凸Cobb角,采用Oswestry功能障碍指数(Oswestry disability index,ODI)评价患者术后行动能力与生活能力。观察术后并发症发生情况。分别于术前和术后当天,抽取患者外周静脉血,采用酶联免疫吸附法测定血清肌酸激酶、肌红蛋白和乳酸脱氢酶水平。结果:①一般结果。3组患者切口长度、手术时间、术中出血量、住院时间、骨折愈合时间组间总体比较,差异均有统计学意义[(7.96±0.85)cm,(2.11±0.56)cm,(12.13±3.94)cm,F=206.542,P=0.000;(94.87±9.32)min,(66.72±8.49)min,(53.58±9.97)min,F=180.208,P=0.000;(114.87±14.32)mL,(81.29±11.17)mL,(67.23±9.81)mL,F=189.815,P=0.000;(10.17±2.47)d,(7.38±1.88)d,(6.08±1.69)d,F=47.207,P=0.000;(5.85±1.17)个月,(5.16±1.02)个月,(4.30±0.89)个月,F=25.429,P=0.000]。经皮入路组、椎旁肌间隙入路组患者手术时间、住院时间、骨折愈合时间均较后正中入路组短(P=0.000,P=0.000,P=0.002;P=0.000,P=0.000,P=0.000),术中出血量均较后正中入路组少(P=0.000,P=0.000)。椎旁肌间隙入路组患者手术时间、住院时间、骨折愈合时间均较经皮入路组短(P=0.000,P=0.000,P=0.000),术中出血量较经皮入路组少(P=0.000)。经皮入路组患者切口长度较后正中入路组、椎旁肌间隙入路组短(P=0.000,P=0.000),后正中入路组患者切口长度较椎旁肌间隙入路组短(P=0.000)。②疗效评价结果。术前3组患者伤椎前后缘高度比、伤椎后凸Cobb角、ODI组间总体比较,差异均无统计学意义[(62.15±7.31)%,(61.88±7.45)%,(62.54±6.97)%,F=0.094,P=0.910;22.15°±1.77°,21.88°±1.55°,21.68°±1.38°,F=0.970,P=0.382;(35.62±2.32)%,(36.37±2.57)%,(35.98±2.11)%,F=1.155,P=0.318]。术后3个月,3组患者伤椎前后缘高度比、伤椎后凸Cobb角、ODI组间总体比较,差异均有统计学意义[(84.87±5.49)%,(89.91±4.63)%,(93.38±4.57)%,F=34.192,P=0.000;7.55°±1.13°,6.43°±1.19°,5.69°±1.05°,F=28.234,P=0.000;(5.25±1.33)%,(4.53±1.17)%,(3.82±1.12)%,F=15.711,P=0.000]。经皮入路组、椎旁肌间隙入路组患者伤椎前后缘高度比均较后正中入路组高(P=0.000,P=0.000),伤椎后凸Cobb角均较后正中入路组小(P=0.000,P=0.000),ODI均较后正中入路组低(P=0.008,P=0.000);椎旁肌间隙入路组患者伤椎前后缘高度比较经皮入路组高(P=0.000),伤椎后凸Cobb角较经皮入路组小(P=0.002),ODI较经皮入路组低(P=0.004)。③安全性评价结果。术前,3组患者血清肌酸激酶、肌红蛋白、乳酸脱氢酶水平组间总体比较,差异均无统计学意义[(160.87±21.32)单位·L^(-1),(162.41±22.57)单位·L^(-1),(161.53±20.97)单位·L^(-1),F=0.057,P=0.944;(100.79±18.31)ng·mL^(-1),(103.19±17.37)ng·mL^(-1),(101.89±15.97)ng·mL^(-1),F=0.218,P=0.804;(108.38±18.77)单位·L^(-1),(111.36±16.35)单位·L^(-1),(113.81±17.08)单位·L^(-1),F=1.095,P=0.337]。术后当天,3组患者血清肌酸激酶、肌红蛋白、乳酸脱氢酶水平组间总体比较,差异均有统计学意义[(352.77±57.73)单位·L^(-1),(254.39±42.53)单位·L^(-1),(251.08±44.62)单位·L^(-1),F=63.193,P=0.000;(240.55±25.49)ng·mL^(-1),(192.53±19.63)ng·mL^(-1),(189.39±20.17)ng·mL^(-1),F=76.981,P=0.000;(190.55±21.43)单位·L^(-1),(163.23±19.19)单位·L^(-1),(160.33±20.21)单位·L^(-1),F=31.292,P=0.000]。经皮入路组、椎旁肌间隙入路组3项指标均较后正中入路组低(P=0.000,P=0.000,P=0.000;P=0.000,P=0.000,P=0.000),而这2组间比较,差异均无统计学意义(P=0.728,P=0.456,P=0.487)。后正中入路组术后并发切口感染2例、下肢深静脉血栓2例、内固定断裂1例,经皮入路组术后并发切口感染2例、下肢深静脉血栓1例、内固定断裂1例,椎旁肌间隙入路组术后并发切口感染1例、下肢深静脉血栓2例、内固定断裂1例;3组患者并发症发生率比较,差异无统计学意义(χ^(2)=0.170,P=0.918)。结论:对于胸腰椎骨折患者,虽然椎旁肌间隙入路切口长度较长,但采用该入路进行椎弓根钉棒系统内固定手术,较经皮入路和传统后正中入路出血少、损伤小、恢复快,更有利于椎体高度和脊柱功能恢复,安全性高。
Objective:To compare the clinical curative effects and safety of three different surgical approaches in pedicle screw-rod system(PSRS)internal fixation for treatment of thoracolumbar fractures.Methods:One hundred and thirty-five patients with thoracolumbar fractures were randomly divided into posterior median approach group,percutaneous approach group and paraspinal approach group,45 cases in each group,and they were treated with PSRS internal fixation through three different surgical approaches respectively by the same surgeon.The incision length,operative time,intraoperative blood loss,hospital stay and fracture healing time were recorded.The ratio of anterior border height to posterior border height(APR)and kyphotic Cobb angle of injured vertebrae were measured,and the postoperative activities of daily living(ADL)were evaluated by using Oswestry disability index(ODI)before the surgery and at 3 months after the surgery respectively.The blood was drawn from the peripheral vein,and the serum levels of creatine kinase(CK),myoglobin(Myo)and lactate dehydrogenase(LDH)were detected by using enzyme linked immunosorbent assay(ELISA)before the surgery and on the day of the surgery respectively,and the postoperative complications were observed.Results:①There was statistical difference in incision length,operative time,intraoperative blood loss,hospital stay and fracture healing time between the 3 groups in general(7.96±0.85,2.11±0.56,12.13±3.94 cm,F=206.542,P=0.000;94.87±9.32,66.72±8.49,53.58±9.97 minutes,F=180.208,P=0.000;114.87±14.32,81.29±11.17,67.23±9.81 mL,F=189.815,P=0.000;10.17±2.47,7.38±1.88,6.08±1.69 days,F=47.207,P=0.000;5.85±1.17,5.16±1.02,4.30±0.89 months,F=25.429,P=0.000).The operative time,hospital stay and fracture healing time were shorter,and the intraoperative blood loss was less in percutaneous approach group and paraspinal approach group compared to posterior median approach group(P=0.000,P=0.000,P=0.002;P=0.000,P=0.000,P=0.000;P=0.000,P=0.000);and the operative time,hospital stay and fracture healing time were shortest,the intraoperative blood loss was least in paraspinal approach group(P=0.000,P=0.000,P=0.000;P=0.000).The incision length was shorter in percutaneous approach group compared to posterior median approach group and paraspinal approach group(P=0.000,P=0.000),and was longest in paraspinal approach group(P=0.000).②There was no statistical difference in APR and kyphotic Cobb angle of injured vertebrae and ODI between the 3 groups in general before the surgery(62.15±7.31,61.88±7.45,62.54±6.97%,F=0.094,P=0.910;22.15±1.77,21.88±1.55,21.68±1.38 degrees,F=0.970,P=0.382;35.62±2.32,36.37±2.57,35.98±2.11%,F=1.155,P=0.318);while the differences between the 3 groups at 3 months after the surgery were statistically significant(84.87±5.49,89.91±4.63,93.38±4.57%,F=34.192,P=0.000;7.55±1.13,6.43±1.19,5.69±1.05 degrees,F=28.234,P=0.000;5.25±1.33,4.53±1.17,3.82±1.12%,F=15.711,P=0.000).The APR of injured vertebrae was higher in percutaneous approach group and paraspinal approach group compared to posterior median approach group(P=0.000,P=0.000),and was highest in paraspinal approach group(P=0.000).The kyphotic Cobb angle of injured vertebrae was smaller in percutaneous approach group and paraspinal approach group compared to posterior median approach group(P=0.000,P=0.000),and was smallest in paraspinal approach group(P=0.002).The ODI was lower in percutaneous approach group and paraspinal approach group compared to posterior median approach group(P=0.008,P=0.000),and was lowest in paraspinal approach group(P=0.004).③There was no statistical difference in the serum levels of CK,Myo and LDH between the 3 groups in general before the surgery(160.87±21.32,162.41±22.57,161.53±20.97 unit/L,F=0.057,P=0.944;100.79±18.31,103.19±17.37,101.89±15.97 ng/mL,F=0.218,P=0.804;108.38±18.77,111.36±16.35,113.81±17.08 unit/L,F=1.095,P=0.337);while the differences between the 3 groups on the day of the surgery were statistically significant(352.77±57.73,254.39±42.53,251.08±44.62 unit/L,F=63.193,P=0.000;240.55±25.49,192.53±19.63,189.39±20.17 ng/mL,F=76.981,P=0.000;190.55±21.43,163.23±19.19,160.33±20.21 unit/L,F=31.292,P=0.000).The serum levels of CK,Myo and LDH were lower in percutaneous approach group and paraspinal approach group compared to posterior median approach group(P=0.000,P=0.000,P=0.000;P=0.000,P=0.000,P=0.000),while no statistical difference between percutaneous approach group and paraspinal approach group(P=0.728,P=0.456,P=0.487).After the surgery,the incision infection was found in 2 patients in posterior median approach group and percutaneous approach group respectively as well as 1 patient in paraspinal approach group;the lower extremity deep venous thrombosis in 2 patients in posterior median approach group and paraspinal approach group respectively as well as 1 patient in percutaneous approach group;and the breakage of internal fixators in 1 patient in posterior median approach group,percutaneous approach group and paraspinal approach group respectively.There was no statistical difference in complication incidences between the 3 groups(χ^(2)=0.170,P=0.918).Conclusion:PSRS internal fixation through paraspinal approach has such disadvantage as longer incision length,but advantages as less intraoperative blood loss,less injury and faster recovery compared to PSRS internal fixation via percutaneous approach and posterior median approach in treatment of thoracolumbar fractures,and it can be more conducive to the recovery of vertebral height and spinal function with high safety.
作者
姚明锋
蒋晖
潘育强
戴龚成
丁辉
YAO Mingfeng;JIANG Hui;PAN Yuqiang;DAI Gongcheng;DING Hui(The Third People’s Hospital of Anji County,Anji 313301,Zhejiang,China)
出处
《中医正骨》
2021年第10期16-22,共7页
The Journal of Traditional Chinese Orthopedics and Traumatology
关键词
脊柱骨折
胸椎
腰椎
骨折固定术
内
手术入路
spinal fractures
thoracic vertebrae
lumbar vertebrae
fracture fixation,internal
operative approach
