多节段非相邻型脊柱骨折的治疗

多节段非相邻型脊柱骨折的治疗,潞河医院脊柱外科袁鑫,概述,多节段非相邻型脊柱骨折 (multiple- level noncontiguous spinal fractures, MNSF)定义：受伤后脊柱骨折多于一个节段, 且至少被一个正常节段所分隔。特点：损伤暴力大, 致伤机制复杂, 常合并其他损伤, 易漏诊或延迟诊断，治疗棘手。,发病率,国外报道：3.2%23.8% 1国内报道：4.1%-6.9% 2 3,1. Powell JN, Waddell JP, Tucker WS, et al. Multiple- level none-continuous spinal fractures J.J Trauma, 1989, 29 (8): 1146-1150.2.李康华, 王朝晖, 王锡阳, 等.多节段非相邻型脊柱骨折的诊治J.中国修复重建外科杂志, 2005, 19(6): 424- 426.3.唐三元, 徐永年, 陈庄洪, 等.多节段非相邻型脊柱骨折J.中国脊柱脊髓杂志, 1996, 6(6) : 247- 249.,分型,A 型:中间间隔 1 个正常节段且为 2 处骨折B型:中间间隔 2 个或 2 个以上正常节段且为 2 处骨折C 型:中间间隔 1 个或 1 个以上正常节段但为 3 处或 3 处以上骨折1Calenoff分型：依据损伤机制按照原发损伤及继发损伤部位分为8个亚型2,1.唐三元, 徐永年, 陈庄洪, 等.多节段非相邻型脊柱骨折J.中国脊柱脊髓杂志, 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 评分 Denis分型 AO分型 TLICS评分 loading-share 评分,诊断,1、确定脊柱稳定性2、确定关键损伤部位：即对脊髓产生最大损伤的椎体,以爆裂型骨折和骨折脱位为主3、次要损伤部位多为压缩性骨折,党洪胜,赵猛,严永祥,等.胸腰椎多节段脊柱骨折的诊治分析J.中国修复重建外科杂志, 2008, 22: 1441-1444.,治疗,1、非手术治疗：稳定型骨折应采取保守治疗, 根据骨折部位可采用支具外固定。 12、手术治疗：不稳定骨折（AO分型 A2.3以上；Denis -型；TLICS评分7分）,非手术治疗, Closed reduction and casting is a safe and effective treatment for thoracolumbar and lumbar burst fractures. Closed reduction may 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 with 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 Thoracolumbar and Lumbar Burst Fractures Managedby Closed Orthopaedic Reduction and Casting SPINE Volume 28, Number 21, pp 24592465 2003,手术方法,单纯后路：单节段 短节段 长节段 是否伤椎置钉单纯前路：经椎间隙植骨 椎体次全切除植骨 固定OR不固定前后路联合是否减压,手术时机,NTDB 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 1Patients with TL trauma should 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 of 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. Dettori, 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,手术方式选择,依据：患者骨质质量 单个椎体骨折类型 TLICS评分（大于4分） 载荷分享评分（大于等于7分） 神经功能状态,后路手术： 长节段：骨质疏松 爆裂骨折尤其伴有旋转或侧方移位者1 短节段：椎体不完全爆裂 屈曲牵张型骨折 单节段：无严重骨质疏松的单椎体骨折、脱位 压缩性骨折中椎体压缩小于 50% 爆裂骨折中 CT 矢状片伤椎碎裂面积小于 30%，且椎弓根完整 一侧终板损伤 载荷分享评分小于 5 分2前后路联合：后路复位固定后载荷分享评分大于等于7分植骨融合：多数学者赞同植骨融合固定节段,1.Tezeren G，Kuru I. Postrior fixation of thoracolumbar burst fracture short -segment pedicle fixation versus long -segment intrumentationJ. J Spinal disord Tech，2005，18：485.2.曾忠友, 程新财, 张建乔, 等. 经伤椎置钉椎弓根螺钉系统单节段固定治疗胸腰椎骨折的临床探讨 J. 脊柱外科杂志,2010, 8(3): 168-171.,经伤椎置钉短节段固定：减少悬挂效应及四边效应，避免应力集中，有助于纠正后凸及复位突入椎管骨块。,宋元进，孙海燕，王谦军，等 后路短节段固定结合伤椎固定经椎弓根植骨治疗胸腰段骨折J 中国矫形外科杂志，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, 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 170176 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), MBBS, 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) 470:567577 2012,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 using 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 Johnson, MD,* and Steven Garfin, MDShort-Segment Fixation of Lumbar Burst Fractures Using Pedicle Fixation at the Level of the FractureSPINE Volume 32, Nu