應(yīng)用AF系統(tǒng)后柱加壓法治療胸腰椎非Chance骨折

1、應(yīng)用AF系統(tǒng)后柱加壓法治療胸腰椎非Chance骨折    【關(guān)鍵詞】  胸腰椎骨折    摘要：目的探討應(yīng)用AF系統(tǒng)后柱加壓法治療脊柱后突角過大等特殊情況下非Chance骨折的可行性。方法對86例非Chance骨折常規(guī)置入椎弓根螺釘后，安裝并旋轉(zhuǎn)正反螺紋套筒，使后柱加壓，促使骨折復(fù)位，復(fù)位后安裝螺帽及橫連桿。結(jié)果術(shù)后傷椎前緣高度恢復(fù)至(9921±714)，Cobb's角恢復(fù)至(-503±639)°，與術(shù)前相比，均有顯著差異(P<001及P<005)；爆裂性骨折椎體后

2、緣高度恢復(fù)至(9919±073)，均較術(shù)前有所恢復(fù)，但統(tǒng)計分析無明顯差別(P>005)。結(jié)論應(yīng)用AF系統(tǒng)后柱加壓法是治療特殊情況下非Chance骨折的有效方法，治療效果滿意，對一般的骨折脫位同樣適用。關(guān)鍵詞： 胸腰椎骨折；AF；內(nèi)固定Treatment of thoracic and lumbar vertebrae nonChance fracture with posterior column compression technique of Arias Fixator systemAbstract：ObjectiveTo investigate the feasibili

3、ty of posterior column compression technique with Atlas Fixator system (AF) for treatment of nonChance factures of special cases like overlarger kyphosis angle.MethodA total of 86 cases of nonChance fractures were instrumented with pedicel screw system generally. The positive and negative threaded s

4、leeve were installed and circumrotated to obtain the compressed posterior column and reduction, then the screw cap was installed.ResultThe anterior edge height of the fractured vertebrae was restored to (99.21 ± 7.14)% postoperatively, there was a significant difference ( P < 0.01 ) compared

5、 with the preoperative radiographic evaluation. For the collapsed fractures, the posterior edge height of the vertebrae body was restored to (99.19 ± 0. 73 ) %, demonstrating improvement compared with preoperative instance, but was not significant statistically ( P > 0.05 ). The Cobb' an

6、gle was restored to (-5.03 ± 6.39 ) degrees, which also had a significant difference compared with preoperative evaluation.ConclusionThe posterior column compression technique with AF system is applicable for treatment of nonChance fractures in special cases, it's also available for common

7、vertebrae fracture or dislocation and could obtain satisfying prognosis.Key words Thoracic and lumbar vertebrae fracture; Atlas Fixator (AF) system;        Internal fixationAF(atlas fixator)系統(tǒng)治療胸腰椎骨折因其結(jié)構(gòu)簡單、調(diào)節(jié)方便、準(zhǔn)確有效，使植入手術(shù)大為簡化，故在臨床上得到了較為廣泛的應(yīng)用。按設(shè)計者的要求，對于Chance骨折，采用后柱

8、加壓法復(fù)位，其它類型骨折一般采用后柱撐開法復(fù)位1、2。在使用AF系統(tǒng)過程中，對于非Chance骨折，有時因椎體前緣壓縮嚴(yán)重，后凸角較大，或因條件所限在非透視下植入螺釘時SSA角矢狀面螺絲釘植入角度負(fù)角過大，致使螺栓套入困難，或雖勉強(qiáng)套入而無繼續(xù)撐開余地。在此情況下，作者嘗試用后柱加壓法治療非Chance骨折，亦取得了良好效果，報道如下。1  臨床資料11  一般資料本組86例，男59例，女27例。年齡1765歲，平均35歲。(1)骨折類型：爆裂性骨折42例，屈曲壓縮性骨折38例，骨折伴前脫位6例；(2)損傷部位，T116例，T12 31例，L1 35例，L3 3例；(3)致

9、傷原因：高處墜落傷34例，重物砸傷47例，車禍傷5例；(4)影像學(xué)檢查：術(shù)前X線片上測量傷椎前后緣高度、后突角、脫位程度(表1)，從CT片測量椎管受壓指數(shù)(按wolter法將椎管橫斷面分成3等分，并用0、1、2、3表示其狹窄或受堵的指數(shù)，椎管無狹窄或無受堵者指數(shù)為0，椎管受壓或狹窄占橫斷面13者指數(shù)為1，占23者指數(shù)為2，椎管完全受壓或完全受堵者為3)，指數(shù)為0者18例，為1者24例，2者36例，3者8例；(5)脊髓損傷按Frankel分級評定(表2)；(6)手術(shù)時間：傷后4 h30d，平均6d。12 手術(shù)方法在局麻、硬膜外麻醉或全麻下，取俯臥位，胸部兩側(cè)及兩髂嵴處墊高，以傷椎為中心取后正中切

10、口，常規(guī)剝離椎旁肌，暴露棘突、椎板、關(guān)節(jié)突及橫突等結(jié)構(gòu)。確定椎體次序后，于傷椎上下相鄰椎體兩側(cè)按Weinstein法或乳突定位法確定進(jìn)針點(diǎn)，依次擰入4枚椎弓根螺釘。螺釘方向：一般可使TSA角水平面螺絲釘植入角度呈1015°，腰椎SSA呈0°，而胸椎因椎弓根的f角在T912為+9+23°，按照正確螺釘孔道唯一性原則2，宜使SSA角呈-10-20°3。根據(jù)傷情及術(shù)前評估，估計間接減壓不能徹底，需開放椎管減壓者，則先切除椎板減壓，并用神經(jīng)剝離子保護(hù)脊髓、神經(jīng)根，向一側(cè)牽拉，探查椎管前壁，將突向椎管內(nèi)的碎骨塊向前推壓或沖擊復(fù)位。術(shù)中注意切除范圍，不能損傷小關(guān)節(jié)突。調(diào)節(jié)AF正反螺紋套筒及角度螺栓至合適長度，將螺釘尾部套入螺栓孔，旋轉(zhuǎn)正反螺紋套筒，使后柱加壓，則螺釘前端呈扇形張開，帶動椎體撐開復(fù)位。關(guān)于術(shù)中復(fù)位情況的判斷，因本組病例手術(shù)均在非透視下完成，一般以上下螺栓距離最小或已復(fù)位完全，棘突靠攏，套筒不能再轉(zhuǎn)動時作為復(fù)位完成的標(biāo)準(zhǔn)。復(fù)位后旋緊球面螺帽，使螺釘進(jìn)一步呈扇形運(yùn)動，糾正殘余移位或稍矯枉過正，最后安裝橫連桿及鎖固螺帽。復(fù)位后椎管已打開的再次探查，明確有無未復(fù)位的殘余骨塊。需植骨的行橫突間植骨融合。硬膜外放置明膠海綿，置橡皮管負(fù)壓引流，術(shù)后2448 h內(nèi)拔除。臥床鍛煉4