脊柱外科杂志  2024, Vol.22 Issue(3): 170-175   PDF    
后路短节段经皮椎弓根螺钉内固定术治疗胸腰椎骨折术中应用横连接的必要性
王越, 李良生, 陈建泉, 陈世杰, 王春, 陈恒梅     
福建医科大学附属闽东医院骨科,宁德 355000
摘要: 目的 探讨后路短节段经皮椎弓根螺钉内固定术治疗胸腰椎骨折术中应用横连接的必要性。方法 2019年1月—2021年12月收治胸腰椎骨折患者72例,所有患者均采用后路短节段经皮椎弓根螺钉内固定术治疗,其中37例应用横连接(横连接组),35例未应用横连接(对照组)。记录2组手术时间、术中出血量、住院时间及并发症发生情况。于术后即刻、3个月、12个月在X线片上测量伤椎局部Cobb角、伤椎前缘高度比,采用疼痛视觉模拟量表(VAS)评分评估疼痛程度,采用Oswestry功能障碍指数(ODI)评估脊柱功能。结果 所有手术顺利完成,所有患者随访时间 > 12个月。横连接组手术时间较对照组长,差异有统计学意义(P < 0.05)。2组术中出血量及住院天数差异均无统计学意义(P > 0.05)。2组各随访时间点伤椎局部Cobb角、伤椎前缘高度比、VAS评分及ODI较术前显著改善,差异均有统计学意义(P < 0.05);组间差异均无统计学意义(P > 0.05)。结论 短节段经皮椎弓根螺钉内固定可提供足够、可靠的稳定性,在该术式中联合应用横连接的临床价值较小。
关键词: 胸椎    腰椎    脊柱骨折    内固定器    
Necessity of using cross-link during posterior short segment percutaneous pedicle screw fixation for treatment of thoracolumbar fractures
Wang Yue, Li Liangsheng, Chen Jianquan, Chen Shijie, Wang Chun, Chen Hengmei     
Department of Orthopaedics, Mindong Hospital, Fujian Medical University, Ningde 355000, Fujian, China
Abstract: Objective To investigate the necessity of using cross-link during posterior short segment percutaneous pedicle screw fixation for treatment of thoracolumbar fractures. Methods From January 2019 to December 2021, 72 patients with thoracolumbar vertebral fractures were admitted. All the patients were treated with posterior short segment percutaneous pedicle screw fixation, with 37 cases using cross-link(cross-link group) and 35 did not using transverse connection(control group). Operation time, intraoperative blood loss, hospital stay and complications were recorded in 2 groups. The local Cobb angle of injured vertebra and the anterior edge height ratio of the injured vertebra were measured on roentgenograph immediately, 3 months and 12 months after surgery. The intensity of pain was assessed by visual analogue scale(VAS) score, and the spinal function was assessed by Oswestry disability index(ODI). Results All the operations were successfully completed, and the follow-up time of all patients was more than 12 months. The operation time of the cross-link group was higher than that of the control group, and the difference was statistically significant(P < 0.05). There was no significant difference in intraoperative blood loss and hospital stay between the 2 groups(P > 0.05). At each follow-up time point, the local Cobb angle of injured vertebra, the anterior edge height ratio of the injured vertebra, VAS score and ODI in 2 groups were significantly improved compared to those before surgery, and the differences were statistically significant(P < 0.05);there was no statistically significant difference between the 2 groups(P > 0.05). Conclusion Short segment percutaneous pedicle screw fixation can provide sufficient and reliable spinal stability, and the combined application of cross-link in this operation has little clinical value.
Key words: Thoracic vertebrae    Lumbar vertebrae    Spinal fractures    Internal fixators    

胸腰段是胸腰椎生理活动的交汇处,应力集中,易发生骨折,其骨折发生率占脊柱骨折的60% ~ 70%[1],其中爆裂性骨折占17%[2]。随着脊柱微创技术和设备的不断发展,对于无神经损伤的胸腰椎骨折患者可采用经伤椎置钉的短节段经皮椎弓根螺钉内固定术治疗,该术式具有切口小、出血量少、椎旁肌肉损伤小、患者术后恢复快等特点,其有效性和安全性已得到国内外脊柱外科医师的广泛认可[3-4]。无论是传统开放手术还是经皮椎弓根螺钉内固定术,都是通过增加对脊柱三柱的把持力提供稳定作用[1]。多项生物力学研究[5-10]证实,无论是长节段还是短节段内固定,联合应用横连接,理论上可将双侧钉棒连接成一个整体,从而进一步增加内固定的稳定性。目前,已有研究[11-12]证实横连接在长节段内固定中的临床应用价值,但横连接在短节段内固定中的应用,尤其是短节段经皮椎弓根螺钉内固定的相关研究较少[13]。基于此,本研究回顾性分析胸腰椎骨折患者的临床资料,探讨横连接在短节段经皮椎弓根螺钉内固定中的临床疗效及使用必要性,为胸腰椎骨折患者手术方式选择提供参考,现报告如下。

1 资料与方法 1.1 一般资料

纳入标准:①单节段胸腰椎骨折,无神经功能损伤;②骨折均由明确外伤因素所致;③胸腰椎损伤分类及严重程度(TLICS)评分[14]≥4分;④骨密度T值> -3.0。排除合并严重基础疾病无法耐受手术者。根据上述标准,2019年1月—2021年12月共收治胸腰椎骨折患者72例,所有患者均采用后路短节段经皮椎弓根螺钉内固定术治疗,其中37例应用横连接(横连接组;横连接为自主设计,专利号:CN201710455633.5、CN202120975176.4),35例未应用横连接(对照组)。2组患者术前基线资料差异无统计学意义(P > 0.05,表 1),具有可比性。本研究获本院伦理委员会审查批准(伦理审批号:2023041101K),所有患者术前均签署知情同意书。

表 1 2组患者基线资料 Tab. 1 Baseline data of 2 groups
1.2 手术方法及术后处理

对照组患者全身麻醉后取俯卧位,C形臂X线机透视标记伤椎及其上下相邻椎体椎弓根螺钉体表位置,常规消毒、铺巾,依次于定位处分别切开2 cm,首先在正位透视下刺入穿刺套针至椎弓根外上方(左侧为10点处,右侧为2点处),随后转为侧位透视,保持与矢状面呈5°、与冠状面呈5°置入,至椎体前1/3处拔出针芯,探查确认工作通道四壁及底部均为骨性通道,置入导针,依次拧入适当长度的螺钉(伤椎为多轴钉,其余为单轴钉),安装连接杆,先拧紧上位椎体螺钉尾帽,适当撑开椎间隙,接着拧紧下位椎体螺钉尾帽,最后拧紧伤椎螺钉尾帽,C形臂X线机透视证实伤椎高度恢复,椎弓根螺钉在位。冲洗创口,逐层缝合各切口,术毕。

横连接组患者全身麻醉后取俯卧位,术中先依次拆卸或折断长臂椎弓根螺钉的钉套延长臂,于中间的手术切口使用特制拉钩显露伤椎螺钉下方区域的连接棒,然后依次放置横连接夹块,使用特制的棘突打孔器在相应位置的棘间韧带或棘突处建立通道,利用连接杆持杆器将连接杆通过该通道安放于双侧夹块中,最后依次拧紧双侧夹块尾帽。其余操作同对照组。

术后密切监测患者生命体征,2组均给予止痛、抗感染等处理,定时翻身及踝泵训练,防止褥疮及下肢深静脉血栓形成。术后2 d在腰围辅助下下床活动,指导患者进行腰背肌功能锻炼,同时做好康复相关知识宣教。

1.3 观察指标

记录2组手术时间、术中出血量、住院时间及并发症发生情况。于术后即刻、3个月、12个月在X线片上测量伤椎局部Cobb角(伤椎上位椎体上终板连线与下位椎体下终板连线间的夹角)、伤椎前缘高度比(伤椎前缘实际高度与邻近上、下位椎体高度平均值的比值),采用疼痛视觉模拟量表(VAS)评分[15]评估疼痛程度,采用Oswestry功能障碍指数(ODI)[16]评估脊柱功能。

1.4 统计学处理

采用SPSS 25.0软件对数据进行统计分析。符合正态分布的计量资料以x±s表示,组间比较采用独立样本t检验或单因素方差分析,组内比较采用配对t检验;不符合正态分布的计量资料以中位数(下四分位数,上四分位数)表示,组间比较采用Mann-Whitney U检验或Kruskal-Wallis H检验,组内比较采用Wilcoxon秩和检验;计数资料以频数或百分比描述,组间比较采用χ2检验或Fisher精确概率检验;以P < 0.05为差异有统计学意义。

2 结果

所有手术顺利完成,所有患者随访时间 > 12个月,手术切口均甲级愈合,无神经、血管损伤等并发症发生,无钉道松动、螺钉退出、钉棒断裂等内固定失效并发症发生,均返院取出内固定。横连接组手术时间较对照组长,差异有统计学意义(P < 0.05,表 2)。2组术中出血量及住院时间差异均无统计学意义(P > 0.05,表 2)。2组各随访时间点、VAS评分、ODI、伤椎局部Cobb角及伤椎前缘高度比较术前改善,差异均有统计学意义(P < 0.05,表 2);组间差异均无统计学意义(P > 0.05,表 2)。2组典型病例影像学资料见图 12

表 2 2组临床疗效评估指标 Tab. 2 Evaluation index of clinical efficiency in 2 groups

图 1 横连接组典型病例影像学资料 Fig. 1 Imaging data of a typical case in cross-link group 女,52岁,L2爆裂性骨折,TLICS评分为4分  a:术前侧位X线片示L2楔形变  b:术前CT示骨折线累及中柱,骨折块突入椎管  c、d:术后正侧位X线片示内固定位置良好,伤椎高度和局部Cobb角均改善良好  e、f:术后CT示横连接杆的通道位于L2棘突下方  g:术后3个月侧位X线片示伤椎高度维持良好  h:术后12个月侧位X线片示伤椎高度维持良好,矫形无明显丢失 Female, 52 years old, L2 burst fracture, TLICS score is 4 a: Preoperative lateral roentgenograph shows L2 wedge-shaped b: Preoperative CT shows that fracture line involves middle column, and bone fracture mass protrudes into spinal canal c, d: Postoperative anteroposterior and lateral roentgenographs show good internal fixation position, with improved vertebral height and local Cobb angle e, f: Postoperative CTs show channel of cross-link rod is located below L2 spinous process g: Lateral roentgenograph at postoperative 3 months shows that height of injured vertebra is well maintained h: Lateral roentgenograph at postoperative 12 months shows that height of injured vertebra is well maintained without significant loss of correction

图 2 对照组典型病例影像学资料 Fig. 2 Imaging data of a typical case in control group 女,53岁,L2爆裂性骨折,TLICS评分为4分  a:术前侧位X线片示L2楔形变  b:术前CT示骨折块进入椎管,继发椎管狭窄  c、d:术后正侧位X线片示内固定位置良好,伤椎高度和局部Cobb角均改善良好  e:术后3个月侧位X线片示伤椎高度维持良好  f:术后12个月侧位X线片示伤椎高度未见明显丢失 Female, 53 years old, L2 burst fracture, TLICS score is 4 a: Preoperative lateral roentgenograph shows L2 wedge-shaped b: Preoperative CT shows that bone fracture mass enter spinal canal and secondary to spinal stenosis c, d: Postoperative anteroposterior and lateral roentgenographs show good internal fixation position, with improved vertebral height and local Cobb angle e: Lateral roentgenograph at postoperative 3 months shows that height of injured vertebra is well maintained f: Lateral roentgenograph at postoperative 12 months shows that height of injured vertebra is well maintained without significant loss of correction
3 讨论

随着微创脊柱外科的发展,经皮椎弓根螺钉内固定术治疗胸腰椎骨折受到广泛认可[3]。单椎体骨折采用后路短节段椎弓根螺钉内固定术治疗,可在重建脊柱序列的同时保留一定的脊柱活动度,被认为是一种理想术式[17]。相较于传统后路开放手术,经皮椎弓根螺钉内固定术具有创伤小、出血量少、手术时间短、患者术后恢复快等特点。但是,由于特殊的生理结构,胸腰段活动度较大,因此,对该节段行内固定时需要寻求更为稳定的内固定器械及更高的生物力学刚度和强度。椎弓根钉棒内固定系统通过对脊柱三柱的把持力提供稳定作用,生物力学研究[6-7]表明,应用横连接可将两边单独分开的钉棒系统连成一个类似“H”形的平行四边形,借助这种连接关系可提高结构轴向旋转的稳定性,从而使其能承受更多的压力,降低螺钉松动的发生率。此外,在长节段内固定中,由于应用第二个横连接对轴向稳定性具有附加效应,因此,认为应用2个横连接较1个效果更好[10-12]

在经皮椎弓根螺钉内固定术中,由于手术切口小、脊柱后部结构完整,因此,无法放置传统的横连接装置。为此,本研究团队在前期设计了微创横连接固定装置,在无须新增手术切口的情况下实现经皮横连接装置的放置,该横连接装置已通过生物力学测定[18]和伦理审查,并成功应用于各节段经皮椎弓根螺钉内固定术中。在经皮椎弓根螺钉内固定术中应用微创横连接装置,可在保持后中线解剖结构完整的同时提供固定节段额外的稳定性。Kyle等[13]在微创椎弓根螺钉内固定术中通过后路旁侧安装横连接,与本研究中微创横连接装置的设计理念相近。但也有学者认为,应用横连接虽然可以增加内固定系统在轴向旋转上的稳定性,但在前屈、后伸、侧曲中并没有稳定效果[19]。尸体生物力学研究[9]进一步发现,在短节段内固定中应用横连接可提高轴向旋转的刚度,但不能恢复不稳定爆裂性骨折模型中的基线稳定性,对于严重损伤,应用横连接不能替代前中柱重建和/或延长内固定节段。

本研究结果显示,2组患者术后伤椎局部Cobb角及伤椎前缘高度比均较术前显著改善,VAS评分及ODI明显降低,证实经伤椎置钉的短节段内固定术在胸腰椎骨折治疗中疗效可靠。此外,所有患者在术后12个月时均获得骨性愈合,随访过程中2组均未发生钉道松动、螺钉拔出或钉棒断裂等内固定并发症,间接说明是否放置横连接对于短节段经皮内固定的稳定性无显著影响。且横连接组的手术时间较长,手术费用也相对较高,因此,本研究组认为,采用经伤椎置钉的短节段椎弓根螺钉内固定术治疗胸腰椎骨折时,横连接的应用价值相对较小。推测原因可能为,单节段胸腰椎骨折采用短节段经皮椎弓根螺钉内固定且无须椎管减压,致使其脊柱后方结构保留完好,轴向旋转的稳定度较高,因此,安装横连接所增加的轴向旋转强度无法体现出其价值。还有研究[20-21]指出,在腰椎区域进行融合的患者中,特别是在手术区无严重不稳定的情况下,应放弃应用横连接,以减少内固定数量和手术费用。Han等[22]通过生物力学研究发现,应用横连接对单节段腰椎融合意义不大,对多节段腰椎融合价值较高。也有研究[23]表明,相较于跨伤椎置钉,经伤椎置钉对复位、矫形效果的维持程度明显更好,经伤椎置钉可提供更好的生物力学环境,维持伤椎高度,降低内固定失效的发生率[24],更有利于改善患者腰椎功能及疼痛状况[25]。但是,本研究结果也显示,术后3、12个月时2组伤椎局部Cobb角较术后即刻有所丢失,探究其原因可能与复位椎体出现“空壳”现象使伤椎生理性应力降低、椎弓根螺钉受力增加有关。申科律等[26]的研究发现,当亚洲人骨质疏松自我筛查工具(OSTA)指数≤1.9或术前椎体压缩率≥31.3%时,术后椎体高度丢失的发生率显著增高。但也有研究[27]显示,术后早期伤椎局部Cobb角的矫正轻度丢失并不影响胸腰椎骨折患者的临床疗效。

综上所述,短节段经皮椎弓根螺钉内固定术治疗单节段胸腰椎骨折可提供可靠的脊柱稳定性,无须联合应用横连接进一步提高稳定性,相反还会增加手术费用及手术时间。但本研究存在样本量较小、随访时间较短等局限性,所得结论尚需多中心、大样本量的长期研究进一步观察验证。

参考文献
[1]
Huang L, Xiong C, Guo Z, et al. Comparison of monoplanar and polyaxial screw fixation systems in percutaneous intermediate fixation for thoracolumbar fractures[J]. BMC Musculoskelet Disord, 2022, 23(1): 172. DOI:10.1186/s12891-022-05129-8
[2]
Pramod Patil R, Joshi V. Comparative study between short segment open versus percutaneous pedicle screw fixation with indirect decompression in management of acute burst fracture of thoracolumbar and lumbar spine with minimal neurological deficit in adults[J]. J Spine, 2016, 5(5): 1-5.
[3]
Sarkar B, Ifthekar S, Kandwal P, et al. Analysis of outcome of percutaneous versus open pedicle screw fixation in the treatment of thoraco-lumbar spine fractures: a prospective comparative study[J]. Int J Res Orthop, 2021, 7(2): 343-350. DOI:10.18203/issn.2455-4510.IntJResOrthop20210628
[4]
赵豪, 高山, 陈文恒, 等. 经伤椎与跨伤椎固定胸腰椎爆裂骨折的比较[J]. 中国矫形外科杂志, 2022, 30(22): 2039-2044.
[5]
王洪伟, 李长青, 周跃, 等. 脊柱骨折经伤椎椎弓根置钉附加横连短节段固定的稳定性测试[J]. 中国脊柱脊髓杂志, 2010, 20(9): 745-748. DOI:10.3969/j.issn.1004-406X.2010.09.12
[6]
Cornaz F, Fasser MR, Snedeker JG, et al. The biomechanical fundamentals of crosslink-augmentation in posterior spinal instrumentation[J]. Sci Rep, 2022, 12(1): 7621. DOI:10.1038/s41598-022-11719-2
[7]
Lehman RA Jr, Kang DG, Wagner SC, et al. Biomechanical stability of transverse connectors in the setting of a thoracic pedicle subtraction osteotomy[J]. Spine J, 2015, 15(7): 1629-1635. DOI:10.1016/j.spinee.2015.03.010
[8]
Hsieh MK, Liu MY, Tsai TT, et al. Biomechanical comparison of different numbers and configurations of cross-links in long-segment spinal fixation—an experimental study in a porcine model[J]. Global Spine J, 2023, 13(1): 25-32. DOI:10.1177/2192568221990646
[9]
Wahba GM, Bhatia N, Bui CN, et al. Biomechanical evaluation of short-segment posterior instrumentation with and without crosslinks in a human cadaveric unstable thoracolumbar burst fracture model[J]. Spine(Phila Pa 1976), 2010, 35(3): 278-285. DOI:10.1097/BRS.0b013e3181bda4e6
[10]
Kuklo TR, Dmitriev AE, Cardoso MJ, et al. Biomechanical contribution of transverse connectors to segmental stability following long segment instrumentation with thoracic pedicle screws[J]. Spine(Phila Pa 1976), 2008, 33(15): E482-E487. DOI:10.1097/BRS.0b013e31817c64d5
[11]
Wang T, Cai Z, Zhao Y, et al. The influence of cross-links on long-segment instrumentation following spinal osteotomy: afinite element analysis[J]. World Neurosurg, 2019, 123: e294-e302. DOI:10.1016/j.wneu.2018.11.154
[12]
苗红战, 王祥善, 王爱国. 双与单横连长节段固定治疗胸腰段骨折-脱位的比较[J]. 中国矫形外科杂志, 2017, 25(24): 2209-2212.
[13]
Kyle McGrath BS, Chris Karas MD. Minimally invasive cross-link: acadaveric feasibility study with a working prototype[J]. Am J Biomed Sci & Res, 2021, 12(3): 268-271.
[14]
Vaccaro AR, Lehman RA, Hurlbert R, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status[J]. Spine(Phila Pa 1976), 2005, 30(20): 2325-2333. DOI:10.1097/01.brs.0000182986.43345.cb
[15]
Huskisson EC. Measurement of pain[J]. Lancet, 1974, 2(7889): 1127-1131.
[16]
Fairbank JC, Couper J, Davies JB, et al. The Oswestry low back pain disability questionnaire[J]. Physiotherapy, 1980, 66(8): 271-273.
[17]
Choudhury AM, Alam MS, Saha MK, et al. Short segment pedicle screw fixation including fracture vertebrae for the management of unstable thoracolumbar burst fracture[J]. Mymensingh Med J, 2021, 30(2): 485-492.
[18]
高连云. 新型微创经皮椎弓根钉系统横连接的设计和生物力学研究[D]. 福州: 福建医科大学, 2013.
[19]
Cornaz F, Widmer J, Snedeker JG, et al. Cross-links in posterior pedicle screw-rod instrumentation of the spine: a systematic review on mechanical, biomechanical, numerical and clinical studies[J]. Eur Spine J, 2021, 30(1): 34-49. DOI:10.1007/s00586-020-06597-z
[20]
Tamer T, Engin T. Is it a requirement or a preference to use cross-links in lumbar instrumentation?[J]. J Surg Med, 2022, 6(12): 943-946. DOI:10.28982/josam.7446
[21]
Burkhard MD, Cornaz F, Spirig JM, et al. Posterior spinal instrumentation and decompression with or without cross-link?[J]. N Am Spine Soc J, 2021, 8: 100093.
[22]
Han L, Yang H, Li Y, et al. Biomechanical evaluation of the cross-link usage and position in the single and multiple segment posterior lumbar interbody fusion[J]. Orthop Surg, 2022, 14(10): 2711-2720. DOI:10.1111/os.13485
[23]
Kapoen C, Liu Y, Bloemers FW, et al. Pedicle screw fixation of thoracolumbar fractures: conventional short segment versus short segment with intermediate screws at the fracture level-a systematic review and meta-analysis[J]. Eur Spine J, 2020, 29(10): 2491-2504. DOI:10.1007/s00586-020-06479-4
[24]
郭钟义, 马俊, 黄亮亮, 等. 经伤椎置钉治疗胸腰椎骨折的研究进展[J]. 脊柱外科杂志, 2021, 19(4): 280-284. DOI:10.3969/j.issn.1672-2957.2021.04.013
[25]
路多, 代文杰, 李海涛, 等. 经伤椎置钉短节段内固定术治疗单节段胸腰椎骨折的临床疗效及术后并发症发生情况[J]. 脊柱外科杂志, 2020, 18(5): 321-324. DOI:10.3969/j.issn.1672-2957.2020.05.007
[26]
申科律, 计李超, 成茂华, 等. 胸腰椎骨折椎弓根螺钉内固定术后椎体高度再丢失的相关影响因素分析[J]. 中华创伤杂志, 2021, 37(11): 990-996. DOI:10.3760/cma.j.cn501098-20210629-00365
[27]
Perna A, Santagada DA, Bocchi MB, et al. Early loss of angular kyphosis correction in patients with thoracolumbar vertebral burst(A3-A4) fractures who underwent percutaneous pedicle screws fixation[J]. J Orthop, 2021, 24: 77-81. DOI:10.1016/j.jor.2021.02.029