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Title: [The effect of the sequence of intermediate instrumentation and distraction-reduction of the fractured vertebrae on the surgical treatment of mild to moderate thoracolumbar burst fractures].
Author: Zhang G, Li P, Qi C, Wang P, Wang J, Duan Y.
Journal: Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi; 2022 May 15; 36(5):600-608. PubMed ID: 35570635.
Abstract:
OBJECTIVE: To investigate the effect of the sequence of intermediate instrumentation with long screws and distraction-reduction on mild to moderate thoracolumbar fractures treated by posterior open and short-segmental fixation. METHODS: The clinical data of 68 patients with mild to moderate thoracolumbar burst fractures who met the selection criteria between January 2016 and June 2019 were retrospectively analyzed. The patients were divided into group ISDRF (intermediate screws then distraction-reduction fixation, 32 cases) and group DRISF (distraction-reduction then intermediate screws fixation, 36 cases) according to the different operation methods. There was no significant difference between the two groups in age, gender, body mass index, fracture segment, cause of injury, and preoperative load-sharing classification score, thoracolumbar injury classification and severity score, vertebral canal occupational rate, back pain visual analogue scale (VAS) score, anterior height of fractured vertebra, and Cobb angle ( P>0.05). The operation time, intraoperative blood loss, complications, and fracture healing time were recorded and compared between the two groups. The vertebral canal occupational rate, anterior height of fractured vertebra, kyphosis Cobb angle, and back pain VAS score before and after operation were used to evaluate the effectiveness. RESULTS: There was no significant difference in intraoperative blood loss and operation time between the two groups ( P>0.05). No vascular or spinal nerve injury and deep infections or skin infections occurred in both groups. At 1 week after operation, the vertebral canal occupational rate in the two groups was significantly improved when compared with that before operation ( P<0.05), no significant difference was found in the difference of vertebral canal occupational rate before and after operation and improvement between the two groups ( P>0.05). The patients in both groups were followed up 18-24 months, with an average of 22.3 months. All vertebral fractures reached bone union at 6 months postoperatively. At last follow-up, there was no internal fixation failures such as broken screws, broken rods or loose screws, but there were 2 cases of mild back pain in the ISDRF group. The intra-group comparison showed that the back pain VAS score, the anterior height of fractured vertebra, and the Cobb angle of the two groups were significantly improved at each time point postoperatively ( P<0.05); the VAS scores at 12 months postoperatively and last follow-up were also improved when compared with that at 1 week postoperatively ( P<0.05). At last follow-up, the anterior height of fractured vertebra in the ISDRF group was significantly lost when compared with that at 1 week and 12 months postoperatively ( P<0.05), the Cobb angle had a significant loss when compared with that at 1 week postoperatively ( P<0.05); the anterior height of fractured vertebra and Cobb angle in DRISF group were not significantly lost when compared with that at 1 week and 12 months postoperatively ( P>0.05). The comparison between groups showed that there was no significant difference in the remission rate of VAS score between the two groups at 1 week postoperatively ( P>0.05), the recovery value of the anterior height of fractured vertebra in ISDRF group was significantly higher than that in DRISF group ( P<0.05), the loss rate at last follow-up was also significantly higher ( P<0.05); the correction rate of Cobb angle in ISDRF group was significantly higher than that in DRISF group at 1 week postoperatively ( P<0.05), but there was no significant difference in the loss rate of Cobb angle between the two groups at last follow-up ( P>0.05). CONCLUSION: In the treatment of mild to moderate thoracolumbar burst fractures with posterior short-segment fixation, the instrumentation of long screws in the injured vertebrae does not affect the reduction of the fracture fragments in the spinal canal. DRISF can better maintain the restored anterior height of the fractured vertebra and reduce the loss of kyphosis Cobb angle during the follow-up, indicating a better long-term effectiveness. 目的: 探讨后路切开短节段内固定治疗轻中度胸腰椎爆裂骨折时，伤椎植入长螺钉与撑开复位的先后次序对手术疗效的影响。. 方法: 回顾分析2016年1月—2019年6月收治且符合选择标准的68例轻中度胸腰椎爆裂骨折患者临床资料，根据治疗方式分为先伤椎植钉再钉棒撑开复位内固定（intermediate screws then distraction-reduction fixation，ISDRF）组（32例）以及先钉棒撑开复位再伤椎植钉内固定（distraction-reduction then intermediate screws fixation，DRISF）组（36例）。两组患者年龄、性别、身体质量指数、骨折节段、致伤原因及术前载荷分享评分、胸腰椎损伤分型和严重评分、椎管侵占率、背部疼痛视觉模拟评分（VAS）、伤椎前缘高度、Cobb角等一般资料比较差异无统计学意义（ P>0.05）。记录并比较两组患者手术时间、术中出血量、并发症发生情况及骨折愈合时间；手术前后采用椎管侵占率、伤椎前缘高度、后凸Cobb角和背部VAS评分评价患者疗效。. 结果: 两组患者手术时间和术中出血量比较差异均无统计学意义（ P>0.05）；术中均未出现血管、脊髓神经损伤，术后无切口深部感染及皮肤感染等并发症发生。术后1周两组椎管侵占率均较术前明显改善（ P<0.05），两组间比较手术前后椎管侵占率差值及改善率差异均无统计学意义（ P>0.05）。两组患者均获随访，随访时间18～24个月，平均22.3个月。术后6个月两组患者骨折均愈合。末次随访时，两组均未出现断钉、断棒等内固定物松动并发症；ISDRF组2例患者在内固定物取出后出现轻度背痛。组内比较显示，术后各时间点两组患者背痛VAS评分、伤椎前缘高度及Cobb角均较术前明显改善（ P<0.05），术后12个月及末次随访时两组背痛VAS评分较术后1周亦有改善（ P<0.05）；末次随访时ISDRF组伤椎前缘高度较术后1周及12个月均有显著丢失（ P<0.05），Cobb角较术后1周时有显著丢失（ P<0.05）；DRISF组伤椎前缘高度及Cobb角较术后1周及12个月时均无明显丢失（ P>0.05）。组间比较显示，两组术后1周VAS评分缓解率差异无统计学意义（ P>0.05）；术后1周ISDRF组伤椎前缘高度恢复值显著高于DRISF组（ P<0.05），末次随访时丢失率亦显著高于DRISF组（ P<0.05）；术后1周ISDRF组Cobb角矫正率显著高于DRISF组（ P<0.05），但末次随访时两组Cobb角丢失率比较差异无统计学意义（ P>0.05）。. 结论: 后路短节段内固定治疗轻中度胸腰椎爆裂骨折时，伤椎植入长螺钉不影响椎管内骨折块复位；DRISF术后能更好地维持恢复的伤椎前缘高度，减少后凸Cobb角的随访丢失，远期疗效更佳。.

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