经Wiltse入路支点复位技术治疗AO-A型胸腰段骨折的临床研究

Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures

干军温 , ^1, ^2, ^* 帝钦江 , ¹ 植森周 , ¹ 范文滕 , ¹ and 云芳赵 ¹

干军温

东莞市东部中心医院骨科（广东东莞 523573）, Department of Orthopedics, Dongguan East Central Hospital, Dongguan Guangdong, 523573, P. R. China 广州中医药大学第一临床医学院（广州 510405）, The First Clinical Medical College of Guangzhou University of Traditional Chinese Medicine, Guangzhou Guangdong, 510405, P. R. China

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帝钦江

东莞市东部中心医院骨科（广东东莞 523573）, Department of Orthopedics, Dongguan East Central Hospital, Dongguan Guangdong, 523573, P. R. China

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植森周

东莞市东部中心医院骨科（广东东莞 523573）, Department of Orthopedics, Dongguan East Central Hospital, Dongguan Guangdong, 523573, P. R. China

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范文滕

东莞市东部中心医院骨科（广东东莞 523573）, Department of Orthopedics, Dongguan East Central Hospital, Dongguan Guangdong, 523573, P. R. China

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云芳赵

东莞市东部中心医院骨科（广东东莞 523573）, Department of Orthopedics, Dongguan East Central Hospital, Dongguan Guangdong, 523573, P. R. China 东莞市东部中心医院骨科（广东东莞 523573）, Department of Orthopedics, Dongguan East Central Hospital, Dongguan Guangdong, 523573, P. R. China 广州中医药大学第一临床医学院（广州 510405）, The First Clinical Medical College of Guangzhou University of Traditional Chinese Medicine, Guangzhou Guangdong, 510405, P. R. China

Corresponding author.

干军温: moc.qq@632796314

温干军，Email： moc.qq@632796314

结果

患者手术时间50～95 min，平均70.7 min；术中出血量50～230 mL，平均132.9 mL；术后18～30个月取出内固定物，平均23.6个月。患者均获随访，随访时间20～32个月，平均25.6个月。均无切口感染、血肿等手术相关并发症以及内固定物断裂残留等并发症发生。16例患者均取得了满意复位效果，术后即刻LKA、AVH、PVH均较术前显著改善（ P <0.05）；取内固定物术前LKA、AVH、PVH均较术后即刻有一定程度丢失，其中LKA差异有统计学意义（ P <0.05），AVH和PVH差异无统计学意义（ P >0.05）；取内固定物术后，LKA、AVH、PVH较取内固定物术前均有一定程度丢失，但仅AVH差异有统计学意义（ P <0.05），LKA和PVH差异无统计学意义（ P >0.05）。术后各时间点腰背部VAS评分均较术前显著改善，取内固定物术前较术后3 d进一步改善（ P <0.05）；取内固定物术后疼痛较取内固定物术前有所加重，VAS评分差异有统计学意义（ P <0.05）。

结论

经Wiltse入路支点复位技术椎弓根内固定手术治疗AO-A型胸腰段骨折手术时间短、术中出血量少，术中很好地保护了后方软组织等结构，能取得满意的复位效果。

Keywords: Wiltse入路, 支点复位技术, 胸腰段骨折, 内固定

Abstract

Objective

To investigate the effectiveness of Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A type thoracolumbar fractures.

Methods

The clinical data of 16 patients with AO-A type thoracolumbar fractures treated with Wiltse approach with fulcrum reduction technique and pedicle internal fixation between September 2013 and January 2019 were retrospectively analyzed. There were 9 males and 7 females, the age ranged from 38 to 60 years, with an average age of 50.7 years. Causes of injury included 9 cases of falling from height, 3 cases of traffic accidents, 3 cases of falling, and 1 case crushed by heavy objects. Fractured segment involved T ₁₁ in 2 cases, T ₁₂ in 5 cases, L ₁ in 7 cases, and L ₂ in 2 cases. There were 6 cases of type A1, 3 cases of type A2, 5 cases of type A3, and 2 cases of type A4 according to AO fracture classification. The operation time, intraoperative blood loss, and removal time of internal fixator were recorded. Before operation, immediately after operation, before and after removal of internal fixator, the local kyphotic angle (LKA), anterior vertebral height (AVH), and posterior vertebral height (PVH) of fractured vertebral body were measured; visual analogue scale (VAS) score of back pain were evaluated before operation, at 3 days after operation, before and after removal of internal fixator.

Results

The operation time of the patients was 50-95 minutes, with an average of 70.7 minutes; the intraoperative blood loss was 50-230 mL, with an average of 132.9 mL; the internal fixator was removed after 18-30 months, with an average of 23.6 months. All patients were followed up 20-32 months, with an average of 25.6 months. No incision infection, hematoma, and other surgery-related complications, and internal fixator rupture residual complications occurred. All 16 patients achieved satisfactory reduction results. Immediate postoperative LKA, AVH, and PVH were significantly improved when compared with preoperative ones ( P <0.05). There was a certain degree of reduction loss before internal fixator removal, and the difference in LKA was significant ( P <0.05), but the difference in AVH and PVH were not significant ( P >0.05). There was a certain degree of reduction loss after internal fixator removal, but only the difference in AVH was significant ( P <0.05), and there was no significant difference in LKA and PVH ( P >0.05). The VAS score of the back pain significantly improved at 3 days after operation and before internal fixator removal when compared with preoperative score ( P <0.05). The pain after internal fixator removal was significantly worse than that before internal fixator removal ( P <0.05).

Conclusion

The Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A thoracolumbar fractures has a short operation time, less intraoperative blood loss, and the posterior soft tissue and other structures are well protected during the operation. It can provide satisfactory clinical reduction results.

Keywords: Wiltse approach, fulcrum reduction technique, thoracolumbar fracture, internal fixation

脊柱骨折占全身骨折的5%～6%，最常见的是胸腰段骨折，约占所有脊柱骨折的75% ^{[

1

]} 。目前，后路椎弓根钉棒复位内固定是胸腰段骨折的主流治疗方法 ^{[

1

-

3

]} 。1968年Wiltse等 ^{[

4

]} 首次描述了最长肌和多裂肌肌间隙入路，通过该入路可以最大程度保护后方肌肉软组织结构及韧带复合体的完整性。Wiltse入路较传统手术入路优势明显，目前已在临床上广泛应用 ^{[

5

-

6

]} 。AO-A型胸腰段骨折大部分仅涉及椎体前中柱，表现为椎体前缘高度（anterior vertebral height，AVH）明显下降及局部后凸，后柱韧带复合体、关节囊等结构完整，行后路手术复位时无需撑开后柱，仅需恢复前中柱高度及局部生理曲度。目前临床后路复位技术很多，大部分是通过撑开椎弓根螺钉恢复椎体高度及脊柱曲度，同时依靠后纵韧带张力来复位突向椎管的骨块以解除神经压迫。于是我们设计通过预弯棒，采用支点复位技术复位此类型骨折。现回顾分析2013年9月—2019年1月于东莞市东部中心医院采用支点复位技术椎弓根内固定手术治疗的AO-A型胸腰段骨折患者临床资料，探讨该复位技术的可行性和临床疗效。报告如下。

1. 临床资料

1.1. 一般资料

纳入标准：① 单节段AO-A型胸腰段骨折；② Load-sharing评分≥4分，有明显的后路手术指征；③ 采用经Wiltse入路支点复位技术椎弓根内固定手术治疗；④ 影像学资料完整。排除标准：① 有明显骨质疏松；② 合并其他部位骨折；③ 胸腰段陈旧性骨折；④ 伴有认知障碍或精神障碍者。2013年9月—2019年1月共16例患者符合选择标准纳入研究。

本组男9例，女7例；年龄38～60岁，平均50.7岁。致伤原因：高处坠落伤9例，交通事故伤3例，摔伤3例，重物压伤1例。骨折节段：T ₁₁ 2例，T ₁₂ 5例，L ₁ 7例，L ₂ 2例。AO骨折分型：A1型6例，A2型3例，A3型5例，A4型2例。患者均无明显神经症状。术前Load-sharing评分4分3例，5分8例，6分4例，7分1例。受伤至内固定手术时间2～6 d，平均3.0 d。

1.2. 手术方法

患者于全身麻醉下俯卧于脊柱骨折复位垫上（保证术中可正常透视），以骨折为中心作胸腰段后正中切口（长约10 cm），切开皮肤、皮下组织；沿皮下层向棘突两旁剥离1 cm，于棘突旁两侧切开胸腰背浅筋膜，用手指钝性分离找到多裂肌及最长肌肌间隙，沿两侧肌间隙找到两侧椎弓根螺钉的进针点（尽量避免破坏进针点周围肌肉的起止点）；然后在骨折椎上、下各1个节段分别打入合适长度的长尾单轴椎弓根螺钉（椎弓根螺钉尽量平行上终板），量取合适长度的连接棒，根据需要恢复局部后凸角度的大小预弯后上棒；先锁紧尾端椎弓根螺钉的螺帽，然后于两侧棒上紧贴头端的椎弓根螺钉夹持一大力持棒钳（防止拧紧螺钉、螺帽过程中后柱短缩），并且以大力持棒钳和头端椎弓根螺钉的接触点为支点，利用连接棒的弧度进行骨折椎体前柱复位；逐步拧紧头端的椎弓根螺钉螺帽，拧紧过程中透视观察骨折复位程度，直至复位满意后停止拧入螺帽；折断椎弓根螺钉尾端，根据需要放置横联杆。见图1 。大量生理盐水冲洗切口，两侧放置引流管；逐层缝合切口。

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图 1

Schematic diagram of vertebral fracture reduction (ful crum reduction technique)

椎体骨折复位（支点复位技术）示意图

1.3. 术后处理及疗效评价指标

术后24 h内拔除引流管；术后3～5 d佩戴支具下地行走，3个月内均需佩戴支具。术后指导患者加强腰背肌功能锻炼，建议患者术后1年半左右取出内固定物。内固定物取出标准：内固定术后1年以上，局部皮肤软组织条件良好，无明显手术禁忌证，影像学检查提示骨性愈合。

记录患者手术时间、术中出血量及取出内固定物时间。术前、术后即刻、取内固定物术前及术后，于侧位X线片上测量局部后凸角（local kyphotic angle，LKA）、骨折椎体AVH、骨折椎体后缘高度（posterior vertebral height，PVH）；术前、术后3 d、取内固定物术前及术后进行腰背部疼痛视觉模拟评分（VAS）评价。

1.4. 统计学方法

采用SPSS23.0统计软件进行分析。计量资料均符合正态分布，数据以均数±标准差表示，多个时间点间比较采用重复测量方差分析，不同时间点间比较采用Bonferroni法；检验水准 α =0.05。

2. 结果

本组患者手术时间50～95 min，平均70.7 min；术中出血量50～230 mL，平均132.9 mL；术后18～30个月取出内固定物，平均23.6个月。患者均获随访，随访时间20～32个月，平均25.6个月。均无切口感染、血肿等手术相关并发症以及内固定物断裂、残留等并发症发生。16例患者均取得了满意复位效果，术后各时间点LKA、AVH、PVH均较术前显著改善，差异有统计学意义（ P <0.05）；取内固定物术前LKA、AVH、PVH均较术后即刻有一定程度丢失，其中LKA差异有统计学意义（ P <0.05），AVH和PVH差异无统计学意义（ P >0.05）；取内固定物术后，LKA、AVH、PVH较取内固定物术前均有一定程度丢失，但仅AVH差异有统计学意义（ P <0.05），LKA和PVH差异无统计学意义（ P >0.05）。术后各时间点腰背部VAS评分均较术前显著改善，取内固定物术前较术后3 d进一步改善，差异均有统计学意义（ P <0.05）；取内固定物术后疼痛较取内固定物术前有所加重，VAS评分差异有统计学意义（ P <0.05）。见表1 ，图2 。

表 1

Comparison of imaging indexes at different time points before and after operation ( n =16,

患者手术前后各时间点各影像学指标比较（ n =16， LKA（°）AVH（mm）PVH（mm）VAS评分
VAS score ^* 与术前比较 P <0.05， ^# 与术后即刻/3 d比较 P <0.05， ^△ 与取内固定物术前比较 P <0.05
^* Compared with preoperative value, P <0.05; ^# compared with postoperative value at immediate/3 days, P <0.05; ^△ compared with the value before internal fixator removal, P <0.05
Preoperative 10.86±3.98 ^# ^△ 21.48±3.81 ^# ^△ 30.59±1.51 ^# ^△ 6.1±1.2 ^#△ 术后即刻/3 d
Postoperative at immediate/3 days −2.08±3.06 ^* 30.31±2.01 ^* 32.53±0.73 ^* 2.3±0.9 ^* ^△ 取内固定物术前
Before internal fixator removal −0.41±3.85 ^*# 29.67±1.84 ^* 32.46±0.73 ^* 0.4±0.6 ^*# 取内固定物术后
After internal fixator removal 1.13±3.67 ^* 28.14±2.64 ^* ^△ 32.32±0.75 ^* 1.3±0.9 ^* ^△ 统计值
Statistic F =14.021
P <0.001 F =36.324
P <0.001 F =40.381
P <0.001 F =109.465
P <0.001

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图 2

Anteroposterior and lateral X-ray films of a 38-year-old male patient with T ₁₂ vertebral compression fracture resulted from falling from height (Load-sharing score was 5, AO type A4)

患者，男，38岁，高处坠落伤致T ₁₂ 椎体压缩性骨折（Load-sharing评分5分，AO分型A4型）正侧位X线片

a、b. 术前LKA为16.93°；c、d. 术后即刻骨折复位满意，LKA为1.23°；e、f. 术后2年取内固定物前AVH部分丢失，LKA为8.98°；g、h. 取内固定物术后3 d示LKA为9.83°

a, b. Preoperative LKA was 16.93°; c, d. Immediate postoperative fracture reduction was satisfactory, LKA was 1.23°; e, f. Partial loss of AVH before internal fixator removal at 2 years after operation, LKA was 8.98°; g, h. LKA was 9.83° at 3 days after internal fixator removal

3. 讨论

胸腰段（T ₁₀ ～L ₂ ）处于稳定性好、活动度小的胸椎与活动度大的腰椎的交界区域，由于其特殊生物力学特性，胸腰段是脊柱最常见的损伤部位。AO-A型胸腰段骨折主要涉及前柱（椎体或椎间盘）损伤，有时也伴有无明显临床意义的横突或棘突骨折；严重的A型骨折主要表现为椎体爆裂性骨折，有时伴有骨折块椎管占位，但无明显后纵韧带复合体损伤及椎体滑移或脱位 ^{[

7

]} 。AO-A型胸腰段骨折最佳治疗策略仍存在争议，许多综述及Meta分析对是否融合、微创或开放、前路或后路等手术策略选择进行了总结分析 ^{[

8

-

11

]} 。

对于胸腰段骨折，保守治疗不仅需要患者长时间卧床休息，生活质量较差且护理成本高，还可能导致骨折节段严重后凸畸形，甚至继发神经损伤 ^{[

12

]} 。微创椎弓根螺钉内固定手术可加快病情恢复，使患者尽早回归正常生活 ^{[

13

]} 。传统手术采用后正中切口椎弓根钉棒系统进行复位内固定 ^{[

14

]} ，但术中大范围软组织剥离增加了手术创伤、手术出血量，减弱了术后椎旁软组织的保护屏障，同时影响了脊柱稳定性，导致术后持续性腰背痛，还加速了手术节段及邻近节段退变 ^{[

15

-

16

]} 。与传统手术入路相比，Wiltse入路在胸腰段骨折治疗中的优势明显，因为胸腰段多裂肌没有下腰部多裂肌粗大，且胸腰段多裂肌及最长肌的肌间隙更明显，两肌肉间隙的血管穿支清晰可见，能完全避免术中损伤血管及减少术中出血量；另外，通过肌间隙植入椎弓根螺钉可避免过度及长时间牵拉肌肉组织造成的肌肉损伤。对于大多数AO-A型无神经症状的胸腰段骨折，术中无需采用后方椎板切除减压，因而采用Wiltse入路可行。本研究采用Wiltse入路治疗AO-A型胸腰段骨折，手术时间短，术中出血量少，并且术中很好地保护了椎旁肌肉组织。

AO-A型胸腰段骨折主要涉及脊柱的前柱，表现为AVH明显下降及局部明显后凸，有时伴有椎间盘损伤。对于该类骨折，后路椎弓根钉棒系统复位内固定是目前主流治疗方法。后路复位技术有很多 ^{[

17

-

18

]} ，大部分是通过撑开椎弓根螺钉来恢复椎体高度，同时通过后纵韧带撑开时的张力来复位突向椎管的骨块，以解除神经压迫，单纯撑开复位技术在复位前中柱高度同时也延长了后柱长度，但撑开过程对关节囊等正常结构的影响尚不明确。对于AO-A型胸腰段骨折，后路椎弓根钉棒系统复位时无需明显延长后柱长度，仅需恢复前中柱高度并同时恢复局部角度。基于此，我们通过预弯棒采用支点复位技术即可满足此类型骨折复位需求。该复位技术是以大力持棒钳和头端椎弓根螺钉的接触点为支点，利用棒的弧度，在拧紧头端椎弓根螺钉螺帽过程中逐渐实现骨折椎体复位。本组16例患者采用该支点复位技术取得了满意复位效果，术后LKA、AVH、PVH均较术前显著恢复；在取内固定物术前，LKA、AVH、PVH较术后即刻都有一定程度丢失，LKA差异有统计学意义，AVH和PVH差异无统计学意义，考虑为局部后凸角度的丢失中有椎间盘高度丢失的因素。取内固定物术后，LKA、AVH、PVH较术后即刻同样有一定程度丢失，但只有AVH差异有统计学意义，LKA和PVH差异无统计学意义，考虑为内固定物去除后，椎体前缘在压力作用下高度有所丢失。腰背部疼痛VAS评分术后3 d较术前明显改善；取内固定物术前VAS评分较术后3 d也有减轻，骨折愈合后疼痛降至最低，但取内固定物术后VAS评分较取内固定物术前有所加重，考虑与术后切口疼痛有关。

综上述，经Wiltse入路支点复位技术椎弓根内固定手术治疗AO-A型胸腰段骨折手术时间短、术中出血量少，术中很好地保护了后方软组织等结构，能获得满意复位效果。但本研究存在以下不足：为回顾性研究，纳入病例数较少，未设立对照组，患者的影像学资料投射角度存在差异，数据测量存在误差，并且取内固定物时间不统一，相关结论有待进一步研究改善。

利益冲突　所有作者声明，在课题研究和文章撰写过程中不存在利益冲突

伦理声明　研究方案经东莞市东部中心医院伦理委员会批准（2019-057）

作者贡献声明　温干军负责临床研究设计及实施、文章撰写；江帝钦负责数据收集整理、统计分析；周植森、滕范文、赵云芳参与数据收集整理

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Articles from Chinese Journal of Reparative and Reconstructive Surgery are provided here courtesy of Sichuan University

经Wiltse入路支点复位技术治疗AO-A型胸腰段骨折的临床研究

Clinical study of Wiltse approach with fulcrum reduction technique in the treatment of AO-A type thoracolumbar fractures

干军 温

帝钦 江

植森 周

范文 滕

云芳 赵

结果

结论

Abstract

Objective

Methods

Results

Conclusion

1. 临床资料

1.1. 一般资料

1.2. 手术方法

1.3. 术后处理及疗效评价指标

1.4. 统计学方法

2. 结果

表 1

3. 讨论

References

干军温

帝钦江

植森周

范文滕

云芳赵