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北京大学学报（医学版） ›› 2021, Vol. 53 ›› Issue (1): 167-174. doi: 10.19723/j.issn.1671-167X.2021.01.025

• 论著 • 上一篇    下一篇

后路短节段跨伤椎椎弓根螺钉固定治疗胸腰段爆裂骨折术后再发后凸的危险因素

侯国进,周方(),田耘,姬洪全,张志山,郭琰,吕扬,杨钟玮,张雅文   

  1. 北京大学第三医院骨科, 北京 100191
  • 收稿日期:2020-03-31 出版日期:2021-02-18 发布日期:2021-02-07
  • 通讯作者: 周方 E-mail:zhouf@bjmu.edu.cn
  • 基金资助:
    北京大学第三医院临床重点项目(BYSY2017014)

Risk factors of recurrent kyphosis in thoracolumbar burst fracture patients treated by short segmental pedicle screw fixation

HOU Guo-jin,ZHOU Fang(),TIAN Yun,JI Hong-quan,ZHANG Zhi-shan,GUO Yan,LV Yang,YANG Zhong-wei,ZHANG Ya-wen   

  1. Department of Orthopaedic Surgery, Peking University Third Hospital, Beijing 100191, China
  • Received:2020-03-31 Online:2021-02-18 Published:2021-02-07
  • Contact: Fang ZHOU E-mail:zhouf@bjmu.edu.cn
  • Supported by:
    Key Clinical Projects of Peking University Third Hospital(BYSY2017014)

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摘要：

目的: 探索后路短节段跨伤椎椎弓根螺钉固定治疗胸腰段爆裂骨折内固定物取出术后再发后凸的危险因素。方法: 回顾性分析北京大学第三医院2010年1月至2017年12月诊治的无神经功能损害的单节段胸腰段爆裂骨折患者的临床资料,共有144例患者纳入该研究。所有患者均采用跨伤椎椎弓根螺钉固定,其中男性74例,女性70例;平均年龄(39.1±13.2)岁。伤椎分布在T12(42例)、L1(72例)和L2(30例),骨折类型为A3(90例)、B1(25例)和B2(29例)。根据取出内固定物后末次随访矫正度丢失是否>5°,将患者分为再发后凸组和无再发后凸组,再发后凸组共纳入92例,无再发后凸组共纳入52例。利用SPSS 26.0软件进行单因素组间比较及Logistic回归分析。结果: 平均随访时间28(20~113)个月,分别于术前、术后3 d、术后12个月及末次随访对患者影像学指标进行测量并对比分析。伤椎前缘高度、局部后凸角、伤椎楔形角、Gardner畸形等指标术后较术前均有明显改善(P<0.05),但在术后1年随访时均有不同程度的丢失;伤椎前缘高度和伤椎楔形角不再因取钉发生变化,而局部后凸角和Gardner畸形在取钉术后仍出现后凸加重(P<0.05);伤椎上、下椎间盘高度随访过程中出现不同程度的塌陷。单因素分析可见,再发后凸组和无再发后凸组患者的性别、年龄(36.9岁 vs. 43.0岁)、上位椎间盘损伤与否、CT值(174 vs. 160)、术前节段后凸角(16.6° vs. 13.3°)、术前伤椎楔形角(16.7° vs. 13.6°)、术前Gardner畸形(19.1° vs. 15.2°)及术前椎体前缘的高度比(0.65 vs. 0.71)差异具有统计学意义(P<0.05)。Logistics回归分析提示,男性(OR: 2.88,95%CI:1.196~6.933)、上位椎间盘损伤(OR: 2.962,95%CI:1.062~8.258)及术前伤椎楔形角是短节段跨伤椎椎弓根螺钉固定治疗胸腰段爆裂骨折取出内固定物后再发后凸的危险因素(P<0.05)。结论: 胸腰段骨折患者经后路短节段跨伤椎内固定能取得满意的术后即刻效果,但随访过程中可能会发生一定程度的矫正角度丢失,男性、上位椎间盘损伤及术前伤椎楔形角是内固定物取出后再发后凸的危险因素。

关键词: 脊柱骨折, 骨折固定术, 内, 椎弓根螺钉, 脊柱后凸, 危险因素

Abstract:

Objective: To analyze the risk factors of recurrent kyphosis after removal of short segmental pedicle screw fixation in patients with thoracolumbar burst fractures.Methods: Retrospective analysis was conducted of 144 cases of thoracolumbar burst fractures without neurological impairment treated in Peking University Third Hospital from January 2010 to December 2017. There were 74 males and 70 females, with an average age of (39.1±13.2) years. The distribution of the injured vertebrae was T12: 42, L1: 72 and L2: 30, with fracture types of A3: 90, B1: 25 and B2: 29. The patients were divided into two groups: Recurrent kyphosis group (n=92) and non-recurrent kyphosis group (n=52). SPSS 26.0 software was used for univariate analysis and Logistic regression analysis.Results: The average follow-up time was 28 (20-113) months. The imaging indexes of pre-operation, 3 days post-operation, 12 months post-operation and the last follow-up were measured and compared. Anterior vertebral body height, segmental kyphosis, vertebral wadge angle and Gardner deformity were significantly improved after operation (P<0.05), and there were some degrees of loss in the 1-year follow-up; anterior vertebral body height and vertebral wadge angle were no longer changed after the removal of the screws; however, segmental kyphosis and Gardner deformity were still aggravated after the removal of the screws (P<0.05). There were some degrees of collapse of the height of the upper and lower discs during the follow-up. Univariate analysis showed that there were statistically significant differences (P<0.05) between the two groups in gender, age (36.9 years vs. 43.0 years), upper disc injury, CT value (174 vs. 160), segmental kyphosis (16.6° vs. 13.3°), vertebral wadge angle (16.7° vs. 13.6°), Gardner deformity (19.1° vs. 15.2°) and ratio of anterior vertebral body height (0.65 vs. 0.71). Logistic regression analysis showed that male (OR: 2.88, 95%CI: 1.196-6.933), upper disc injury (OR: 2.962, 95%CI: 1.062-8.258) and injured vertebral wedge angle were risk factors of recurrent kyphosis after removal of internal fixation for thoracolumbar burst fracture (P<0.05).Conclusion: The patients with thoracolumbar burst fracture can obtain satisfactory effect immediately after posterior short segmental pedicle screw fixation, however, there may be some degree of loss during the follow-up. Male, upper disc injury and injured vertebral wedge angle are the risk factors of recurrent kyphosis after removal of internal fixation for thoracolumbar burst fracture.

Key words: Spinal fracture, Fracture fixation, internal, Pedicle screws, Kyphosis, Risk factors

中图分类号: 

  • R683.2

图1

侧位X线片测量指标"

表1

胸腰段脊柱骨折的载荷分享评分"

Items Load-sharing classification
1 2 3
Comminution (by CT) <30% 30%-60% >60%
Apposition of fragments (by CT) <1 mm ≥2 mm, displacement of
<50% cross section of body		 >2 mm, displacement of
>50% cross section of body
Reducibility of sagittal deformation (by X-ray) <4° 4°-9° >9°

表2

不同时期各指标的测量结果(x-±s)"

Variables Pre-operation 3 d after operation 12 months after operation Last follow-up
Ratio of anterior height 0.67±0.11 0.93±0.09 0.90±0.09 0.89±0.08
Ratio of posterior height 0.89±0.08 0.97±0.04 0.96±0.05 0.94±0.12
Ratio of discs height 0.89±0.13 0.90±0.13 0.86±0.10 0.82±0.15
Segmental kyphosis/(°) 15.4±7.3 6.7±6.9 9.5±7.7 13.4±8.6
Vertebral wage angle/(°) 15.6±4.7 7.2±3.5 8.4±3.7 8.7±3.5
Gardner deformity/(°) 17.7±6.2 8.7±4.7 11.5±5.7 13.8±5.6
Upper intervertebral angle/(°) -2.5±2.9 -4.2±2.9 -2.5±2.9 0.1±3.1
Lower intervertebral angle/(°) -5.9±2.4 -5.5±2.6 -5.0±2.0 -3.9±2.4

表3

再发后凸组及无再发后凸组患者的一般资料比较"

Variables Non-recurrent kyphosis (n=52) Recurrent kyphosis (n=92) Statistics P value
Gender (Male/Female) 18/34 56/36 χ2=9.167 0.002
Age/years 43.0±13.1 36.9±12.7 t=2.764 0.006
Body mass index 24.1±3.4 23.9±3.5 t=0.397 0.692
Location (T12/L1/L2) 12/30/10 30/42/20 χ2=2.098 0.350
Type of fracture (A3/B1/B2) 36/8/8 54/17/21 χ2=1.687 0.430
Disc injury (No/Uncertain/Yes) 16/16/20 16/10/66 χ2=16.122 <0.001
PLC injury (No/Yes) 36/16 54/38 χ2=1.573 0.210
Load-sharing classification 5.5(4.0-7.0) 6.0(4.0-8.0) Z=1.699 0.089
CT value 160.7±40.6 174.4±35.2 t=-2.031 0.045
SK pre-operation/(°) 13.3±7.6 16.6±6.9 t=-2.611 0.010
VWA pre-operation/(°) 13.6±4.7 16.7±4.4 t=-4.080 <0.001
Gardner deformity pre-operation/(°) 15.2±5.8 19.1±6.0 t=-3.800 <0.001
UIVA pre-operation/(°) -2.8±2.3 -2.4±3.3 t=-0.789 0.431
LIVA pre-operation/(°) -5.9±2.4 -5.9±2.5 t=-0.021 0.983
A% pre-operation 0.71±0.13 0.65±0.09 t=2.520 0.014
P% pre-operation 0.91±0.08 0.89±0.08 t=1.529 0.128
Ratio of upper/lower discs height 0.91±0.13 0.89±0.13 t=0.702 0.484
Vertebral height restoration/% 0.24±0.14 0.27±0.10 t=-1.402 0.163

表4

术后再发后凸的危险因素Logistics回归分析结果"

Variables Regression coefficient SE Wald χ2 P OR 95%CI
Gender (Male/Female) 1.058 0.448 5.565 0.018 2.880 1.196-6.933
Upper disc injury (No/Uncertain/Yes) 24.789 <0.001
Uncertain vs. No -2.437 0.767 10.100 0.001 0.087 0.019-0.393
Yes vs. No 1.086 0.523 4.309 0.038 2.962 1.062-8.258
VWA pre-operation 0.283 0.063 19.874 <0.001 1.327 1.172-1.503
Constant -4.321 0.984 19.281 <0.001 0.013

图2

典型病例1(男性,54岁,T12爆裂骨折)"

图3

典型病例2(女性,53岁,T12爆裂骨折)"

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