【专题文献】——胸腰椎骨折——防止并发症：胸腰椎爆裂性骨折

Complication Avoidance: Thoracolumbar and Lumbar Burst Fractures防止并发症：胸腰椎爆裂性骨折
Of the 79,000 spinal fractures that occur in the United States each year, 72.5% involve the thoracic or lumbar spine. The most common site of injury is the thoracolumbar junction, which represents a mechanical transition zone between the rigid thoracic and the more mobile lumbar spine. Notwithstanding the thoracolumbar junction, the lumbar spine itself may be more prone to injury than the thoracic spine. Anatomic explanations include the lumbar spine’s absence of stabilizing articulations with the ribs, lordotic posture, and more sagittally oriented facet joints. In contrast,greater energy is required to produce an injury in the more inherently stable thoracic spine, which may help explain the higher rate of neurologic deficits with fractures in this region.
美国每年发生79000例脊柱骨折，其中72.5%涉及胸椎或腰椎。最长发生损伤的部位是胸腰椎交界部，即静止的胸椎和移动性较高的腰椎的机械过渡区域。尽管胸腰椎交界部更容易受伤，但腰椎本身可能比胸椎更易于受伤。解剖的解释包括腰椎缺乏肋骨的稳定衔接、脊柱前突的姿势以及小关节关界面的更大的角度。相反，对于更加内在稳定的胸椎造成损伤则需要更大的能量，这也更有助于解释这个区域更容易出现骨折后的神经功能缺损。Burst fractures account for 14% of all spinal injuries. Although common, thoracolumbar and lumbar burst fractures present many important treatment challenges. There is substantial controversy regarding the indications for nonoperative or operative management of thoracolumbar and lumbar burst fractures. Disagreement also exists regarding the choice of surgical approach. In practice, the management of each patient should be individualized based on a variety of factors, including the presence of neurologic deficit; type, extent, and location of the injury; and nonspinal factors, such as age and medical comorbidities.
在所有的脊柱外伤中，爆裂骨折占14%。尽管常见，但胸腰椎和腰椎爆裂骨折的治疗目前面临众多重要的挑战。关于非手术或手术治疗胸腰椎和腰椎爆裂骨折的适应症问题有众多争议。在外科手术的方法选择上同样存在着分歧。在实践中，每位病人应遵循众多因素来决定个体化的治疗方案，这些因素包括存在神经功能缺损；类型、程度以及损伤的部位；以及非脊柱因素，如年龄和并发症。
Pitfalls are best avoided by following an algorithmic approach to patient assessment, radiographic workup, and ultimate management decision making. An intimate understanding of the mechanism of injury and the unique biomechanical propensities after various forms of treatment can help the spinal practitioner manage patients effectively and prevent potential complications.
避免陷阱的最佳方法是遵循以下方法来评估病人的状态，放射学检查和最终方案的制定。损伤机制的确切阐述和多种形式的治疗后的独特的生物力学特性可以帮助脊柱医生更有效的治疗病人，并阻止潜在的并发症。
Initial assessment
初步评估

Patients should be immobilized until the stability of the fracture can be assessed adequately. When the patient has been hemodynamically stabilized, a full neurologic examination should be performed in the supine position on the stretcher. The patient should not be moved until the baseline neurologic status has been documented; this is particularly crucial if surgery is planned. In neurologically intact patients, the goal is to avoid any loss of neurologic function. If the patient arrives with a deficit, however, the goal is to avoid worsening from transfers, positioning, or direct injury during spinal procedures. A progressive neurologic deficit is a widely accepted indication for urgent surgical intervention. The only way this deficit can be recognized is through serial assessments after a baseline examination.
直到骨折的稳定性可以充分被评估时病人应当固定。当患者血流动力学稳定了，病人应当在担架上仰卧姿势的进行完整的神经学查体。直到神经状态的基线被记录下来病人不应被移动，如计划施行手术这将特别重要。在神经学正常的患者，其目的是为了避免出现任何神经功能的丧失。然而，如果病人接诊的时候就存在神经功能缺失，不移动病人的目的就是为了避免转运、换姿势或者脊柱运送程序中直接损伤神经。进展性神经功能缺失被认为是紧急手术干预的广泛适应症。唯一能确认神经功能缺失方法只有经过一系列的基线检查。Because the spinal cord can terminate variably between T11 and L2, neurologic deficits from thoracolumbar burst fractures can involve the spinal cord or the cauda equina; this contributes to the wide spectrum of severity of neurologic injuries. Sensation in each dermatome should be assessed, and at least one muscle or movement should be graded for each cervical and lumbar nerve root level. Upper and lower extremity deep tendon reflexes also should be tested. If possible, bladder function can be assessed by urodynamic or cystometric testing. A high postvoid residual can signify urinary retention, which suggests a cauda equina injury. Serial digital rectal examinations should be performed to assess the anal sphincter tone and perianal sensation.
因为脊髓终于胸11和腰2之间的差异，胸腰椎爆裂骨折的神经功能缺失可以涉及脊髓或马尾；这导致了神经损伤的严重程度的广泛。每个皮肤的感觉都应该被评估，并且每一个颈椎和腰椎神经根水平只少一个肌肉或运动应当被分级。上肢和下肢深部腱反射也应进行测试。如果可能的话，膀胱功能可以通过尿动力学和膀胱测压试验来检查。高残余尿剩余可意味着尿潴留，这意味着马尾神经损伤。为了评估肛门括约肌声调和肛周感觉应进行串行数字直肠检查。
The potential for neurologic recovery usually can be estimated shortly after injury, provided that the deficit is not progressive, and the spine can be stabilized in a timely manner to prevent further neural trauma. Because the presence and severity of neurologic injury influences the treatment choice, an accurate and thorough neurologic examination is essential. Importantly, a normal neural examination does not preclude the possibility of a spinal fracture because most thoracolumbar injuries do not have associated neurologic deficits.
如果神经功能缺失不再进行性加重，并且脊柱可以被及时制动来阻止进一步的神经损伤，潜在的神经功能恢复能力通常在术后可以很快被估计出来。因为神经受损的出现和严重性影响治疗方法的选择，所以准确和全面的神经学检查是必要的。更重要的是，因为大多数胸腰椎损伤并不与神经功能缺失相关联，所以正常的神经检查并不能预先排除脊柱骨折的可能。
A detailed neurologic examination is not always possible in an acutely traumatized patient. A motor or sensory examination cannot be performed in obtunded or comatose patients. Notwithstanding observing gross extremity motion, examination can be difficult and unreliable in agitated, intoxicated, or anxious patients. Despite these limitations, a reflex examination, including assessment of the bulbocavernosus reflex and rectal tone, should be performed at a minimum.
详细的神经学检查在急性创伤病人经常是不可能的。运动觉和感觉在失去知觉和昏迷病人是不能检查的。尽管可以观察到大致的末端运动，但是检查在激动、醉酒或焦虑的病人可能是很困难和不可靠的。尽管有这些限制，应在最低限度完成包括海绵体反射和直肠基调的评估的反射检查。
With the neurologic examination complete, attention should be turned to the remainder of the physical examination. The spinous processes should be palpated systematically for tenderness, bogginess, or gaps within the interspinous interval. The skin should be inspected for any lacerations, abrasions, or ecchymosis. The posture and contour of the neck and back also should be noted because it may reveal obvious deformities.
随着神经学检查完成，重点应当转移到剩余的体格查体上。棘突的行程应系统的触诊包括柔韧性、坑洼或棘间间隔的间隙。外观应检查任何割伤，擦伤，或瘀血。颈背部的姿势和轮廓也应该注意，因为它可能显示出明显的畸形。
Imaging
影像学

The so-called initial trauma series comprises lateral cervical, anteroposterior chest, and anteroposterior pelvic radiographs. Standard chest x-rays are inadequate, however, to view the spine for fractures. In many centers, helical CT has replaced plain radiography as an initial screening modality. Many thoracolumbar and lumbar injuries are first detected on CT scan. CT yields more diagnostic information than plain radiographs regarding the extent of bony injury. Canal compromise is best assessed using CT. In addition, lamina and articular process fractures typically are missed on plain films and are best visualized on axial CT slices. Regardless, if an injury is detected, the authors obtain dedicated anteroposterior and lateral plain films of the region because plain films are used for preoperative planning and serial radiographic follow-up examinations.
所谓的初始创伤系列包括颈椎侧位、胸部前后位和骨盆前后位的影像。然而要检查脊椎骨折，标准的胸部X线片是不够的。在许多中心当中，螺旋CT已经取代了最初的筛选方式的一般X光片。许多胸腰椎和腰椎损伤是首先通过CT扫描发现的。关于骨损伤的程度CT比普通X线平片提供了更多的诊断信息。管道损害最好使用CT评估。此外，椎板和关节突骨折通常在X光片上被遗漏，最好在轴位CT片观察。无论如何，如果检查到损伤，或者专用部位的前后位和侧位平片是很必要的，因为平片是用来术前规划和随访检查的系列影像学资料。Sagittal and coronal reconstructions have made three-dimensional visualization of these fractures easier, particularly in appreciating kyphosis and translation, which is difficult with axial images alone. Images should be analyzed in a systematic manner. Using a lateral radiograph or sagittal CT reconstruction, the degree of kyphosis can be measured using the Cobb method. The angle between perpendiculars drawn along the superior and inferior end plates of the suprajacent and infrajacent uninjured vertebrae is measured. In addition, vertebral body height and comminution, disk spaces, interpedicular distances, and interspinous process intervals should be noted and compared between injured and noninjured levels.
矢状面和冠状面重建的三位成像使这些骨折更容易发现，特别在观察后凸和翻译的骨折在单纯轴位像上很难发现。影像学图片应该系统的进行分析。通过侧位片或CT失状位重建，可以用cobb角来测量后凸的程度。角度由沿上位和下位未损伤椎体终板的垂线测量得来。此外，椎体高度和粉碎程度，椎间隙，椎弓根间距，和棘间行程的间隙也应该在损伤和非损伤水平被注意和比较
CT scans have limited capacity to visualize soft tissue injuries, such as disk herniations, epidural or subdural hematomas, posterior ligamentous disruption, or spinal cord parenchymal injury. MRI has improved the ability to visualize the soft tissue components of spinal injuries .MRI is particularly useful at the thoracolumbar junction because of the variable location of the conus medullaris in adults. Despite its utility, MRI is not always acutely available. In some cases, it is contraindicated because of the presence of ferromagnetic biomedical implants, such as cardiac pacemakers and aneurysm clips. In the authors’ practice, MRI evaluation is reserved for patients with a neurologic deficit or in whom the integrity of the posterior ligamentous complex (PLC) is in question. In these scenarios, the short tau inversion recovery sequence is particularly valuable for detecting acutely injured soft tissues.
CT扫描对软组织损伤的观察有限，比如椎间盘突出，硬膜外或硬膜下血肿，后韧带断裂，或脊髓实质损伤。磁共振成像提高了脊髓损伤的软组织的可视能力。由于成人脊髓圆锥的位置不固定，因此磁共振成像在胸腰椎交界处是特别有用的。尽管它很有用，但磁共振成像在急性期并不总是可以应用。在某些情况下，因为具有磁性的生物医学植入物而禁止应用，例如心脏起搏器和动脉瘤夹。在作者的实践中，磁共振成像评价被保留用于具有神经功能缺失或者后纵韧带完整性有疑问的病人。在这些情况下，短头反转恢复序列对检测急性软组织受伤特别有价值。
Injury mechanism
损伤机制

With upright posture, gravity exerts a continual axial load on the vertebral column. The body’s center of gravity passes anterior to the thoracic spine, through the thoracolumbar junction, posterior to the lumbar spine, and through the sacral promontory of S2. With abrupt increases in axial loads, with or without flexion or extension moments caused by sudden acceleration or deceleration, various components of the vertebral column can fail. With burst fractures, axial loading of the vertebral body causes multiple fracture lines to propagate. This is called comminution and can lead to discontinuity of the posterior vertebral body and the adjacent pedicles. The explosive nature of a burst fracture leads to variable degrees of vertebral body retropulsion into the canal.
由于直立的姿势，重力不断对脊柱施加轴向负荷。身体的重心通过胸椎的前方，穿过胸椎交界处，向后到腰椎，并通过骶2的骶岬。随着轴向负荷突然增大，伴随或不伴随屈曲或伸展动作的突然加速或减速，不同的脊椎组成部分可能出现问题。如伴随爆裂骨折，椎体的轴向负荷导致多发性骨折线扩散。这就是所谓的粉碎，并可导致后路椎体和相邻的椎弓根的骨折。一个爆炸性的爆裂骨折导致不同程度椎体向后凸入椎管。
Burst fractures can be associated with disruption of the PLC, which consists of the interspinous process ligaments and ligamentum flavum. PLC failure likely occurs from the addition of a flexion
component to the injury vector. Conceptually, when the vertebral body has been compressed to a critical amount, the posterior ligaments are thought to fail in tension.
爆裂性骨折可与后纵韧带破裂相关，它包括棘间韧带和黄韧带后纵韧带损伤很可能是由于额外的损伤的屈曲向量导致的。从概念上讲，当椎体已被压缩到一个临界值，后部韧带损伤被认为是紧张所致。
Whitesides used the analogy of a construction crane to explain this phenomenon. The weight to be lifted (ie, the injury force) is in front of the crane. When the weight is lifted, compressive loads are transmitted to the boom (ie, vertebral body or anterior column), while tension is developed in the crane’s cable (ie, PLC). Failure of either the boom or the cable results in collapse. Continuing with this example, failure of the cable leads to the crane falling forward; in the spine, this is typified by the characteristic kyphotic deformity seen with unstable burst fractures. Mechanically, the anterior column must be able to sustain the axial load, whereas the PLC must be able to counteract the ventral bending moments to maintain a zero net sum of vectors to achieve stability.
Whitesides使用建筑起重机的比喻来解释这一现象。被举起的重量（即伤害力）在吊车前面。当重量被举起来，压缩载荷传输到吊杆（即椎体或前柱），而紧张是作用在起重机的电缆上（即后纵韧带）。无论是繁荣失效或崩溃的电缆结果。继续此例，电缆故障导致起重机前倾，而在脊柱，这就是以凸畸形为典型出现不稳定爆裂骨折。机械上讲，前柱必须能够承受轴向负荷，与此同时后纵韧带必须能够抵消屈曲动作的向量来保持持零向量的总向量和以达到稳定。
Fracture classification
骨折的分类

Several fracture classification schemes have been created for thoracolumbar and lumbar burst fractures. Many of these are based on methods or criteria for describing stability. Holdsworth proposed a two-column model of spine stability in the 1960s. He separated the spine into an anterior weight-bearing column, consisting of the vertebral body, and a posterior tension-bearing column, consisting of the PLC. He classified burst fractures as unstable if the PLC was disrupted. Building on this thinking, Denis developed a three-column classification of spinal fractures in the early 1980s. This system was based on the premise that injury to the middle column, consisting of the posterior portion of the vertebral body, posterior longitudinal ligament, and posterior disk, was necessary and sufficient to create instability.
已经产生了多种胸腰椎爆裂骨折的骨折分类办法。其中许多是基于描述稳定性的方法或标准。Holdsworth在20世纪60年代提出了脊柱的稳定性两柱模型。他将脊柱分成前部重量承载柱，由椎体组成，以及一个后部张力承载柱，由后纵韧带组成。如果后纵韧带断裂，他将爆裂骨折归类为不稳定。基于这一思想，Denis在80年代初创立的脊柱骨折三柱分类。这个系统是基于的前提是中柱损伤，包括椎体后部，后纵韧带，和椎间盘后部，这些是产生不稳定的必要的和足够的部分。
Denis further categorized unstable fractures into three types: mechanical (first degree), neurologic (second degree), or combined mechanical/ neurologic (third degree). This categorization was particularly relevant for thoracolumbar burst fractures because Denis observed they exhibited neurologic instability (ie, neurologic decline). Although it is generally agreed that most neural injury occurs with initial impact, sustained or increased compression of the spinal cord or cauda equine can lead to worsening deficits. In his series of patients, Denis reported that 20% of patients treated nonoperatively for a burst fracture developed a new neurologic deficit. What is unclear from this study is which of these injuries had disruption of the PLC, which many surgeons believe is an indication for surgical stabilization because of its propensity also to be mechanically unstable.
Denis进一步将不稳定骨折分为三种类型：机械性（Ⅰ级），神经性（Ⅱ级），或合并机械/神经性（Ⅲ级）。因为Denis观察发现胸腰椎爆裂骨折表现出神经学的不稳定性（即神经功能下降），所以这个分类特别适用于胸腰椎爆裂性骨折。尽管普遍认为大多数神经损伤是发生在最初的压迫，但是持续的或不断增加的脊髓或马尾受压会导致功能缺失的进一步恶化。在他的一系列的病人中，Denis报道了20％的爆裂骨折的病人在非手术治疗后出现了新的神经功能缺失。这个研究涉及的损伤是否包括后纵韧带的断裂是不确定的，很多医生认为后纵韧带断裂是外科不稳定的指征同事也意味着机械性不稳定。
Soon after the introduction of Denis’ system, McAfee and colleagues proposed a related classification and treatment scheme. This system also divided the spine into three columns. Also concentrating on the middle column, this system distinguished injuries based on how the middle column failed, with burst fractures exhibiting middle column failure in compression. Recognizing the importance of the PLC and Denis’ high rate of neurologic decline, McAfee’s system also distinguished between burst fractures with and without a PLC disruption because the former were considered unstable.
采用Denis系统不久，McAfee和同事们提出了相关的分类和治疗方案。该系统也将脊柱分为三柱。同样集中在中柱，该系统依据中柱是否受损将损伤进行分类，爆裂骨折在压缩时表现为中柱破坏。认识到后纵韧带的重要性和Denis的神经功能下降的高发生率，由于后纵韧带断裂被认为是不稳定的骨折，McAfee系统也将爆裂骨折分为伴随或不伴随后纵韧带断裂。
More recently, McCormack and coworkers proposed the load-sharing classification. In contrast to other systems, it was designed specifically for and relevant to thoracolumbar burst fractures. It uses a point system that grades the amount of vertebral body comminution, displacement of fracture fragments, and degree of kyphosis. The original goal of the load-sharing system was to predict the failure of short-segment posterior fixation for a burst fracture because it prescribes that injuries with high scores should undergo supplemental anterior column support.
最近，McCormack和同事提出的负载共享分类。与其他系统相比，它是专门为胸腰椎爆裂骨折设计并与之相关的。它应用点系统来为椎体粉碎的数量、骨折碎片的移位和后凸畸形的程度进行分级。因为它规定高分的损伤应施行前柱的附加支持，所以负载－共享系统的最初目的是预测爆裂骨折短节段后路固定的失败与否。
Avoiding pitfalls with surgical decision making
避免手术决策的陷阱

There are three components of surgical treatment of thoracolumbar and lumbar burst fractures: neural decompression, stabilization, and fusion. Complications and treatment failures can occur within each. Although there are no hard and fast rules, a coherent and logical rationale should be followed to avoid common complications.
胸腰椎和腰椎爆裂骨折的手术治疗包括三个部分：神经减压、稳定和融合。并发症和治疗失败可发生在三者的任何环节。虽然没有硬性的和快速和规定，避免常见的并发症应该是一致的和负荷逻辑的解释。
Neural decompression
Burst fracture with neurologic deficit
神经减压
神经功能缺损的爆裂骨折



Thoracolumbar and lumbar burst fractures with neurologic deficits typically are treated with surgery. A primary goal of surgery is decompression of the spinal canal. Surgical treatment seems to result in better neurologic recovery rates than nonoperative management. The methods of decompression can vary. Studies have shown greater neurologic improvement after anterior decompression compared with posterior or posterolateral decompression (88% versus 64% improvement). Return of normal bowel and bladder control is achieved more frequently in patients treated with anterior decompression compared with posterior decompression (69% versus 33%). Even in cases of long-standing compression after fracture, anterior decompression can result in modest improvements in neurologic function.
伴随神经功能缺失的胸腰椎和腰椎爆裂骨折通常手术治疗。手术的主要目标是椎管减压。与非手术治疗相比，手术治疗在神经功能恢复方面看起来效果更好。减压的方法可以多种多样。研究显示前路减压的神经功能改善率要优于后路和后外侧减压（88％比64％的改善率）。前路减压病人的正常直肠和膀胱控制的恢复比后路减压出现的更频繁（69％比33％）。即使在骨折后长期受压的病例，前路减压在神经功能上可以得到一定程度的改善。Anterior decompression is performed via corpectomy of the fractured vertebra. This approach results in a maximal degree of canal decompression. In one study, follow-up radiographic examination showed an average 25.9% of residual canal compromise after posterior surgery compared with less than 1% after anterior surgery. Patients with incomplete deficits (spinal cord or cauda equina level) are ideal candidates for anterior decompression because they have the greatest chance for neural recovery.
前路减压是通过对椎体骨折的切除施行的。这种方法导致了最大程度的椎管的减压。在一项研究中，随访的X线平片检查显示了残余椎管在后路减压平均25.9％受累，而前路手术则少于1％。伴随不完全神经功能缺失（脊髓或马尾级）的病人是前路减压的理想人选，因其有最大的神经恢复的机会。
Posterior decompression alone via laminectomy for thoracolumbar fractures does not provide any substantial decompression of the neural elements. A laminectomy to reduce entrapped nerve roots in combination with an anterior decompression is often performed, however. Dural lacerations have been observed in 7% to 27% of patients with burst fractures of the lower thoracic or lumbar spine. Because of the more fluid nature of the dural sac of the cauda equina, lumbar burst fractures with neurologic deficits have been found to be at high risk. A concomitant lamina fracture has been identified as a risk for dural tear with entrapped roots. Left unrepaired, it can lead to neural element herniation and entrapment, epidural or subdural hematoma, or cerebrospinal fluid leak and pseudomeningocele. MRI may offer some advantages in detecting post-traumatic cerebrospinal fluid leak; however, this study is not always obtained in an acute trauma patient.
胸腰椎骨折的后路减压单纯通过椎板切除并不提供任何实质性的神经减压元素。然而，为了减少神经根被包围，常常应用椎板切除术联合前路减压。下位胸椎或腰椎的爆裂骨折的病人可以观察到7％到27％的硬脑膜裂伤。由于马尾的硬膜囊具有更多液体的性质，腰椎爆裂骨折已被认为有很高的风险会伴有神经功能缺失。附属的椎板骨折被认为是有硬膜撕裂伴神经根受压的危险因素。如未能修复，可能导致神经元症和受压，硬膜外或硬膜下血肿，或脑脊液漏和假性脊膜膨出。磁共振成像在检测外伤后脑脊液漏可提供一些优势；然而，研究中的急性外伤病人的磁共振成像并不是总能得到。
An alternative to direct anterior decompression that still allows direct fragment manipulation and removal is the lateral extracavitary approach. It enables access to the anterior and the posterior elements via a single dorsal incision. A hockey stick–shaped incision can be made beneath the paraspinal muscles to allow for lateral visualization of the thecal sac. Ventral dissection exposes the lateral border of the injured vertebral body for fragment removal and subsequent reconstruction. Tempering interest in this technique, Resnick and Benzel reported a 55% complication rate, noting that it is highly technically demanding. These authors recommended that the technique should be reserved for cases in which other methods of decompression may not be feasible. The authors have found benefit for this technique in some older or medically infirm patients who are unable to withstand a thoracotomy for pulmonary reasons.
直接前路减压的替代方法，仍然允许直接操作并移除骨折快的是侧方胸腔外侧入路。它通过单独一个椎骨切口可以接触到前方和后方的组织。在椎旁肌肉下面的曲棍球棒形状的切口使侧方硬膜囊可以被观察到。腹面解剖暴露了受伤椎体的侧方用来移除骨折块和做随后的椎体重建。在此项技术锻炼的兴趣，Resnick 和 Benzel报道了55％的并发症发生率，并指出它需要更高的技术要求。这些作者建议此项技术应当被保留用于那些其他减压方法未必可行的病人。作者们发现此项技术是有效益的，因为它不能应用于那些由于呼吸原因不能承受开胸手术的一些年老或体弱的病人。
Treatment of low lumbar (L3-5) burst fractures requires some distinction from that of thoracolumbar (T10-L2) fractures. Neurologic deficit is observed in 50% of patients with lumbar burst fractures. Although anterior corpectomy is usually feasible for low lumbar fractures, it becomes increasingly difficult at each lower level. The problem with low lumbar surgeries performed anteriorly is that the iliopsoas muscle hinders the decompression and the fusion/stabilization. If the muscle is aggressively dissected to provide exposure, hip flexor weakness occurs. As such, when a stabilization construct extends to the L4 level or lower, the authors prefer to operate via a posterior approach.
治疗下腰椎（腰3-5）爆裂骨折与胸腰椎（胸10－腰2）有所区别。腰椎爆裂骨折有50％的病人有神经功能缺失。虽然在下腰椎前路椎体切除是可行的，但在较低的每个节段手术变得越来越难。低节段腰椎前路手术的问题是由于，髂腰肌的肌肉阻碍了减压和融合/稳定。如果肌肉积极解剖来提供显露，臀部会发生屈肌薄弱。因此，当一个稳定构造延伸到腰4水平或更低，笔者更愿意通过后路手术。
Timing of decompression
减压时机

The optimal timing of surgery for patients with a neurologic deficit from a burst fracture is unclear. There are few indications for emergent surgery to treat a thoracolumbar or lumbar burst fracture; a progressive neurologic deficit is one salient example. Theoretically, the earlier decompression is performed, the better the neural recovery should be. Animal data have lent some
support to this relationship. Human studies have not been as supportive. Most clinical studies have shown no correlation between timing and the amount of neurologic recovery. Only one retrospective study found improved neurologic recovery with surgery within 72 hours compared with surgery within 10 to 14 days. It is unclear, however, how comparable the severity of the injuries were in the two groups. Often, urgent or early surgery may be more difficult than late surgery because of local soft tissue conditions, increased operative blood loss, or concomitant visceral or skeletal injuries. In addition, some authors believe that the operative trauma from decompression of an acutely edematous spinal cord potentially can lead to further neurologic injury. Although it may differ for the thoracolumbar spine, the safety of early surgery has been shown clearly in various studies of cervical fractures with spinal cord injury.
具有神经功能缺失的爆裂骨折病人的最佳手术时机尚不清楚。急诊手术治疗胸腰椎或腰椎爆裂骨折有几条指征；进行性神经功能缺失就是一个突出的例子。从理论上讲，越早进行减压，神经恢复应该越好。有一些动物数据支持这种关系。人体研究没有被支持。大部分临床研究显示，手术时机和神经恢复的多少不具有相关性。只有一个回顾性研究发现，72小时内手术的神经功能恢复要优于10天到14天手术的病人。通常情况下，由于局部软组织条件、术中失血量增加或伴随内脏或骨骼损伤使得急诊或早期手术较晚期手术更加苦难。此外，一些作者认为，急性脊髓水肿减压的手术创伤可能会导致潜在的进一步的神经损伤。尽管与胸腰椎骨折不同，伴随脊髓损伤的颈椎骨折早期手术的安全性液被多项研究证实。
Is decompression indicated for complete spinal cord injuries?
完全行的脊髓损伤是减压的指征？
The severity of deficit is determined primarily by the degree of trauma imparted to the neural elements at the time of initial impact. Cauda equine (low lumbar) injuries are much less likely to be complete compared with conus medullaris or spinal cord injuries. An injury can be considered complete if there is no motor, sensory, or bladder/bowel function distal to the fractured level only after spinal shock has resolved, which usually occurs by 48 hours. This determination can be made only after serial examinations over at least 2 days. Although decompression of a patient with a complete injury is unlikely to result in neurologic recovery, surgical stabilization may prove to be beneficial in facilitating transfers and rehabilitation in paraplegic patients. In addition, pain resulting from instability can be a problem in patients treated nonoperatively. It is unclear whether decompressing the neural elements at the caudal aspect of the spinal cord can decrease the development of posttraumatic syringomyelia.
神经功能缺失的严重性主要取决于最初损伤施加于神经元素的外伤程度。马尾（下腰椎）损伤与圆锥或脊髓损伤相比较少可能出现完全性的神经损伤。通常发生与48小时后的脊髓休克被解决后，如无运动、感觉或损伤水平远端的膀胱/直肠功能，损伤才能被考虑为完全性的损伤。仅当至少两天的系列检查后才能定论。尽管完全性损伤的病人减压后不可能恢复神经功能，但手术固定可能证明有利于促进截瘫病人的转运和康复。此外，源于不稳定的疼痛可能是非手术病人的问题。目前还不清楚脊髓尾部神经元素的减压是否可能降低脊髓空洞症的发展。
Is there an indication for decompression with no neurologic deficit?
不伴随神经功能缺失的是否有指征减压？
Most patients with thoracolumbar and lumbar burst fractures are neurologically intact. Most can be managed with nonoperative care. Occasionally, patients present with a mechanically unstable burst fracture, defined by a disrupted PLC, without a neurologic deficit. These patients also would be considered as neurologically unstable by Denis because they are at potential risk for neurologic decline without operative stabilization.
大多数具有胸腰椎和腰椎爆裂骨折的病人神经学是正常的。大部分都可通过非手术治疗。有时，病人出现机械性不稳定爆裂骨折，是由后纵韧带断裂来判断的，并不伴随神经功能的缺失。根据Denis的理论，这些病人如不进行手术固定也会被认为是神经学不稳定的，因其具有潜在的神经功能缺失的风险。
The critical issue in this subset of patients is accurately and reliably determining the integrity of the PLC. Classic recommendations suggested that the posterior ligaments are likely to have failed if there is greater than 30_ of kyphosis or 50_ of vertebral body height loss. These radiographic criteria have not proved to be reliable because many patients with injuries that surpass these thresholds can be treated successfully with nonoperative means. Some surgeons rely on physical examination features, such as a palpable gap between the spinous processes, although this also has been found to have limitations. More recently, MRI has been used to assess the continuity of the posterior ligaments. Although the reliability of this method has not yet been assessed, it is being used routinely for thoracolumbar burst fractures in some centers. Finally, PLC disruption can be detected by comparing standing with supine radiographs.
在这样的病人的关键问题是专确和可靠的确定后纵韧带的完整性。经典的建议指出，如后凸角度大于30°或椎体高度丢失大于50％时，后纵韧带很可能断裂。这些X线的标准并没有证实是可靠的，因为很多超过阈值的损伤的病人可以通过非手术治疗治愈。一些医生依靠体格检查的特征，如明显的棘突之间的深沟，尽管这也被发现有局限性。最近，磁共振成像已被用来评估后韧带的连续性。 虽然这种方法的可靠性尚未被评估，在一些中心它常规用于评价胸腰椎爆裂骨折。最后，后纵韧带断裂可以通过立位和仰卧位X线片的比较被发现。
Surgery should be considered for neurologically intact patients with PLC disruption. Although stabilization and fusion are the primary goals in this subset, some surgeons believe that the presence of substantial canal compromise is an indication for decompression of the spinal canal. Although indirect decompression using a distracting posterior pedicle-screw construct presents little additional risk, the same may not be said for anterior decompression. There is a low risk that manipulation and removal of retropulsed bone fragments can result in neural injury. If anterior surgery is elected primarily for anterior column support, some would recommend removal of enough of the vertebral body to allow insertion of a strut without entering the spinal canal. Some surgeons are concerned about leaving bone fragments in the spinal canal, particularly if there is greater than 50% canal compromise. Although this threshold has been cited in many textbooks, there are no evidence-based clinical data to support this criterion. Resorption of the fragments occurs over time with brace and posterior stabilization alone. Anecdotally, the authors have made a practice of performing a pedicle-to-pedicle decompression of all bone fragments when anterior surgery is performed.
伴随后纵韧带断裂的神经学正常的病人应该考虑手术治疗。尽管固定和融合在这样的病人中成为了主要目标，一些医生认为，大量的椎管退让的出现是椎管减压的的指征。尽管应用分散后路应力的椎弓根螺杆间接减压较少出现额外的风险，但同样的方法并不适用于前路减压。放置并移除后退的碎骨块可能导致神经损伤具有一定的低风险。如果前路手术主要是为前柱的支持而选，一些人会建议切除足够多的椎体来插入支撑物，而并不会进入椎管。有些医师也担心留在椎管内碎骨片，尤其是当超过50％椎管退让时。虽然这个阈值在许多教科书中被引用，但并没有循证医学证据来支持这个标准。随着时间的推移，碎骨块和支撑物开始被吸收，只剩下后方的固定物。据传，作者在前路手术中也尝试过进行椎弓根到椎弓根的全部骨折片的减压。
Lamina fractures can occur concomitantly with thoracolumbar burst fractures. This injury combination may be associated with a dural tear and entrapped nerve roots. Although surgical exploration might be more readily considered in a patient with a neurologic deficit, the decision is more difficult in patients without deficits. It is unclear if laminectomy and reduction of the displaced roots followed by dural repair offers any advantages in a neurologically intact patient.
椎板骨折可能伴随胸腰椎爆裂骨折出现这种合并损伤可能与硬膜撕裂和神经根包埋有关。虽然手术探查可能更容易在一个有神经功能缺失的病人被考虑，但在没有缺失的病人作这种决定就更加困难。目前仍不清楚在神经学完整的病人通过硬膜修复后椎板和移位的神经根的降低是否提供了任何优势。
Stabilization
固定

Instability with burst fractures can be the result of decompression (eg, corpectomy) or the trauma of the injury itself (eg, PLC disruption). In rare circumstances, an unstable burst fracture might be treated by nonoperative measures. Because of the propensity for deformity, this injury requires a prolonged period (approximately 3 months) of bed rest or recumbency. This method of treatment also increases the risk for complications such as decubitus ulcers, deep vein thrombosis, and pneumonia.
爆裂骨折的不稳定可能是减压的结果（如椎体切除）或是创伤的伤害本身（如后纵韧带的断裂）。在极少数情况下，不稳定的爆裂骨折可能通过非手术治疗的手段治疗。由于畸形的倾向，这种损伤需要长时间（大约3个月）的卧床休息或躺着休息。这种治疗方法还增加了如褥疮，深静脉血栓形成和肺炎等并发症的风险。
The primary role of instrumentation is to restore immediate stability to and correct the acute deformity of the injured spine. Ultimately, instrumentation serves these roles until solid fusion is achieved, which is essential for long term maintenance of stability and alignment. The options for surgical stabilization include anterior, posterior, and combined techniques.
器械的主要作用是立即恢复稳定性和纠正损伤脊柱的急性畸形。最后，器械起到这些作用直到实现坚固的融合，这对于长期的维持固定和调整是至关重要的。脊柱固定的方法包括前路、后路和联合的方法。
Anterior stabilization
前路固定

Anterior stabilization of thoracolumbar fractures can include rod-screw or plate-screw constructs. Early attempts at anterior instrumentation were adaptations of Harrington rod devices. The development of the Kaneda device represented a major step in the anterior treatment of thoracolumbar burst fractures. This device consists of two screws placed through a staple into the intact suprajacent and infrajacent vertebral bodies. These are then connected to two cross-linked rods (Fig. 1). In contrast to older plating systems, the Kaneda system allows the surgeon to use the screw-staple anchors (before placement of the rods) to distract the corpectomy site to allow better strut graft fitting. Biomechanical studies have shown this device to have superior rigidity compared with earlier plate systems. As a result of better engineering and component design, newer plate-screw systems seem to be as or more stable than some dual-rod screw constructs.
胸腰椎骨折前路固定可以包括钉棒或钢板螺钉结构。早期尝试的前路器械是改进的Harrington棒器械。Kaneda器械的研制代表了胸腰椎爆裂骨折的前路治疗的重要进步。这种器械包括两个螺钉通过一个主要的置入完整的损伤的上位和下位相邻椎体。然后将这些连接到两个交联杆（图1）。相对于早期的固定系统，Kaneda系统允许医生使用主要螺旋锚（置入棒之前）来分散椎体切除部位的应力，以便更好的支撑移植的固定物。与早期的固定系统相比，生物力学研究显示此设备具有更好的刚性。由于更好的工程学和组件的设计，新型的钉板系统看起来似乎或者比某些双杆钉棒螺钉结构更加稳定。
Immediate stability is maximized with bicortical screw purchase. The risk of vascular or visceral injury can be decreased by limiting hole preparation (ie, drilling) of the near cortex only; this has not been shown to diminish the biomechanical strength of screw purchase. After placement of the interbody strut, but before securing the rods, any bend in the table should be neutralized. Although this maneuver can facilitate surgical exposure and graft placement, securing the rods in this position can result in a coronal plane deformity. Cross-connectors are a crucial component to a dual rod-screw system. They improve resistance to rotational, torsional, and bending forces.
即刻的固定最大限度的是通过双皮质螺钉获得的。血管或脏器的损伤风险可以仅仅通过附近皮质的限制孔的准备（例如钻孔）而降低；但这还没有显示获得的螺钉的生物力学强度的减低。椎间支撑物放置完成后，在拧紧棒之前，任何视野内的弯曲都应当被抵消。虽然这个动作可以促进手术显露和固定物的放置，但是在这个位置拧紧螺钉可能导致冠状面的畸形。交叉连接器是双杆螺钉系统的关键组件。他们用来提高抵抗旋转，扭转，弯曲的力量。
A potential advantage of anterior stabilization is limiting fusion to the level above and below the injury. Although short segment posterior instrumentation can be used, it often results in failure with loss of alignment correction. Biomechanical investigation has shown the Kaneda device to have about twice the stiffness of posterior constructs with axial compressive and torsional loading. These advantages must be weighed against the morbidity of an anterior approach.
前路固定的潜在的优势是限制损伤节段以上和以下节段的融合。虽然短节段后路可以使用，但往往导致校准修正的丢失所致的失败。生物力学研究表明了Kaneda设备有大约两倍的后部结构刚度与轴向压缩和扭转载荷。这些优势必须与前路手术的并发症相权衡。

Fig. 1. A 14-year-old girl jumped from a window (20 ft) to meet her boyfriend against her parents’ wishes. Because of anticipated noncompliance with a conservative bracing regimen, the parents elected to have an anterior L2 corpectomy surgery. (A) Sagittal CT scan shows canal impingement by fracture fragment in midline. (B) Sagittal CT scan postoperatively shows canal clearance with improved sagittal plane alignment. (C) Coronal CT scan postoperatively shows generous quantity of bone in carbon fiber cage. Vertebral body screws are positioned bicortically, and alignment is maintained. (D) Axial CT scan postoperatively is noteworthy for a pedicle-to-pedicle decompression and a well-centered carbon fiber cage filled with autologous bone graft.
图1.一名反对父母的意愿的14岁女孩从窗户跳下去见男朋友。因为预见病人会不遵循保守的支具治疗方案，家长选择了前路腰2椎体切除手术。（A）矢状面CT扫描显示骨折在中线侵犯椎管。（B）术后矢状面CT扫描显示改善了的矢状平面线形椎管清除。（C）术后冠状面CT扫描显示大量的骨位于碳纤维笼。椎体螺钉固定于近端，并且维持于校准的位置。（D）术后轴位CT扫描值得注意的是椎弓根到椎弓根的减压和恰好位于中心自体骨填补的碳纤维笼。
Posterior stabilization
后路固定

Options for posterior stabilization include rods secured by screws, hooks, or wires. Although hooks and wires still may be used, they have been largely supplanted by pedicle screws. Pedicle screws, particularly in the thoracolumbar and lumbar regions, are relatively easy to insert and offer substantial biomechanical advantages compared with hooks or wires. Pedicle screws enable restoration of stability with fewer anchoring points, which can spare motion segments.
后路固定的选择包括由螺钉固定的棒，钩或者线。虽然钩和线可能仍然使用，但是他们已经很大程度上被椎弓根螺钉所取得。椎弓根螺钉，特别是在胸腰椎和腰椎部分，是比较容易插入，相比钩和线可提供大量的生物力学的优势。椎弓根螺钉可通过较少的支撑点来恢复稳定，这可保留运动节段。
Pedicle screw systems theoretically provide three-column fixation. It is the authors’ practice to instrument two levels and above and below the injured level for most thoracolumbar burst fractures (Fig. 2). Although some authors advocate short-segment fixation (including only one level above and below), this has resulted in high rates of construct failure in many cases. If sparing motion segments is a priority, but maximal stability is desired, short-segment pedicle screw stabilization can be combined with anterior instrumentation. In the authors’ practice, this is preferred in young, active patients. In the low lumbar spine, short-segment fixation is more durable, likely because of lordotic alignment and the large pedicles that permit larger diameter screws to be used. The rod must be contoured in an appropriate amount of lordosis to avoid the sequelae of so-called flat-back syndrome (Fig. 3).
理论上椎弓根螺钉系统提供了3柱的固定。对于大多数胸腰椎爆裂骨折作者的实践是通过损伤的上下各两个节段放置器械（图2）。虽然有些作者主张短节段固定（包括上面和下面只有一个椎体），然而很多情况下这导致了很高的固定失败率。如果优先保留运动节段，同时需要最大限度的固定，可以短节段椎弓根螺钉固定联合前路器械。在作者的实践中，这首选于年轻和生命力较强的病人。在下部腰椎，短节段固定更耐用，很可能是因为脊柱前凸的调整和粗大的椎弓根可应用较大直径的椎弓根缘故。杆必须弯成具有一定的前凸形状，避免所谓的平背综合征的后遗症（图3）。
A common complication of posterior stabilization of thoracolumbar burst fractures is a loss of correction. In these cases, fractures tend to collapse to their original degree of kyphosis. In response to this, McCormack and associates developed the load-sharing classification system to attempt to determine when the anterior column (ie, vertebral body) was rendered insufficient to resist compressive loads from bending moments. Using their point system, a score of 6 or more indicated that short-segment fixation would have a substantial likelihood of failing. In these cases, anterior fixation was recommended. Alternatively, many surgeons would posteriorly instrument an additional level above and below.
胸腰椎爆裂骨折后常见的并发症是固定的矫正丢失。在这种情况下，骨折往往塌陷到他们原来的后凸程度。为了回应这个问题，McCormack和同事们开发了负载分享的分类系统，试图以此确定何时前柱（即椎体）不足以抵抗屈曲动作的压力负荷。利用他们的计分系统，6分或更多更多则表明短节段固定有很大的可能会失败。在这种情况下，建议应用前路内固定。另外，许多医生会应用后路在损伤的上下节段放置额外的器械。
Placement of pedicle screws is technically demanding. It incurs the potential risk for nerve root, spinal cord, or vascular injury if the cortical borders are breached. Careful preoperative planning and intraoperative imaging help to ensure that screws are placed in the correct location. Rods should be precontoured before fixation to the screws. In situ bending has been found to weaken the screw-bone interface and usually is not advised. Screw breakage may occur more frequently with smaller diameter screws (4.5 mm or 5 mm) compared with larger diameter screws (6 mm or 7 mm). Ultimately, the size of the screw is determined by measuring the maximal transverse pedicle diameter on preoperative CT or MRI.
椎弓根的放置螺钉是需要技术的。如果打进皮质的边界会招致潜在的神经根、脊髓、或者血管的损伤。细心的术前计划和术中成像有助于确保螺钉位于正确的位置。棒在固定到螺钉上之前应被预弯。在原位弯曲可减弱螺钉骨关界面，并且通常不建议这样做。相对于较大直径的螺钉（6毫米或7毫米），较小直径的螺钉（4.5毫米或5毫米）更经常出现断钉。最终，螺丝的大小取决于术前CT或MRI测量的最大横向椎弓根直径。

Fig. 2. A 35-year-old man jumped 50 ft in a suicide attempt. He sustained multiple injuries, including open fractures of both upper extremities, comminuted pelvic fractures, and an L1 burst fracture. An ASIA A spinal cord injury victim, he underwent posterior thoracolumbar surgery from T11-L3 with a pedicle screw-rod construct. (A) Axial CT scan at the level of the L1 pedicles shows the retropulsed bone fragment. (B) Axial CT scan postoperatively at the L1 pedicle level shows canal decompression achieved via a bilateral transpedicular approach with reduction of the fracture fragments. (C) Anteroposterior plain radiograph shows a well-aligned posterior construct. (D) Lateral plain film radiograph shows good sagittal alignment in a construct that consisted of stabilization two levels above and two levels below the injured segment.
图2。一位35岁的男子企图在50英尺高跳下自杀。他经受了多处损伤，包括双上肢开放性骨折，粉碎性骨盆骨折，腰1爆裂性骨折。受伤者的脊髓损伤的美国脊髓损伤协会评分为A，他施行了胸11到腰3的胸腰椎后路椎弓根钉棒系统固定。（A）轴位CT扫描在腰1椎弓根水平显示骨折碎片的后退。（B）术后腰1椎弓根水平的轴位CT扫描显示，通过双侧椎弓根入路减少骨折碎片占位实现了椎管减压。（C）前后位的平片显示后部置入物对齐良好。（D）侧位的平片显示置入物良好的矢状位对齐，包括损伤节段的上两个和下两个节段的固定

Fig. 3. A 17-year-old girl jumped down an 8-step height and landed on her feet. She developed immediate back pain, L3 numbness, and bladder retention. Surgery was a partial corpectomy via a bilateral L3 transpedicular approach posteriorly. (A) Lateral plain radiograph shows an L3 fracture with diminished height anteriorly and mild kyphosis. (B) Axial CT scan shows a large bone fragment retropulsed into the spinal canal. (C) Sagittal CT scan shows a dramatic degree of canal compromise with loss of height. (D) Anteroposterior plain radiograph postoperatively shows good alignment of a posterior pedicle screw-rod L1-4 construct. As the anterior column integrity was preserved, this construct was performed to maintain lumbar mobility with two levels above and only a single level below included. (E) Lateral radiograph postoperatively shows excellent alignment with preserved lordosis of lumbar spine measuring 40_. (F) Axial CT scan postoperatively at the level of the L3 pedicle shows excellent decompression of the bone fragment and a defect from where the fragment had extruded.
图3。一名17岁的女孩从8级台阶高跳下后并用脚先着地。她立即出现了背痛，腰3麻木和膀胱储留。手术是通过后路双侧腰3椎弓根入路的部分椎体切除。（A）侧位平片显示腰3椎体前方高度的减低和轻微的脊柱后凸。（B）轴位CT扫描显示一个大的碎骨片向后退入了椎管。（C）矢状位CT扫描显示戏剧性的椎管后退程度同时伴有高度的丢失。（D）术后前后位平片显示，腰1到4的后方椎弓根钉棒置入物对齐良好。由于前柱的完整性被保留，这种置入的应用是为了保留腰椎的上两节段和仅仅下面的单一一个节段的运动功能。（E）术后侧位片显示保持了测量为40°腰椎前凸，并且对齐良好。（F）术后轴位CT扫描在腰3椎弓根层面显示良好的碎骨片的减压和骨折片曾经占据处的一个裂缝。
In the special instance of patients who sustain complete sensorimotor deficits from a spinal cord injury (American Spinal Injury Association [ASIA] class A), the authors prefer a posterior approach. The goal of surgery is to decompress as best as possible from the dorsal approach. Resection of one or more pedicles may help to facilitate the decompression. After this resection, stabilization is performed using a pedicle screw-rod construct. The more unstable the initial injury, the more levels are treated. In highly unstable injuries, the authors have instrumented three levels above and three levels below and use 1⁄4 -inch diameter rods. The authors reserve anteroposterior surgeries for patients with unstable injuries who are neurologically intact or who have incomplete spinal cord injuries (ASIA classes B-D).
在特定的脊髓损伤的完全性的感觉运动功能缺失（美国脊髓损伤协会[ASIA]分级为A）的病人，作者更倾向于后路。该手术的目的是从背侧入路尽量解压。一个或多个椎板切除可能有助于减压。经过切除后，固定是用椎弓根螺钉棒结构。最初的损伤越不稳定，治疗的节段越多。在高度不稳定的伤害中，作者曾放置直径1/4英寸的棒于损伤的上三个节段和下三个节段。作者保留为不稳定损伤的病人如神经学完整或具有不完全脊髓损伤（美国脊髓损伤协会分级为B到D）的病人施行前后路手术的观点。
Anteroposterior stabilization
前后固定

Highly unstable burst fractures typically are part of a fracture-subluxation pattern of injury. There also may be a rotational or translational component to these injuries. If the victim of one of these injuries has preservation of neurologic function, either as an incomplete spinal cord injury or as neurologically intact, an anteroposterior surgery is indicated (Fig. 4). The surgery itself is as described in the separate anterior and posterior stabilization sections. The decision to perform both parts of the surgery on the same day or to stage the surgeries as two separate procedures performed under separate anesthetics is determined by the medical condition and age of the patient. In general, if the patient is able to undergo both parts of an anteroposterior surgery on the same day safely, it is preferable to do this because it expedites rehabilitation and recovery. Anteroposterior surgery has greater blood losses and requires more operative time, so the physiologic demands on the patient are greater. These risks are offset by the need to decompress, fuse, and stabilize adequately a patient with a highly unstable spine injury and preserved neurologic function.
极度不稳定爆裂性骨折通常是一个外伤后骨折脱位模式的一部分。这些损伤也包括旋转或平移的部分。如果这些损伤的伤者保留了神经功能，不完全脊髓损伤或神经学正常，提示应进行前后路手术。手术本身已在单独的前路和后路固定中作描述。在同一天施行两部分手术或同一台施行独立两个步骤并进行单独的麻醉的手术的决定是由病人的状况和年龄决定的。一般来说，如果病人能够在同一天安全的施行前后路的两部分手术，因为它可加快康复和神经功能的恢复，因此这样做是更可取的。前后路手术的失血量更多，并且需要更多的手术时间，所以对病人的生理需求更多。这些风险被高度不稳定脊柱外伤病人的减压、融合和充分固定的需求所抵消，并保留了神经功能。

Fig. 4. A 31-year-old woman jumped 30 ft to escape a domestic dispute. She sustained multiple trauma, including a complex pelvic fracture, an ASIA C spinal cord injury with a neurogenic bladder, and bilateral lower extremity fractures. She also had burst fractures of the L1 and the L2 vertebrae. (A) Axial CT scan shows L1 fracture with bone retropulsed into the canal. (B) Axial CT scan shows more severe burst fracture with a greater degree of canal intrusion. (C) Sagittal CT scan postoperatively after the first stage of surgery, which included corpectomies of L1 and L2 and placement of a carbon fiber cage filled with autograft bone. (D) Anteroposterior plain radiograph postoperatively after the second stage of the surgery, which was a hybrid construct with laminar hooks, pedicle screws, and rods from T11-L4. (E) Lateral plain film radiograph shows the anteroposterior surgical construct. The patient regained normal motor power and bladder function postoperatively and resumed full activities.
图4。为逃避家庭纠纷，一名31岁的女子从30英尺高跳下。她经受了多处外伤，包括复杂的骨盆骨折，美国脊柱损伤协会脊髓分级为C并具有神经源性膀胱，和双侧下肢骨折。她还有腰1和腰2椎体的爆裂骨折。（A）轴位CT扫描显示腰1骨折块后退入椎管。（B）轴位CT扫描显示更严重的爆裂性骨折伴随更大程度的椎管侵入。（C）第一阶段手术后矢状面CT扫描，其中包括腰1椎体的次全切和腰2置入的碳纤维自体填充骨笼。（D）第二阶段手术后的前后位平片显示，是混合了薄层钩、椎弓根螺钉和胸11到腰4的棒的结构。（E）侧位平片显示了前后位置的置入物。病人恢复了正常的运动功能、术后的膀胱功能并恢复了全面的活动能力。Fusion techniques
融合技术

Although it provides immediate stability to facilitate patient rehabilitation and mobilization and prevent further neural insult, the long-term goal of instrumentation is to maintain the spine in a corrected position until bony fusion occurs. The fusion provides long-standing stability. Without solid fusion, metallic implants eventually break until fatigue failure occurs from cyclic loading. Successful fusion requires a bone graft or bone graft replacement that has three essential characteristics: osteogenicity (usually provided by bone cells), osteoinductivity (the ability to activate and sustain the cascade of biochemical processes that leads to bony healing), and osteoconductivity (the ability to provide a scaffold to which the new bone can attach to and propagate). For anterior interbody fusions, such as would follow a thoracolumbar corpectomy, the bone graft strut also must have sufficient mechanical properties to sustain loads.
虽然提供了即刻的稳定性方便了病人的康复和活动，并且阻止了进一步的神经损伤，但是器械的长期目的在于维持脊柱于正确的位置，直到骨性融合。融合提供了长期稳定。如果没有坚强的融合，最终金属植入物会因循环载荷疲劳出现断裂。成功的融合需要植骨或骨移植，这具有三个基本特点：成骨（通常由骨细胞提供），骨诱导性（能够激活和维持过程中的生化级联反应和骨生成（提供一个支架来让那些新骨能附着和繁殖的能力）。对于前路椎体间融合，例如将遵循胸腰椎椎体切除术，植骨支撑也必须具有足够的机械性能来维持负载。Anterior fusion
前路融合

After removal of a fractured vertebral body, a void is present between the uninjured vertebrae to be fused. This void must be filled with something that can sustain axial compressive loads and maintain kyphosis correction. Choices include autograft (usually iliac crest bone graft), allograft (usually a segment of femoral or humeral shaft), or synthetic cages filled with morcellized autograft or allograft.
在骨折椎体移除后，在未受伤椎体之间的空腔必须被融合。这个空腔必须被填充来维持轴向的压力载荷和保持后凸的矫正状态。选择包括自体（通常髂骨植骨），同种异体（通常是股骨或肱骨干），或充满粉碎的自体或同种异体骨充满的合成的笼。
The authors prefer to use autologous bone graft when possible. In many cases, this bone graft is harvested from the iliac crest. Vertebral bone can be salvaged from the corpectomy as well. If a titanium mesh cage is used, salvaged bone can be combined with cancellous bone from the iliac crest and packed inside the cage. The use of titanium mesh cages in the setting of trauma has provided good results. The authors have substantial experience with the use of radiolucent, carbon fiber cages that are filled with autologous bone from the corpectomy. Kyphosis must be maximally corrected before placement of the device. Slight distraction of the corpectomy site using the screw-staple anchor or a Kaneda-type device can facilitate this correction and insertion of the cage. Although the cartilaginous material must be removed to allow fusion, the end plates of the adjacent vertebra should not be violated because this would cause subsidence regardless of the choice of graft or strut.
在可能的情况下作者倾向于使用自体骨移植。在很多情况下，可以从髂嵴获取大量的这种骨。椎体切除的椎体骨也可以废物利用。如果使用钛网笼，切除下的骨和髂嵴的松质骨可以联合并在笼内压紧。创伤的环境中钛网笼的应用提供了良好的预后。作者有可透射线的充满来自椎体切除的自提骨的碳纤维笼的应用大量经验。在器械放置前后凸必须被最大限度的纠正。采用螺旋锚或Kaneda-类型的器械来轻微的远离椎体切除的部位可以方便纠正畸形和笼的插入。虽然必须移除软骨来达到融合，不管移植或支撑因其会导致骨质塌陷，所以相邻椎体终板不应受到破坏。
Proper orientation of the graft is important. Biomechanically, it should be placed as close to the anterior vertebral body as possible. Optimally, it should be centered along the end plates to ensure even distribution of compressive loads. After the cage or strut is placed, a Penfield 4 elevator should be used to confirm that there is adequate space anterior to the dural sac. Axial compression can be delivered using the vertebral body screws to ensure a tight interference fit between the end plates and the cage or bone graft. Using these principles, the risk of cage or graft dislodgment or failure can be reduced.
正确的移植方向非常重要。生物力学，应该放在尽可能靠近椎体前方。最理想的，应该沿终板为中心，以确保平均的压缩载荷分布。在笼或支撑物放置后，彭菲尔德4的升降机应当被应用来确定有足够的空间到达前方的硬膜囊。轴向的压力可以通过椎体螺钉传递以确保终板和笼或植骨之间紧密的接触。应用这些原则，笼或移植物脱落或失败的风险可以减少。Posterior fusion
后路融合

Techniques of posterior fusion are familiar to most spinal surgeons. After placement of instrumentation, solid fusion is facilitated by decorticating all exposed bone elements. Provided that they are present, these include the laminae, facet joints, and transverse processes. The interspinous process ligaments (if intact) of the vertebra to be fused also can be resected using a rongeur to enable union between these bony surfaces. After this resection, large amounts of autogenous bone graft harvested from the iliac crest are packed over the surfaces. If autogenous graft harvest is not feasible, allogeneic graft can be used if combined with an osteoinductive agent, such as demineralized bone matrix.
脊柱外科医生最熟悉的是后路融合技术。放置器械后，牢固的融合是通过剥离了所有骨外露部分促成的。倘若它们存在，包括椎板、小关节和横突。被融合椎体的棘间韧带（如完好）也应该被咬骨钳切除，来使骨表面结合。在切除之后，从髂嵴收获的大量自体骨被移植在上述表面压紧。如果收获的自体移植是不足，同种异体骨可以联合应用骨诱导剂，如脱钙骨剂。
General considerations
总的考虑

Smoking increases the chance for nonunion. Although a patient may be asked to quit smoking before an elective fusion for a degenerative disorder, this is not possible in an acute trauma patient. In such cases, it is the authors’ strong preference to use autogenous bone for fusion. One also might consider application of special devices, such as bone growth stimulators, to encourage fusion. In addition, the patient is encouraged not to smoke after surgery for at least 12 weeks.
吸烟增加了不愈合的机会。虽然在退行性疾病选择融合前可要求病人戒烟，但在急性外伤病人中这种方法是不可能的。在这种情况下，作者强烈倾向于使用自体骨进行融合。也可以考虑应用特殊的方法，如骨生长促进因子来加速融合。此外，至少术后12周是不鼓励病人吸烟的。
Other factors that can influence fusion rates include the use of steroids and nonsteroidal anti-inflammatory drugs. Although the use of steroids for a medical comorbidity such as autoimmune diseases might not be avoided, their routine use for such indications as postoperative laryngeal swelling (often prescribed by anesthesiologists) should be avoided. Likewise, the use of ketorolac (Toradol), a powerful nonsteroidal anti-inflammatory drug that has a demonstrated inhibitory effect on bone healing, should be avoided for at least 2 to 4 weeks after fusion surgery.
其他可影响融合率的因素，包括类固醇及非类固醇类抗炎药物的使用。虽然如自身免疫性疾病的合并症可能无法避免使用类固醇，他们常规应用的适应症如术后喉头水肿（通常由麻醉师所开）也应当避免。同样，应用酮咯酸（酮咯酸注射剂），强大的非甾体抗炎药，证明对骨愈合的抑制作用，至少在融合术后2到4周也应当避免应用。
Potential medical complications
潜在的并发症

Perioperative medical problems can arise from inadequate intraoperative fluid rescuscitation (leading to hypotension), overrescuscitation (potentially leading to massive swelling and pulmonary edema), or electrolyte imbalance. These require careful attention in a critical care unit.
围手术期的问题可能由于纠正体液不足（导致低血压），过度纠正（潜在的会导致大规模的肿胀和肺水肿）或电解质失衡。这些需要在危重症病房细心注意。Particularly in patients who have sustained a spinal cord injury, have sustained multiple trauma, or are being treated nonoperatively, problems related to immobility and recumbency are common. Among others, these include pneumonia from insufficient pulmonary toilet, deep venous thrombosis and pulmonary embolism, urinary tract infections, and decubitus ulcers. Other perioperative complications involve a lacerated dura and hemothorax.
特别是在有脊髓损伤的病人，具有多处创伤，或正在接受非手术治疗，制动和卧床的相关问题是常见的。其中，这些包括肺排泄不畅所致的肺炎，深静脉血栓和肺栓塞，泌尿道感染和褥疮溃疡等。围手术期的其他并发症包括硬脑膜撕裂和血胸。
Superficial and deep wound infections can develop after surgical management. Data suggest that wound infections are more common after surgery for thoracolumbar trauma than for degenerative conditions. Superficial infection can be treated with local wound de′bridement and oral antibiotics. Deep wound infections must be treated with open de′bridement, irrigation, closure, and parenteral antibiotics.
浅和深部伤口感染可能在手术后形成。数据表明，胸腰椎外伤术后伤口感染后比退行性状况更为普遍。浅表感染可经局部伤口清创和口服抗生素治疗。深部伤口感染必须用开放清创、冲洗、闭合和静脉应用抗生素治疗。
Summary
摘要

Although most thoracolumbar and lumbar fractures can be treated conservatively, many require surgery. Choosing an appropriate surgical option requires an in-depth understanding of various methods of decompression, stabilization, and fusion. Anterior surgery leads to the greatest degree of spinal canal decompression and offers the potential benefit of limiting the motion segments fused. These advantages come with the added time and morbidity of the surgical approach. Posterior surgery is more familiar to most surgeons and can be an effective approach to the management of these injuries. Its limitations must be recognized, however, to avoid complications, such as inadequate decompression, recurrent deformity, and construct failure. Although many of the principles are the same, the treatment of low lumbar burst fractures requires some additional consideration of the difficulty of approaching this region anteriorly.
虽然大部分胸腰椎骨折可通过保守治疗，但是很多需要手术治疗。选择合适的手术方案需要深入了解各种减压、固定和融合的方法。前路手术可最大程度的进行椎管减压并且提供潜在限制融合节段运动的益处。这些优势是由更多的时间和手术方式的应用率带来的。后路手术是外科医生比较熟悉的，并可成为这些损伤的有效的治疗方法。必须认识到其局限性，然而，为了避免并发症，如减压不足，经常性畸形和植入物断裂。虽然许多原则是相同的，下腰椎爆裂骨折的治疗需要需要额外的考虑前路到达这个区域的困难。References