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

doi:10.19723/j.issn.1671-167X.2021.01.025

摘要/Abstract

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

侯国进,周方,田耘,姬洪全,张志山,郭琰,吕扬,杨钟玮,张雅文. 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[J]. 北京大学学报（医学版）, 2021, 53(1): 167-174.

HOU Guo-jin,ZHOU Fang,TIAN Yun,JI Hong-quan,ZHANG Zhi-shan,GUO Yan,LV Yang,YANG Zhong-wei,ZHANG Ya-wen. Risk factors of recurrent kyphosis in thoracolumbar burst fracture patients treated by short segmental pedicle screw fixation[J]. Journal of Peking University (Health Sciences), 2021, 53(1): 167-174.

图/表 7

图1

表1

表2

表3

表4

图2

图3

参考文献 31

[1]	Wood KB, Bohn D, Mehbod A. Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: A prospective, randomized study[J]. J Spinal Disord Tech, 2005,18:S15-S23. doi: 10.1097/01.bsd.0000132287.65702.8a pmid: 15699801
[2]	Rajasekaran S, Kanna RM, Shetty AP. Management of thoracolumbar spine trauma: An overview[J]. Indian J Orthop, 2015,49(1):72-82. doi: 10.4103/0019-5413.143914 pmid: 25593358
[3]	伍骥, 郑超, 黄蓉蓉. 重新认识胸腰段脊柱骨折的诊断和治疗[J]. 中国骨与关节杂志, 2016,5(6):401-404.
[4]	Pellise F, Barastegui D, Hernandez-Fernandez A, et al. Viability and long-term survival of short-segment posterior fixation in thoracolumbar burst fractures[J]. Spine J, 2015,15(8):1796-1803. doi: 10.1016/j.spinee.2014.03.012 pmid: 24642054
[5]	Lee MC, Solomito M, Patel A. Supine magnetic resonance imaging Cobb measurements for idiopathic scoliosis are linearly related to measurements from standing plain radiographs[J]. Spine(Phila Pa 1976), 2013,38(11):E656-E661. doi: 10.1097/BRS.0b013e31828d255d
[6]	Wang XY, Dai LY, Xu HZ, et al. Kyphosis recurrence after posterior short-segment fixation in thoracolumbar burst fractures[J]. J Neurosurg Spine, 2008,8(3):246-254. doi: 10.3171/SPI/2008/8/3/246 pmid: 18312076
[7]	Zou D, Li WS, Deng C, et al. The use of CT Hounsfield unit values to identify the undiagnosed spinal osteoporosis in patients with lumbar degenerative diseases[J]. Eur Spine J, 2019,28(8):1758-1766. doi: 10.1007/s00586-018-5776-9 pmid: 30306332
[8]	Sander AL, Laurer H, Lehnert T, et al. A clinically useful classification of traumatic intervertebral disk lesions[J]. AJR Am J Roentgenol, 2013,200(3):618-623. doi: 10.2214/AJR.12.8748 pmid: 23436852
[9]	McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures[J]. Spine, 1994,19(15):1741-1744. doi: 10.1097/00007632-199408000-00014 pmid: 7973969
[10]	Roy-Camille R, Saillant G, Mazel C. Plating of thoracic, thoracolumbar, and lumbar injuries with pedicle screw plates[J]. Orthop Clin North Am, 1986,17(1):147-159. pmid: 3945476
[11]	Cho DY, Lee WY, Sheu PC. Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short-segment pedicle screw fixation[J]. Neurosurgery, 2003,53(6):1354-1361. doi: 10.1227/01.neu.0000093200.74828.2f pmid: 14633301
[12]	Kim JY, Ryu DS, Paik HK, et al. Paraspinal muscle, facet joint, and disc problems: Risk factors for adjacent segment degeneration after lumbar fusion[J]. Spine J, 2016,16(7):867-875. doi: 10.1016/j.spinee.2016.03.010 pmid: 26970600
[13]	Furderer S, Wenda K, Thiem N, et al. Traumatic intervertebral disc lesion: Magnetic resonance imaging as a criterion for or against intervertebral fusion[J]. Eur Spine J, 2001,10(2):154-163. doi: 10.1007/s005860000238 pmid: 11345638
[14]	Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures: A five to seven years prospective randomized study[J]. J Bone Joint Surg Am, 2009,91(5):1033-1041. doi: 10.2106/JBJS.H.00510 pmid: 19411450
[15]	Kerttula LI, Serlo WS, Tervonen OA, et al. Post-traumatic findings of the spine after earlier vertebral fracture in young patients: clinical and MRI study[J]. Spine, 2000,25(9):1104-1108. doi: 10.1097/00007632-200005010-00011 pmid: 10788855
[16]	Chen JX, Xu DL, Sheng SR, et al. Risk factors of kyphosis recurrence after implant removal in thoracolumbar burst fractures following posterior short-segment fixation[J]. Int Orthop, 2016,40(6):1253-1260. doi: 10.1007/s00264-016-3180-9 pmid: 27116190
[17]	Alanay A, Acaroglu E, Yazici M, et al. Short-segment pedicle instrumentation of thoracolumbar burst fractures: does transpedicular intracorporeal grafting prevent early failure?[J]. Spine, 2001,26(2):213-217. doi: 10.1097/00007632-200101150-00017 pmid: 11154543
[18]	Jun DS, Shin WJ, An BK, et al. The relationship between the progression of kyphosis in stable thoracolumbar fractures and magnetic resonance imaging findings[J]. Asian Spine J, 2015,9(2):170-177. doi: 10.4184/asj.2015.9.2.170 pmid: 25901226
[19]	Mahar A, Kim C, Wedemeyer M, et al. Short-segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture[J]. Spine, 2007,32(14):1503-1507. doi: 10.1097/BRS.0b013e318067dd24 pmid: 17572619
[20]	魏富鑫, 刘少喻, 赵卫东, 等. 胸腰椎爆裂性骨折伤椎固定的生物力学研究[J]. 中华创伤骨科杂志, 2006,8(9):857-860.
[21]	Li K, Zhang W, Liu D, et al. Pedicle screw fixation combined with intermediate screw at the fracture level for treatment of thoracolumbar fractures: A meta-analysis[J]. Medicine (Baltimore), 2016,95(33):e4574. doi: 10.1097/MD.0000000000004574
[22]	Rajasekaran S, Maheswaran A, Aiyer SN, et al. Prediction of posterior ligamentous complex injury in thoracolumbar fractures using non-MRI imaging techniques[J]. Int Orthop, 2016,40(6):1075-1081. doi: 10.1007/s00264-016-3151-1 pmid: 26983409
[23]	唐一村, 林本丹, 林慰光, 等. X线片和CT影像对胸腰椎后方韧带复合体损伤的诊断意义[J]. 中国脊柱脊髓杂志, 2016,26(9):801-806.
[24]	Machino M, Yukawa Y, Ito K, et al. Posterior ligamentous complex injuries are related to fracture severity and neurological damage in patients with acute thoracic and lumbar burst fractures[J]. Yonsei Med J, 2013,54(4):1020-1025. doi: 10.3349/ymj.2013.54.4.1020 pmid: 23709440
[25]	McLain RF. The biomechanics of long versus short fixation for thoracolumbar spine fractures[J]. Spine(Phila Pa 1976), 2006,31(11 Suppl):S70-S79. doi: 10.1097/01.brs.0000218221.47230.dd
[26]	张阳, 张志成, 李放, 等. 后方韧带复合体损伤在胸腰段骨折患者评估中的意义[J]. 中国骨与关节杂志, 2016,5(6):425-428.
[27]	张亚军, 方礼明, 张军, 等. 经椎旁肌间隙短节段椎弓根钉固定治疗伴后方韧带复合体损伤的胸腰椎骨折[J]. 中华创伤骨科杂志, 2013,15(12):1049-1053.
[28]	何海潮, 吕晓强, 张永进. 短节段经皮微创与传统椎弓根螺钉内固定治疗伴后方韧带复合体损伤的胸腰椎骨折的比较[J]. 中国骨伤, 2016,29(4):329-334. doi: 10.3969/j.issn.1003-0034.2016.04.009
[29]	Parker JW, Lane JR, Karaikovic EE, et al. Successful shortsegment instrumentation and fusion for thoracolumbar spine fractures: A consecutive 41/ 2-year series[J]. Spine, 2000,25(9):1157-1170. doi: 10.1097/00007632-200005010-00018 pmid: 10788862
[30]	Rihn JA, Anderson DT, Harris E, et al. A review of the TLICS system: A novel, user-friendly thoracolumbar trauma classification system[J]. Acta Orthop, 2008,79(4):461-466. doi: 10.1080/17453670710015436 pmid: 18766477
[31]	Kaul R, Chhabra HS, Vaccaro AR, et al. Reliability assessment of AOSpine thoracolumbar spine injury classification system and thoracolumbar injury classification and severity score (TLICS) for thoracolumbar spine injuries: results of a multicentre study[J]. Eur Spine J, 2017,26(5):1470-1476. doi: 10.1007/s00586-016-4663-5 pmid: 27334493

Metrics

Viewed

Full text

Abstract

Cited

Shared

Discussed

Items	Load-sharing classification
Items	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°

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

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

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