多節(jié)段非相鄰型脊柱骨折的治療

1、多節(jié)段非相鄰型脊柱骨折的治療,潞河醫(yī)院脊柱外科袁鑫,概述,多節(jié)段非相鄰型脊柱骨折 (multiple- level noncontiguous spinal fractures, MNSF)定義：受傷后脊柱骨折多于一個(gè)節(jié)段, 且至少被一個(gè)正常節(jié)段所分隔。特點(diǎn)：損傷暴力大, 致傷機(jī)制復(fù)雜, 常合并其他損傷, 易漏診或延遲診斷，治療棘手。,發(fā)病率,國外報(bào)道：3.2%~23.8% [1]國內(nèi)報(bào)道：4.1%-6.9% [2] [3],1

2、. Powell JN, Waddell JP, Tucker WS, et al. Multiple- level none-continuous spinal fractures [J].J Trauma, 1989, 29 (8): 1146-1150.2.李康華, 王朝暉, 王錫陽, 等.多節(jié)段非相鄰型脊柱骨折的診治[J].中國修復(fù)重建外科雜志, 2005, 19(6): 424- 426.3.唐三元, 徐永

3、年, 陳莊洪, 等.多節(jié)段非相鄰型脊柱骨折[J].中國脊柱脊髓雜志, 1996, 6(6) : 247- 249.,分型,A 型:中間間隔 1 個(gè)正常節(jié)段且為 2 處骨折B型:中間間隔 2 個(gè)或 2 個(gè)以上正常節(jié)段且為 2 處骨折C 型:中間間隔 1 個(gè)或 1 個(gè)以上正常節(jié)段但為 3 處或 3 處以上骨折[1]Calenoff分型：依據(jù)損傷機(jī)制按照原發(fā)損傷及繼發(fā)損傷部位分為8個(gè)亞型[2],1.唐三元, 徐永年, 陳莊洪, 等.

4、多節(jié)段非相鄰型脊柱骨折[J].中國脊柱脊髓雜志, 1996, 6(6) : 247- 249.2. Calenoff L, Chessare JW, Rogers LF, Toerge J, Rosen JS. Multiple level spinal injuries:importance of early recognition.AJR Am J Roentgenol. 1978 Apr;130(4):665-9.,,骨折分型

5、評分 Denis分型 AO分型 TLICS評分 loading-share 評分,診斷,1、確定脊柱穩(wěn)定性2、確定關(guān)鍵損傷部位：即對脊髓產(chǎn)生最大損傷的椎體,以爆裂型骨折和骨折脫位為主3、次要損傷部位多為壓縮性骨折,黨洪勝,趙猛,嚴(yán)永祥,等.胸腰椎多節(jié)段脊柱骨折的診治分析[J].中國修復(fù)重建外科雜志, 2008, 22: 1441-1444.,治療,1、非手術(shù)治療：穩(wěn)定

6、型骨折應(yīng)采取保守治療, 根據(jù)骨折部位可采用支具外固定。 [1]2、手術(shù)治療：不穩(wěn)定骨折（AO分型 A2.3以上；Denis Ⅱ-Ⅳ型；TLICS評分≥7分）,非手術(shù)治療,● Closed reduction and casting is a safe and effective treatment for thoracolumbar and lumbar burst fractures.● Closed reduction may

7、relieve neurologic symptoms in patients with radiculopathy after burst fracture.● Reduction is better maintained in thoracolumbar fractures than in lumbar fractures.● Posterior ligamentous instability was associated wi

8、th poor pain and functional outcomes in this series.,Patrick Tropiano, MD,* Russel C. Huang, MD,? Christian A. Louis, MD,*Dominique G. Poitout, MD,* and Rene P. Louis, MDFunctional and Radiographic Outcome of Thoracolumb

9、ar and Lumbar Burst Fractures Managedby Closed Orthopaedic Reduction and Casting SPINE Volume 28, Number 21, pp 2459–2465 2003,手術(shù)方法,單純后路：單節(jié)段 短節(jié)段 長節(jié)段 是否傷椎置釘單純前路：經(jīng)椎間隙植骨 椎體次全切除植骨 固定OR不固定前后路聯(lián)合是否減壓,手術(shù)時(shí)機(jī),NTD

10、B records indicate that the majority of patients with spinal fractures undergo operative fixation within 3 days, and that these patients had less complications and required less resources [1]Patients with TL trauma sho

11、uld undergo early ( 72 hours) stabilization of their injury to reduce morbidity and possibly mortality [2],1.Kerwin AJ, Griffen MM, Tepas JJ 3rd, Schinco MA, Devin T, Frykberg ER. Best practice determination of timing o

12、f spinal fracture fixation as defined by analysis of the National Trauma Data Bank. J Trauma. 2008 Oct;65(4):824-30; discussion 830-12. Carlo Bellabarba, MD,* Charles Fisher, MD, MPH,? Jens R. Chapman, MD,*Joseph R. De

13、ttori, MPH, PhD,? and Daniel C. Norvell, PhDDoes Early Fracture Fixation of Thoracolumbar Spine Fractures Decrease Morbidity or Mortality?SPINE Volume 35, Number 9S, pp S138 –S145 2011,手術(shù)方式選擇,依據(jù)：患者骨質(zhì)質(zhì)量

14、單個(gè)椎體骨折類型 TLICS評分（大于4分） 載荷分享評分（大于等于7分） 神經(jīng)功能狀態(tài),,后路手術(shù)： 長節(jié)段：骨質(zhì)疏松 爆裂骨折尤其伴有旋轉(zhuǎn)或側(cè)方移位者[1] 短節(jié)段：椎體不完全爆裂 屈曲牽張型骨折 單節(jié)段：無嚴(yán)重骨質(zhì)疏松的單椎體骨折、脫位 壓縮性骨折中椎體壓縮小于 50% 爆裂骨折中 CT

15、矢狀片傷椎碎裂面積小于 30%，且椎弓根完整 一側(cè)終板損傷 載荷分享評分小于 5 分[2]前后路聯(lián)合：后路復(fù)位固定后載荷分享評分大于等于7分植骨融合：多數(shù)學(xué)者贊同植骨融合固定節(jié)段,1.Tezeren G，Kuru I. Postrior fixation of thoracolumbar burst fracture short -segment pedicle fixation versus long -segment int

16、rumentation[J]. J Spinal disord Tech，2005，18：485.2.曾忠友, 程新財(cái), 張建喬, 等. 經(jīng)傷椎置釘椎弓根螺釘系統(tǒng)單節(jié)段固定治療胸腰椎骨折的臨床探討 [J]. 脊柱外科雜志,2010, 8(3): 168-171.,,經(jīng)傷椎置釘短節(jié)段固定：減少懸掛效應(yīng)及四邊效應(yīng)，避免應(yīng)力集中，有助于糾正后凸及復(fù)位突入椎管骨塊。,宋元進(jìn)，孫海燕，王謙軍，等． 后路短節(jié)段固定結(jié)合傷椎固定經(jīng)椎弓根植骨治療胸腰

17、段骨折［J］． 中國矯形外科雜志，2010，2:110 －112．,,nonfusion method appears to be effective at achieving stability and sagittal alignment and for regaining motions of fixed segments.,Yong-Min Kim, MD, Dong-Soo Kim, MD, Eui-Sung Choi, MD

18、, Hyun-Chul Shon, MD, Kyoung-Jin Park, MD, Byung-Ki Cho, MD, Jae-Jung Jeong, MD, Young-Chan Cha, MD, and Ji-Kang Park, MDNonfusion Method in Thoracolumbar and Lumbar Spinal FracturesSPINE Volume 36, Number 2, pp 170–17

19、6 2011,,Operative treatment may result in improved kyphosis correction, but it does not appear to be associated with substantial benefits in long-term pain and function.,Sonali R. Gnanenthiran MBBS,Sam Adie BSc(Med), M

20、BBS, MSpMed MPH,Ian A. Harris MBBS, MMed(Clin Epid), PhD, FRACS(Orth)Nonoperative versus Operative Treatment for Thoracolumbar Burst Fractures Without Neurologic DeficitClin Orthop Relat Res (2012) 470:567–577 2012,,,

21、Nonsegmental posterior instrumentation has reported unacceptable rates of instrumentation failure when not accompanied by an anterior construct for stabilizing lumbar burst fractures Creating a segmental construct by u

22、sing pedicle screws at the level of the fracture increases construct stiffness for axial torsion stiffness,Andrew Mahar, MS,*? Choll Kim, MD, PhD,* Michelle Wedemeyer, BS,Lance Mitsunaga, BS,* Tim Odell, BS,? Bryce Johns

23、on, MD,* and Steven Garfin, MDShort-Segment Fixation of Lumbar Burst Fractures Using Pedicle Fixation at the Level of the FractureSPINE Volume 32, Number 14, pp 1503–1507 2007,,生物力學(xué)研究顯示，經(jīng)椎弓根螺釘固定時(shí)椎弓根提供了至少 60%的抗拔出力強(qiáng)度及