【专题文献】之胸腰椎骨折-下腰椎爆裂骨折的诊断和治疗

Seminars in Spine Surgery，Volume 22, Issue 1, March 2010, Pages 33-37
Thoracolumbar Spine Injuries

Diagnosis and Management of Low Lumbar Burst Fractures
下腰椎爆裂骨折的诊断和治疗

Charles A. Sansur MD, MHSca and Christopher I. Shaffrey MD
a Department of Neurosurgery, University of Virginia, Health Sciences Center, Charlottesville, VA
Available online 13 February 2010.

Fractures of the low lumbar spine are relatively uncommon and have various injury patterns. Treatment must be individualized and should take into account the fracture type, ligamentous injury pattern, neurological injury, the limitations of surgical implants, and the anatomical approaches available. Nonoperative management of burst fractures for patients without neurological deficits has generally been reported to have acceptable outcomes. For low lumbar burst fractures or fracture dislocations of the lumbosacral segment where neurological injury has occurred, surgery is indicated. This surgery should include decompression (posterior or anterior), spinal realignment with maintenance of lumbar lordosis, and instrumentation over minimal segments. Conservatively managed patients require continued follow-up to manage symptoms and check for possible development of deformity.
脊柱骨折中下腰椎骨折相对少见且椎体损伤形式多种多样。治疗必须个体化，制定治疗方案时需考虑骨折类型，韧带及神经损伤情况，外科植入物的限制和可供选择的手术入路。有研究显示爆裂骨折病人如果无神经功能障碍采取非手术治疗预后令人满意。下腰椎爆裂骨折或腰骶节段骨折脱位伴神经损伤为手术适应症。手术包括前后路进行减压，恢复腰椎前凸椎体序列和最少节段间行内固定术。保守治疗的病人需要长期随访以便随时处理新出现的症状并检查可能发生的腰椎畸形。

Keywords: burst; fracture; lumbar; trauma; vertebrae
关键词：爆裂； 骨折； 腰部； 外伤； 椎体

Burst fractures of the lower lumbar spine (L4 and L5) account for approximately 1% of all lumbar fractures, and most often result from high-impact trauma.1 Seybold et al2 noted only 31 such fractures in a span of over 16 years in their multi-institutional study. Because of the infrequency of these fractures, only a limited number of reports exist on their optimal management.
The lumbosacral spine plays a major role in axial weight-bearing of the spine. This segment of the spine provides support primarily through the vertebral bodies, the pelvis, the ilio–lumbar ligaments, and the local musculature. Because the structural integrity of the L4 and L5 vertebral bodies is responsible for the maintenance of lumbar lordosis, burst fractures at these levels can lead to reversal of this lordosis. This in turn influences the biomechanical properties of this segment of the spine.3
在所有腰椎骨折病例中，下腰椎爆裂骨折（腰4和腰5）约占1%，且多由高能量创伤造成。Seybold等在他们16年的多机构研究中仅记录了31例下腰椎爆裂骨折。由于这种骨折很少发生关于其最佳治疗的报道也十分有限。
腰骶椎在脊柱轴向承重方面起主要作用，通过椎体，骨盆，髂腰韧带和周围肌肉组织为人体提供支撑。由于腰4和腰5椎体结构完整性与腰椎前凸密切相关，该节段发生爆裂骨折可逆转腰椎前凸并影响其生物力学特性。


Initial Management of Low Lumbar Fractures
下腰椎骨折的早期治疗

Early response in all patients with suspected neurological injury may lead to better outcome.[4], [5] and [6] Patients who have been victims of any high-energy traumatic event can be prone to a potentially unstable spine. Guidelines of the Advanced Trauma Life Support system should be followed.
Upon the initial encounter in the emergency room, a visual assessment of the patient's back is essential. Significant bruising, lacerations, and abrasions should be noted as these may be important predictors of the extent of the injury. Tenderness on palpation is also important to assess. Palpation of a step-off, or gross misalignment of the spinous processes may also reveal extensive underlying injury.
The examiner should then proceed with a complete neurological examination. Preservation of rectal tone and pinprick sensation in the perineal can be associated with an improved prognosis.7 Because the spinal cord may terminate at L2 (although it ends at L1 in most patients), low lumbar injuries may manifest themselves in a variety of ways, depending on the extent of ligamentous injury and degree of bony retropulsion.
针对怀疑有神经损伤的病人早诊断早治疗可使他们获得更好的预后。有高能量创伤史的病人均有可能发生脊柱不稳，需遵循高级创伤生命支持指南。
在急诊室收治病人时背部的视诊非常重要。明显的瘀伤，撕裂伤和擦伤是受伤程度的重要指标需特别留意。触诊时产生的压痛也是衡量受伤程度的重要指标。触诊发现脊柱椎体错位或棘突序列不良也能显示广泛的潜在性损伤。
检查者需施行全套神经系统检查。直肠张力和会阴针刺觉存在与预后改善有关。脊髓神经终止于腰2水平，随着韧带损伤和椎体后凸畸形程度不同，下腰椎骨折的症状也多种多样。


A thorough radiological assessment is necessary in these patients. Anteroposterior and lateral x-rays of the entire spine are the initial studies performed in patients with a history of a high-impact injury. Depending on the individual circumstances of each patient's injury, the presence of nonspinal injuries must also be evaluated. Chance fractures are frequently found in conjunction with abdominal injuries.[8] and [9] Fractures of the calcaneus and tibia are commonly found in patients with burst fractures who have fallen from significant heights.10 Subcutaneous air and soft tissue swelling on plain films may also represent coexisting injury.
In patients with suspected pathology, computed tomographic (CT) scanning is performed. Clinical measurements of the spine, including the degree of canal compromise, extent of displacement, and changes in angulation can easily be assessed using CT-scanning, and may correlate with the degree of neurological deficit.11
Magnetic resonance (MR) imaging is recommended in patients with neurologic deficits to visualize the neural elements and prepare for surgical intervention. This is particularly relevant in pediatric patients, as the conus may be low lying in some cases. MR imaging is also useful in detecting ligamentous disruption, disc herniation, and extent of edema when CT-scans appear normal.12 MR imaging is also important to obtain in the neurologically intact patient with high energy trauma, as plain films and CT are not completely reliable in determining the relative stability of the spine. In one study, MR imaging and x-ray/CT images of 21 patients with 25 burst fractures were retrospectively evaluated to compare the ability to detect ligamentous integrity among the different imaging modalities.13 Radiographic indicators of posterior ligamentous disruption were present in only 33% of patients who had ligamentous injury found on MR imaging.13
对于下腰椎骨折病人彻底的影像学检查十分重要。针对有高能量创伤史的病人，首先行全脊柱前后位及侧位的X线检查。根据每个病人损伤情况的不同，我们还需要评估非脊髓损伤。Chance骨折的发生常伴随腹部损伤。从高处坠地下腰椎爆裂骨折的病人常伴发跟骨和胫骨骨折。平片常同时发现皮下气肿和软组织肿胀。
诊断不明时行CT检查。CT可以清楚显示与神经功能障碍有关的椎管受压程度，椎体移位及成角，从而确定脊柱损伤情况。
在神经功能障碍的病例中建议术前行MRI检查对脊髓进行显像。由于某些小儿病例脊髓圆锥发育不成熟，术前MRI检查显得格外重要。MRI检查也有助于发现韧带损伤，椎间盘突出和CT扫描显示正常的神经水肿。在有高能量创伤史神经功能正常的病例，MRI可以发现平片和CT无法发现的脊柱不稳。一项回顾性研究通过对21例椎体爆裂骨折（病例总数25） 病人行MRI和X线/CT检查，比较不同影像学检查手段检测韧带损伤的能力。相比MRI，X线和CT检查仅能发现其中33%的病例出现后纵韧带损伤。



Differential Diagnosis
鉴别诊断

Low lumbar burst fractures can be classified according to the Denis model.14 F. Denis, The three column spine and its significance in the classification of acute thoracolumbar spinal injuries, Spine 8 (1983), pp. 817–831. 14 These fractures result from a combination of excessive flexion and axial loading, and involve the anterior and middle spinal columns. On plain films, there is a demonstration of loss of posterior vertebral body height, retropulsion of bone into the canal, and enlargement of the distance between pedicles. In the absence of flexion, pure axial loading may result in a fracture that maintains lumbar lordosis. It is more common, however, for flexion to be associated with axial compression, hence leading to kyphosis and neurological deficit from bone fragments encroaching the spinal canal.[15] and [16]
根据Denis三柱理论对下腰椎爆裂骨折分型（参考文献：F. Denis, The three column spine and its significance in the classification of acute thoracolumbar spinal injuries, Spine 8 (1983), pp. 817–831.）。椎体过度屈曲和轴向负重增加导致下腰椎爆裂骨折并累积前中柱。平片检查可发现后侧椎体高度降低，椎体后凸碎骨块进入椎管以及相邻椎弓跟距离增加。单纯脊柱轴向负重增加不伴椎体过度屈曲也可导致椎体骨折，但腰椎前凸生理弯曲存在。前者较常见，累及前中柱的下腰椎爆裂骨折导致椎体后凸畸形，如碎骨块进入椎管则引起神经功能障碍。
Flexion distraction injuries are commonly associated with seat belts in motor vehicle crashes. In flexion distraction injuries, all 3 columns are involved, but there is preservation of the anterior longitudinal ligament. When the spine is flexed due to rapid deceleration at the time of injury, the seat belt functions as a pivot.1 Thus, the level of lumbar spine injury is often dependent on the position of the seat belt. These fractures are generally viewed as being unstable because of the coexisting ligamentous injury.8
Of all lumbar spine fractures, fracture-dislocations are the least stable. These fractures are caused by a combination of flexion-distraction, shear, and rotational forces. All 3 columns are affected in these highly unstable fractures, and the anterior longitudinal ligament gets injured as well. Because of the severe instability associated with fracture dislocations, the patients require operative management.
屈曲分离型骨折多见于汽车安全带损伤，所以又被称为安全带骨折，常累及三柱但前纵韧带常完整。汽车急刹车时脊柱以安全带为支点屈曲，骨折节段与安全带捆绑位置相关。由于常伴有韧带损伤屈曲分离型骨折被分类为不稳定骨折。
在所有腰椎骨折中，由于脊柱过度屈曲并受到剪应力和旋转暴力作用屈曲分离型骨折最不稳定。三柱全部受累且前纵韧带损伤。由于骨折移位椎体极度不稳，病人需要接受手术治疗。


Operative and Nonoperative Management
手术治疗和非手术治疗

Conservative Treatment
保守治疗

The optimal treatment of low lumbar burst fractures is a point of debate among spine surgeons. While some studies advocate nonoperative management in the neurologically intact patient, other studies recommend surgery. Patients who are conservatively managed require pharmacologic pain control and may benefit from a thoracolumbosacral orthosis.17 Regular radiographic follow-up is important in this setting to verify that there is no development of progressive kyphosis. Early studies have indicated that conservative management of low lumbar burst fractures can be associated with good short-term pain outcomes.[5], [18] and [19] A recent article examined the management of patient L5 isolated burst fractures with a 10-year follow-up.20 Fourteen patients were in this study, and 74% of the patients were managed conservatively. The authors reported superior radiographic outcomes in the nonoperative group. The nonoperative group had a 15.7% mean loss of anterior vertebral height and a mean kyphotic deformity of 10.4, while the surgical group had a mean of 19% anterior vertebral height loss, with 11° of kyphosis. Furthermore, the conservative group was associated with superior clinical results at follow-up regarding pain status, return to work, and overall satisfaction.20
In contrast to the above, there also is evidence that the radiographic outcome in patients who receive conservative treatment is inferior.18 In An's series of 22 patients, although there was satisfactory control of pain with conservative management, the loss of lordosis and vertebral column height in the conservative group was significantly high (9.2° of kyphosis and 31% loss of vertebral height in the nonoperative group, vs 1° and 19% loss in the surgical group).18
脊柱外科医生对下腰椎爆裂骨折的最佳治疗方法一直存在争论。有研究支持对无神经功能障碍的病人采取保守疗法，也有研究建议手术治疗。保守治疗包括镇痛和佩戴胸腰骶矫形器，定期影像学随访对确定脊柱后凸畸形发生进展十分重要。早期研究显示保守治疗下腰椎爆裂骨折对于缓解短期疼痛效果良好。最近有一项关于单纯腰5爆裂骨折的10年随访研究， 14例患者中74%的病例采取保守治疗。保守治疗组椎体前部高度平均丢失15.7%，腰椎后凸畸形角度为10.4度；手术治疗组椎体前部高度平均丢失19%，腰椎后凸畸形角度为11度。该研究还发现保守治疗组疼痛缓解程度，复工时间以及总体满意度均优于手术治疗组。
与上文相反，也有研究显示手术治疗病例较保守治疗可获得更好的影像学转归。An的研究显示：在22例下腰椎爆裂骨折病例中，虽然采取保守治疗可以有效控制疼痛但脊柱正常生理弯曲和椎体高度的丢失保守治疗组远高于手术治疗组（保守治疗组腰椎后凸畸形角度为9.2度，椎体高度平均丢失31%；手术治疗组腰椎后凸畸形角度为1度，椎体高度平均丢失19%）。


Surgical Management
手术治疗

Although there is no universal consensus, it is generally believed that surgery is indicated when an injury is complicated by neurologic deficit, evidence of ligamentous injury on MR imaging, or instability using dynamic radiographic imaging.[4] and [6]
Typically, fractures with 40% or more canal compromise, kyphosis of greater than 25°, and 50% or more loss of vertebral height require surgery.21 Surgery is necessary in these circumstances to decompress the neural elements and provide stability to the injured spine, with the maintenance of lumbar lordosis.21
Depending on the degree of canal compromise and surgeons' preference, the posterior approach can be used to treat low lumbar burst fractures. Posterior instrumentation with decompression of neural elements can be performed, along with the reduction of distracted facet joints, if needed. After the laminectomy is performed, retropulsed burst fragments can be impacted away from neural structures to facilitate decompression of the central canal. Dural tears are commonly associated with lumbar burst fractures, and special attention needs to be made during the posterior decompression to avoid injury to the nerve roots.22
虽然没有普遍的共识，通常认为下腰椎爆裂骨折的手术指征为：神经功能障碍合并MRI显示韧带损伤或动态影像学检查发现椎体不稳。
通常下腰椎爆裂骨折伴椎管占位大于40%，腰椎后凸畸形大于25度或椎体高度降低50%时，必须采取手术治疗。手术能有效减压，恢复不稳的椎体并维持正常腰椎生理弯曲。
根据椎管占位程度和术者的偏好选择后路手术治疗下腰椎爆裂骨折。手术治疗包括：后路椎管减压内固定，如有必要还可复位临近关节突关节。行椎板切除术后可取出突入椎管的碎骨块达到减压的目的。硬脊膜撕裂常伴随下腰椎爆裂骨折发生，行后路减压术时需特别注意勿损伤神经根。


Because wide laminectomies have been demonstrated to increase the risk of lumbar instability postoperatively,23 fusion and instrumentation play an integral role in the patients with burst fractures, who require a posterior decompression. Although the modern transpedicular screw fixation technique is simple and effective, surgeons should attempt to limit the extent of the construct to a minimum number of levels to help reduce adjacent segment degeneration and flat-back syndrome.24
A variety of factors come into play when deciding to what extent instrumentation is required and which instrumentation system to use. Individual patient characteristics, such as pedicle size and anatomy, bone quality, and history of previous surgery may all play an integral role in this decision-making process. Although rods and screws with larger diameter have greater potential to resist bending moments, older patients with poor bone quality and rigid constructs can develop fractures at the cranial and caudal aspects of their constructs.[25] and [26] Injection of vertebroplasty cement can be used to treat fractures at the cranial end of a long-segment fusion.26 Furthermore, cement can be used to above-mentioned fusion constructs to prevent fractures from forming in osteoporotic patients. Cement can also be placed into vertebral bodies intraoperatively to increase pullout strength in the setting of poor bone quality.27 There are no prospective long-term studies to demonstrate the efficacy of bone cement as described above, but it has been used successfully by the senior author to augment fusions in patients with poor bone quality.
由于广泛的椎板切除会引起腰椎不稳，针对需要后路减压的腰椎爆裂骨折的病人内固定及融合术不可或缺。虽然椎弓根钉固定术简单有效，但术者仍需尽量减少固定节段避免相邻椎体退变和平背综合征的发生。
如何确定内固定节段和选择内固定系统与许多因素有关。制定个体化治疗方案需要考虑椎弓根钉的尺寸，骨的质量和前次的手术方案。虽然大直径的钉棒系统可以有效对抗折弯，但若使用于伴有骨质疏松的老年病人则会导致固定节段两端的椎体骨折。长节段融合头侧椎体骨折可采用椎体成形术注入骨水泥治疗。椎体成形术注入骨水泥适用于以上病例，可防止骨质疏松病人融合节段发生骨折。术中如果发现骨的质量不佳也可注射骨水泥增加抗拉强度。目前没有前瞻性随访研究支持上文所述骨水泥的作用，但其在临床已被本文第一作者成功应用于骨质不佳的病例以增加融合强度。

In cases of canal compromise that cannot be corrected from a posterior only route, anterior column reconstruction should be considered (Fig. 1). The advantage of the anterior approach is the direct access to the main pathology causing neural compression. Anterior-only surgery is possible when the injury is limited to the anterior and middle columns.28 If the injury involves all 3 columns, anterior-posterior surgery is required for decompression and stabilization.28 Access to the L4 and L5 vertebral bodies can be difficult due to the positioning of the great vessels, or in the setting of previous abdominal surgery. In these cases, an access surgeon may be indicated. Recently, there have been more reports demonstrating success in reconstruction of the anterior and middle columns from a posterior approach. Zhang et al29 reported their posterior-only technique, the treatment of 22 lumbar burst fractures requiring anterior and middle column reconstruction. Using their method, the transverse processes of the affected lumbar level is used to obtain access to the vertebral body. This provides them with the window needed to decompress the spinal canal and insert a titanium mesh cage packed with autograft to reconstruct the anterior and middle columns. This construct was them supplemented with pedicle screws in the adjacent levels. They had an average of 17.2 months follow-up, with good radiographic results. They reported 3 cases of transient weakness from nerve root injury and 1 case of hardware loosening.29 Other surgeons have reported the use of vertebroplasty cement to increase the vertebral body height of the burst fracture level in conjunction with short segment instrumentation.[30] and [31] Although this technique is by no means the gold standard, it demonstrates that over time surgeons are seeking ways to treat burst fractures in a posterior only fashion, especially when patients have no neurological deficits. For those patients who have significant neurological compromise, the anterior approach with or without posterior fixation is the gold standard.28
单纯后路手术无法完全解除椎管占位时，需考虑行前柱重建术（图1）。经前路手术的优势在于可直观的发现并处理引起神经压迫的椎管占位。对于仅累及前柱和中柱的爆裂骨折可考虑行单纯前路手术。如果骨折累及三柱则需要联合前后路进行手术。腹部大血管的存在或二次手术正常组织结构遭到破坏都增加了暴露腰4，5椎体的难度，这种情况促使外科医生思考新的手术入路。最近，关于经后路成功实施前柱和中柱重建的手术报道越来越多。宁波第六医院徐荣明，郑智玉教授报道：他们成功经后路对22例下腰椎爆裂骨折病人实行前柱和中柱的重建手术,术中通过骨折节段椎体横突暴露椎体，通过该窗口对椎管进行减压植入钛网cage并填充自体骨重建前柱和中柱。术后随访17.2个月，影像学检查结果良好，仅有3例因神经根损伤造成一过性下肢无力，仅1例出现内固定物松动。也有医生报道经后路使用椎体成形术水泥增加爆裂骨折节段椎体高度并联合短节段内固定治疗下腰椎爆裂性骨折。虽然上述后路手术方式不是治疗下腰椎爆裂性骨折的金标准，但它们的出现表明骨科医生在不断探索不断完善单纯后侧入路术式，特别是治疗不伴神经功能障碍的病例。治疗下腰椎爆裂骨折伴明显神经功能障碍手术入路的金标准为单纯前侧入路或前后联合入路。

Conclusions
结论

Low lumbar burst fractures are uncommon, and are found to result from high-impact trauma. These patients should undergo a complete traumatic evaluation. Conservative treatment of stable injuries without neurological deficit provides acceptable results. For those patients with neurological compromise or instability, treatment options include surgery via an anterior, posterior, or combined approach. There is an increase in the trend to develop technologies aimed at posterior only surgery, but this has been limited to experience in patients without neurological deficits.
高能量创伤导致的下腰椎爆裂骨折并不常见，需彻底评估病人的外伤情况。不伴神经功能障碍稳定性骨折的病例可采取保守治疗，对于有神经功能障碍或不稳定性骨折病例需经前路，后路或联合入路行手术治疗。针对脊柱后路手术的新技术不断发展，但它仅适用于无神经功能障碍的病例。

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