译文发布帖—胸腰椎骨折—胸腰椎骨折前路手术治疗

ThoracolumbarFractureManagement:AnteriorApproach
胸腰椎骨折的前路手术治疗

Abstract
Thesurgeonwhotreatspatientswithspinetraumamustbeabletoapplyavariety
ofmanagementtechniquestoachieveoptimalcareofthepatient.Theanteriorsur-
gicalapproachisappropriateforsomethoracolumbarburstfracturesinpatientswith
neurologicde?citandwithoutposteriorligamentousinjury.Surgeryismostoften
indicatedforpatientswithincompletede?cit,especiallythosewithalargeretro-
pulsedfragment,markedcanalcompromise,severeanteriorcomminution,orky-
phosis>30!a.Thisapproachprovidesexcellentvisualizationoftheanterioraspecto
theduramaterfordecompression.Reconstructionoftheanteriorbodydefectcanbe
donewithautograft,allograft,oracage.Supplementationofthegraftwithanterior
internal?xationhelpspreventkyphosis.Clinicalresultsdemonstrateimprovedneu-
rologicfunctioninmostpatientsaswellaslowpseudarthrosisrates.Inpatients
withincompletede?cit,improvementinneurologicfunctionusuallycanbeexpected
withfewcomplications.













摘要：治疗脊柱损伤的外科医生必须能够运用多种治疗技术已达到对病人的最适宜治疗。对于胸腰椎爆裂性骨折伴有神经功能损伤但是不存在后柱韧带损伤的患者适宜采用前路手术治疗。手术最适宜用于伴有不完全神经功能损伤的患者，尤其是有大块爆裂骨块造成明显椎管挤压，严重前柱粉碎或者后凸畸形大于30°。前路手术可以为硬脊膜前方减压提供清晰视野。可以运用自体骨移植、异体骨移植或者cage进行前柱功能重建。除了骨移植外，前路内固定器也有助于防止后突畸形。临床研究结果显示在很多患者中神经功能的改善同时假关节现象的发生率也比较低。在有不完全性神经功能损伤的患者中，预期神经功能改善同时伴有较少的并发症。
Thegoalsofthoracolumbarfracture
managementaretopreserveorre-
storetheneurologicandbiomechan-
icalfunctionsofthespine.Bothnon-
surgicalandsurgicalmanagement
havearole.Optimalsurgicalmanage-
mentofthoracolumbarfracturesre-
quiresunderstandingthepatient!fl
clinicalsituation,thefractureclassi-
?cation,andthestrengthsandweak-
nessesofavarietyofapproachesand
stabilizationtechniques.











正文：胸腰椎骨折的治疗目的是保留或者重建神经功能以及脊柱的生物力学功能。手术治疗和非手术治疗各具作用。胸腰椎骨折最佳治疗方案需要了解患者的病史、骨折的分型、不同治疗方法和固定技术的优缺点。
Theanteriorapproachcanbeused
forbothmanagementoftheneuro-
logicde?citandrestorationofstabil-
itytothespine.Inmostpatients,neu-
rologicde?citiscausedbyimpact
and/orcompressiontotheventralsur-
faceofthespinalcord.Theanterior
approachprovidesoptimaldirectex-
posureforvisualizationoftheven-
tralaspectoftheduramaterduring
1
Additional-
surgicaldecompression.
ly,forfracturepatternsinvolving
markedcomminutionwithlossofsup-portoftheanteriorandmiddlecol
umnsofthespine,theanteriorap
proachprovidesexcellentexposurefo
reconstructionwithstructuralgraft
orimplants.Thisallowsrestoration
ofheightandcorrectionofkyphosi
whilelimitingthenumberofmotion
segmentsfused.Thisisespeciallyuse
fulinpatientswhosegeneralcondi
tionpreventsposteriorreductionin
the?rst7to10daysafterinjury.The
anteriorapproachalsoavoidsaddi
tionalinjurytotheparaspinalmus
clesanddisruptionoftheirinnerva
tion.However,comparativestudie
betweenanteriorandposteriorap
proachesarelimited.Thus,itisdif
?culttopresentobjectiveevidencetha
oneapproachisbetterthantheoth
er,especiallyinthe?rst7to10day
afterinjury.Additionally,nonsurgica
managementaswellasanteriorand
posteriorapproacheseachhavethei
uniqueroleinthetreatmentofpatient
withthoracolumbarspineinjury.






































前路手术可用于神经功能损伤的治疗以及重建脊柱的稳定性。在很多病人中，神经功能损伤源自脊髓腹侧面的受压。在减压手术中，前路手术可以为硬脊膜腹侧面提供清晰直接的暴露视野。另外，对于明显粉碎性骨折病人伴有脊柱前柱和中柱丢失的病人，前路手术可以为运用骨移植或者植入物进行重建提供最佳暴露。尽管这样限制融合阶段活动度，但是它允许脊柱高度的重建以及纠正后突畸形。对于在受伤后7-10天总体条件可以预防后柱减低的病人前路手术尤其适用。前路手术也能避免对脊柱肌肉群的损伤以及破坏他们的神经支配。尽管，有关前路手术和后路手术的对照研究有限。因此很难提供一种手术优于另一种手术的客观证据，尤其在受伤后7-10天。另外，对于胸腰椎损伤患者的治疗非手术治疗与前路、后路手术各具独特作用。
PatientEvaluation
Appropriatetreatmentofpatientswith
thoracolumbarinjuriesisguidedby
athoroughhistoryandphysicalex-
amination,withparticularattention
paidtotheneurologicassessment.The
historyshouldincludethemechanism
ofinjury;thepresenceofpain,weak-
ness,andlossofsensation;andare-
viewofcomorbidities.Thephysical
examinationshouldincludelogroll-
ingtoallowvisualinspectionandpal-
pationofthebackandspine.Local
tenderness,swelling,gapsbetween
spinousprocesses,gibbousdeformi-
ty,andecchymosisshouldbenoted.
Neurologicexaminationofthelow-
erextremitiesandperineumiscrit-
icalandshouldincludeevaluationof
sensation,motorfunction,andre?ex-
es.Radiographs,computedtomogra-
phy(CT),and,onoccasion,magnet-
icresonanceimaginghelpdelineate
thenatureofthefractureandextent2
ofinjury. Magneticresonanceimag-
ingisindicatedinthepresenceofan
unexplainedneurologicde?cit,pro-
gressivedeterioration,ornotablesoft-
tissueinjury



























.
患者评估：胸腰椎损伤的患者合适治疗要通过完整的病史、体格检查来指导，尤其要重视神经功能的评估。病史应包括受伤的机制，痛点，感觉减弱和消失的地方以及类似症状疾病的辨别。体格检查包括：将病人滚筒式翻转以清楚视诊和触诊后背和棘突。应将局部压痛点、肿胀突起、相邻棘突阶段之间阶梯征、后突畸形以及皮肤瘀斑一一记录。四肢及会阴部位的神经功能检查是关键，同时应包括感觉、运动功能以及神经反射的评估。X线、CT有时核磁共振成像也能帮助描绘骨折的性质以及受伤的程度。出现不能解释的神经功能损伤、进行性加重或者重要的软组织损伤是应用磁共振检查的指征。
Patientswithfractureinthepres-
enceofmultisystemtraumarequire
specialconsideration.Bloodlosscan
besigni?cant(upto1,500mL)with
heanteriorapproach,whichcanlead
ocoagulopathyandhypoperfusion
nthepresenceofotherinjuries.Both
hetransdiaphragmaticandthetho-
racicapproachescantemporarilyim-
pairpulmonaryfunction,leadingto
markedpulmonarycompromise,es-
peciallyinthepresenceofclosed
chestinjury.Intra-abdominalinjury
canleadtonotableperitonealdisten-
sion,makingretroperitonealexpo-
suredifficult.Patientswithmultiple
extremityand/orpelvicfractures
maybebetterservedbyreduction
andstabilizationofunstablethora-
columbarfracturesthroughaposte-
riorapproach,thusallowingformore
efficientcareoftheotherinjuries
Assessmentofthesefactors,inad-
ditiontofracturepatternandneuro-
ogicstatus,arecriticaltomaking
heappropriatetreatmentselection
orthepatientwiththoracolumbar
rauma.



























出现多系统创伤的骨折患者需要特殊照顾。前路手术中失血量（达到1500ml）需要重视，失血量过多在伴有其它损伤时可以导致凝血功能障碍和血流灌注量减少。跨膈以及胸廓的手术入路会暂时损伤肺功能，导致明显肺脏受压，尤其是存在胸部闭合性损伤的患者。腹内伤会导致显著腹膜膨胀造成腹膜后的显露困难。伴有多发四肢骨折或者骨盆骨折的患者通过前路手术对不稳定的胸腰椎骨折进行复位和固定可以得到更好治疗，因为这样允许对其他损伤提供更为有效的治疗。除了评估以上这些因素，另外骨折类型以及神经系统的状态也是为胸腰椎创伤的患者选择治疗手段的关键。
ClassificationofInjury
Themechanisticfractureclassi?ca-
2
is
tion,asmodi?edbyMcAfeeetal,
thepreferredthoracolumbarfracture
classi?cationsystembecauseitcan
provideimportantinsightintoreduc-
tionmechanismsandstabilization
needsaswellasguidethesurgeon
totheappropriatesurgicalproce-
3
Thisclassi?cationschemecom-
dure.
prisescompression,stableburst,and
unstableburstfractures;?exion-
distractioninjury;andfracture-dis-
2
emphasized
location.McAfeeetal
theimportanceofDenis!flmiddlecol
umnandclassi?edfracturesasfail-
ureofthemiddlecolumnincompres-
sion,distraction,ortranslation.























损伤的分型：依照McAfeeetal修订的骨折分型机制是最受欢迎的胸腰椎骨折分型系统，因为它为复位的机制以及固定的要求提供重要的理解，同时指导外科医生选择合适的治疗方法。这种分类方法包括压缩性骨折、稳定性爆裂性骨折、不稳定性爆裂性骨折、屈曲-牵张性损伤以及骨折脱位型。McAfeeetal强调丹尼斯理论中中柱的重要性以及分类骨折依据中柱在挤压，牵伸，翻转运动中功能的丧失。
Indications
Theanteriorapproachismostcom-
monlyindicatedforanunstable
burstfracturefromT10toL3(al-
thoughitcanbeuseduptoT5)
associatedwithanincompleteneu-
rologicde?citandradiologically
demonstratedneuralcompres-
1,4 5,6
Recentstudies havere?ned
sion.
theradiologicandclinicalfeatures
ofpatientswithincompletede?cits
inwhomtheanteriorapproachisin-
dicated.Thesefeaturesmayinclude
alargeretropulsedfragmentwith
marked(>67%)canalcompromise,
anteriorcomminutionandkyphosis
>30!a,andtimeofmorethan4day
5
Patientswithincom-
frominjury.
pletefracturereductionafterapos-
teriorapproachmaybecandidates
foranteriordecompressionifneuro-
logicrecoveryisincompleteandre-
sidualcompressionpersists.


























手术指征：前路手术通常最适宜的手术指征是：从T10-L3（尽管可以用于T5）的不稳定性爆裂性骨折同时伴有不完全性神经功能损伤以及反射学显示脊髓受压最近的研究重新定义了伴有不完性神经功能损伤患者运用前路手术治疗的放射学和临床特征。这些特征包括：大块爆裂性骨块造成明显椎管受压(>67％),前柱粉碎以及后突畸形大于30°，损伤时间超过4天。通过后路手术存在不完全复位的患者如果神经功能不完全以及存在残留神经受压症状也是前路手术的指征。
Parkeretalreviewedtheirinsti-
tution!flsexperiencewiththeload
sharingclassi?cation,whichis
basedontheextentofcomminution
anddisplacement.Patientswhohad
fractureswithahighdegreeofcom-
minution,displacement,andkypho-
sishadabetterresultwithanterior
stabilizationbecauseitprovided
greaterrestorationofanteriorcol-
umnsupportthandidshort-seg-
mentpediclescrew?xation.Others
havefoundthatlongerposteriorfu-
sionconstructsprovideadequate
stability.














Parkeretal回顾他们医院负荷分享分类的经验，这种分类方法依据粉碎和移位的程度。存在严重粉碎骨折，移位，以及畸形的患者运用前路固定会有较好治疗结果，因为这样与段阶段椎弓根螺钉固定相比可以进行更大程度的前柱支撑功能的重建。其他一些学者发现长阶段的后路融合装置也能提供足够的稳定性。
Controversyexistsaboutwhether
patientswithcompleteneurologicin-
jurieswarrantdecompressioninad-
ditiontostabilization.Patientswith
completethoraciclevelparaplegia
(aboveT10)haveapoorprognosisfor
recoveryandgenerallyarebesttreat-
edwithposteriorstabilization.Pa-
tientswiththoracolumbarjunctionor
lumbarinjurieswhoinitiallyappear
tobeneurologicallycompletebutare
stillinspinalshockcanbetreated
moreaggressivelywithpromptsur-
gery.Nodataindicateadifferencein
recoverybetweenanteriororposte-
riorapproachwhenadequatedecom-
pressionisobtained.Becauseofalack
ofde?nitivestudiesdemonstratinga
clearadvantageofoneapproachover
theother,bothareconsideredfor
managementinappropriatecircum-
stances.Asummaryofrelativeindi-
cationsfortheanteriorapproachis
listedinTable1.























争论存在于有完全性神经功能损伤的患者除了固定是否需要减压。有完全性胸椎水平截瘫的患者（T10以上）预后恢复不理想通常采用后路固定。胸腰连接部或者腰椎损伤病人最初出现完全性神经功能损伤但是同时仍旧处于脊休克期可以采用更为积极治疗方法—急诊手术。没有数据资料显示在减压充分的情况下前路手术与后路手术存在不同。因为缺乏明确显示一种治疗方法明显优于另一种方法的研究，前路手术和后路手术被认为是在各自适宜的情况下治疗手段。前路手术治疗的相对适应症总结见于表1。
Theanteriorapproachismoredif-
?cultforlowlumbarfractures(ie,L4
andL5)becauseofanatomiccon-
straints,especiallyforrestoringalign-
mentandattainingsatisfactory?xa-
tion.However,theseinjuriesrarely
requiresurgeryandgenerallyshould
bemanagedposteriorlyinpatientsin
whomstabilizationisrequired.Be-
causeofthelargeratioofcanalarea
toneuralelement,lowlumbarfrac-
turesbehavedifferentlyfromupper
lumbarfracturesandgenerallydo
wellwithnonsurgicalmanagement,
exceptincasesofinstability.Forpa-tientswithinstability,theposterior
approachispreferable.















由于解剖的限制，腰椎（L4、L5）骨折的患者进行前路手术治疗很困难，尤其是进行椎体序列的重建以及获得满意的固定。尽管，这些损伤几乎不需要手术或者通常需要进行后路固定。因为相对于神经组织有较大比率椎管容积，低位腰椎骨折的症状不同于高位腰椎骨折，除了骨折不稳定的病例，通常采用非手术治疗。对于骨折不稳定的患者后路手术是可取的

Anteriordecompressionisrarely
usedaloneforinjuriesotherthan
burstfractures.Mostotherfracture
typesareeitherwelltreatednonsur-
gically(ie,compressionfractures)or
managedwithaposteriorapproach
torestoretheintegrityoftheposte-
riorelementsandpreventkyphosis
(ie,?exion-distractioninjuries).Incer-
tainlimitedcircumstances,thesein-
juriesmayrequireanadjunctivean-
teriordecompressionbecauseof
herniateddisk,markedcomminution
ofthemiddlecolumn,orconcern
aboutadditionaldisplacementof
fragmentsintothecanal.Insuchcas-
es,acombinedapproachshouldbe
considered.Mostfracture-disloca-
tions,becauseoftheirextremeinsta-
bility,arebestmanagedwithapos-
teriorapproach.Spinalstabilityof
fracture-dislocationsafteranteriorde-
compression,evenwithinternal?x-
ation,isinsufficient;thus,theanteri-
orapproachshouldbeavoided.
























除了爆裂性骨折的患者前路减压极少单独使用。很多其他类型的骨折可以采用非手术治疗（压缩性骨折）或者采用后路手术恢复后柱组织的完整性以及预防后突畸形（屈曲-牵张型损伤）。在一定的特定条件下，这些损伤可能需要附加的前路减压手术，因为存在突入椎管的椎间盘组织，明显的粉碎性中柱骨折，或者考虑进入椎管的移位骨块。在一些病例中，应考虑前后路联合手术。一些骨折脱位型患者由于骨折的极其不稳定性，最好采用后路手术治疗。骨折脱位型患者行前路减压后，尽管使用内固定器，脊柱的稳定程度也是不足的，因此应避免前路手术。
Contraindications
Preexistingmedicalconditionsand
concurrenttraumaticinjuriestothe
abdomenandchestmayrepresen
relativecontraindicationstothean
teriorapproach.Patientswithsevere
pulmonarydiseasemayhavelimit
edreserveforpulmonaryfunction
andmaynottoleratethoracicortho
racoabdominalapproaches.Severe
chestorabdominalinjuriesalsomay
limitpulmonaryreserveorimpairex
posure.Markedosteoporosisinad
jacentvertebraemayresultinimpac
tionofthestrutgraftandfailureo
screwpurchase,leadingtononunion
and/orkyphosis.Morbidobesity
mayimpairexposureandleadtoin
adequatevisualizationforsafede
compression.Whentheseconditions
arepresent,thesurgeonmustbalance
therelativemeritsofanteriorand
posteriorapproachesforthespeci?c
fracture.























禁忌症：现实的医疗条件和同时存在的腹部和胸部损伤代表着前路手术的相对禁忌症。有严重肺部疾病的患者可能有有限的保留肺功能，可能不能耐受胸部或者胸腰联合的手术入路。严重胸部或者腹部损伤患者也存在有限的残留肺功能或者有碍手术视野的显露。邻近椎体明显骨质疏松可能会导致支撑植入骨的嵌入以及螺钉把持的失效，导致骨不连或者畸形。过度肥胖有碍于显露，并导致安全减压的视野不够。当这些情况出现。外科医生需要权衡对于特殊骨折行前路手术和后路手术的相对优缺点。
Timing
Thetimingofdecompressionremains
controversial,withadivergencebe-
tweentheresultsofanimalstudies
andclinicalreports.Somebasicsci-
encedataindicatethatearlydecom-
pressionresultsinimprovedneuro-
logicrecovery.Insurgicallycreated
acutecordcompressioninacanine
model,neurologicrecoverywasbet-
terwhenreleasewasdonewithin1
hourratherthanafterlongertimepe-
7 8
Carlsonetal studiedregion-
riods.
alblood?ow,theinterfacepressure
betweenthespinalcordandacom-
pressingpiston,andsomatosensory
evokedpotentialsinacaninemodel
withdecompressionat5minutesand
withnodecompression.Regional
blood?owreturnedtonormalwith-
in3hoursafteronsetofcompression.
Theviscoelasticityofthecordallowed
theinterfacepressuretodecreaseto
<20%ofthemaximuminthe?rst
hourofcompressionandwasapprox-
imately10%by3hours.Despitethese
changes,somatosensoryevokedpo-
tentialsdidnotshowimprovement,
indicatingthemultifactorialnatureof
spinalcordinjury.Theauthorssug-
gestedthatsustaineddisplacement
initiatedasecondaryphaseofphys-
iologicevents.Acorrelationofevoked
potentialrecoverywithregional
blood?owduringcompressionwas
laterreported,supportingtheconcept
ofanischemicmechanismofsecond-
9
Thesefactorsledtotheim-
aryinjury.
pressionthatthereisalimitedwin-
dowofopportunityforobtaining
optimalneurologicrecoveryinsuch
injuries.Unfortunately,thiswindow
appearstobetoobrieftoallowclin-
icalrescue,resuscitation,diagnosis,
andinductionofanesthesiaforurgent
decompression.Recoveryofcauda
equinaorrootinjuriesdoesnotap-
peartobeastime-dependent.



















































时机:由于动物实验结果与临床报告存在分歧，进行减压的时机仍存在争议。一些基础学科资料指出早期减压可引起神经系统功能恢复的改善。外科创造的严重脊髓受压狗模型中，神经系统功能得到较好恢复在于1个小时内减压而不是很长时间后减压。Carlsonetal对区域血流，脊髓与挤压活塞之间的界面压，以及狗模型中躯体知觉唤醒状态在5分钟内进行减压和没有减压两种情况下进行对比研究。区域血流在受压开始后3个小时内可以恢复到正常状态。脊髓的弹性状态允许界面压在受压后最初1小时内减少至最大值的20％，3小时后减少至10％。尽管存在这些变化，躯体直觉唤醒状态没有表现出改善，显示出脊髓损伤的多因素性质。作者暗示持续存在的移位会引起二期病理变化。唤醒阈改善与受压时区域血流状态的关系最近才被报道，提供二期损伤的缺血性机制概念。这些因素引起这个印象：在这些损伤中获得最佳的神经系统功能恢复存在有限的机会窗。不幸的是，这个机会窗太短以至于不能进行临床抢救、复苏、诊断急诊手术减压的麻醉诱导。马尾神经和神经根损伤的恢复并没有表现出时间依赖性。
Clinicaldataaboutthetimingof
corddecompressionarelimitedand
mostlyrelatetocervicalinjuries.Ear-
lyclosedreductionofcervicalsublux-
ationhasbeenshowntobepossibleasearlyas2hoursafterinjury,with
noneurologicdeteriorationdirectly
attributedtotractionandreduc-
10
tion.
Comparisonsofearlyandlate
decompressionarefew.Vaccaroet
11
didaprospective,randomized
al
studyofsurgerydoneearly(<72
hours)versuslate(>5days)afterspi-
nalcordinjury.Theyfoundnosignif-
icantbene?ttoneurologicfunction
lengthofstay,orlengthofrehabili-
tationwhenthesurgerywasdone
early.Authorsofamorerecentret-
rospectivestudycomparingexperi-
enceattwodifferentinstitutions
foundthatearlysurgery(within72
hoursofinjury)wasnotassociated
12
withahighercomplicationrate.
Theyalsosuggestedthattheearly
surgerygroupmayhavehadim-
provedneurologicrecoveryinspite
ofearlyclosedreductioninboth
groups.Thisdifferencecouldbeex-
plainedbyvariationsinsurgeons
sites,methodsofneurologicevalua-
tion,andpreoperativefunction,but
itwarrantsfurtherstudy.Although
thesestudiesinvolvecervicalinjuries
theydoprovidesomeinsightintothe
issuesrelatedtothetimingofsurgery
forcordinjuries.Todate,thereisno
cleardifferenceinoutcomesbasedon
timingofsurgery.









































关于脊髓减压时机的临床资料有限并且大多是关于颈椎损伤。颈椎半脱位的早期闭合复位在受伤后2个小时内以显示出可能性，不会发生神经功能恶化直接归因于牵引和复位。早期和晚期减压的对比研究很少。Vaccaroetal做了一项前瞻性随即对照研究，脊髓损伤后早期（小于72小时）与晚期（大于5天）外科敢于的对照研究。他们发现早期外科干预对于神经功能、损伤持续时间、康复时间没有明显益处。最近很多进行回顾性研究对比两个不同机构治疗经验的作者发现早期手术（受伤后72小时内）与较高的并发症发生率没有相关性。他们也暗示早期手术组可能有神经功能恢复的改善，尽管两个研究组都进行早期闭合复位。这个不同可以由外科医生、治疗机构、神经系统功能评估方法、术前功能状态的不同来解释，但是这仍需要进一步研究。尽管这些研究包括颈椎损伤，这确实能够为关于脊髓损伤手术时机问题提供一些理解。目前，仍旧没有由于外科手术时机不同出现明显不同的结果。
Thetiminganduseoftheanterior
approachinmultiplyinjuredpatients
requirescoordinationbetweentrau-
masurgeonsandspinesurgeons.
Acutelife-threateninginjuries,such
asunstablepelvisfractures,head,
chest,andabdominalinjuries,and
limb-threateninginjuries,suchas
openlongbonefractures,shouldbe
handled?rst,followedbyspinecare.
Itisimportanttoconsiderearlyde-
compressionofincompletespinal
cordinjurieswithin24to48hoursas
anemergentorurgentprocedure,be-
forethetypicalonsetofpulmonary
complicationsresultingfromthepa-
tient!flsinjuries.Earlydecompressio
hasbeenshowntobesafeandeffec-
tive,withthemajordifferencebe-
tweenurgentandearlytreatment
13
beingtheextentofbloodloss.Managementofinjuriesinvolvingthe
caudaequinaorrootde?citsare
plannedassoonasthepatient!flsover
allconditionissatisfactory,usually
withinthesametimeperiod,butoc-
casionallyupto7to10daysinpa-
tientswithlife-threateningchestand
abdominalinjuries.




























对于多发复合伤的患者，手术时机以及行前路手术需要创伤科医生和脊柱外科医生协调一致。危机生命严重创伤，例如不稳定骨盆骨折、头、胸、、腹部伤以及危机肢体的创伤例如开放性长骨骨折，这些情况需要首先处理然后处理脊柱损伤。对于不完全脊髓损伤的患者考虑早期减压是很重要的，在24-48小时内急诊手术处理，要在由患者创伤引起典型肺部并发症以前进行。早期的减压认为是安全有效的，早期处理和紧急处理出现最大不同的原因在与失血量的程度。只要患者的总体情况满意处理包括马尾神经和神经根性的损伤都应计划进行，通常在同一时期进行，但是对于有危及生命的胸部和腹部损伤可以延至7-10天后。
Patientsinitiallytreatednonsurgi-
callyorwithaposteriorapproach
whohavepersistentcordcompres-
sionmaybecandidatesforlatede-
compressionandmayobtainclinical
improvement.Theanteriorapproach
canbeusedmonthsoryearsafterini-
1 14
Bohlmanetal studied
tialinjury.
patientstreatedforlatepainand/or
paralysisameanof4.5yearsafterin-
jury(range,3monthsto21years).
Theynotedimprovementinpainfor
41of45patients(91%)andimprove-
mentinneurologicfunctionin21of
25patients(84%).
















最初进行非手术治疗或者后路手术治疗的患者仍旧存在脊髓受压可以进行晚期减压并且可能获得临床疗效的改善。前路手术可以在受伤后数月或者数年之后进行。Bohlmanetal研究在受伤后平均4.5年内治疗晚期疼痛和截瘫的患者，发现45名患者中41名疼痛症状有改善，25名患者中21名神经功能有改善。
Reconstruction
Patientswithburstfractureshavefail-
ureoftheanteriorcolumnincom-
pression,producingakyphoticdefor-
mityandinabilityofthespinetoresist
axialload.Whenassociatedwithloss
oftheposteriorcolumntensionband
theresultisanextremelyunstable
spinalinjury.Anteriordecompression
oftheneuralelementsfurtherdesta-
bilizesthespinalcolumnbyremov-
ingwhateveranteriorsupportre-
mains.Thus,theprimaryprinciple
forreconstructionafteranteriorde-
compressionisrestorationofthean-
teriorcolumnsothatitcanresistax-
ialcompression.Iftheposterior
tensionbandalsohasfailed,poste-
riorstabilizationmayberequired,as
well.



















重建：爆裂性骨折的患者存在前柱受压丢失，后突畸形，脊柱不稳不能承担轴向负荷。当伴有后柱牵张带丢失时，这种情况就是极度不稳脊柱损伤。通过移去任何残留前柱支撑的前路减压会造成严重脊柱不稳。因此，前路减压后最主要的重建原则是重建前柱以使其能承担轴向压力负荷。如果后柱的张力带作用消失，同时需要后路固定。
Reconstructiongenerallyinvolves
twocomponents:immediatestabili-
tyandrestorationofnormalalign-
ment.Immediatestabilitycanbeob-
tainedwithavarietyofdevices,such
ascages,rod-and-screworplate-and-
screwconstructs,andexternalbrac-
es.Iliaccrestautograftwasinitiallyusedforthestrutgraft,butmorere-
cently,tibialorhumeralallografthas
15
beenused.
Ventralcagescontaining
cancellousautografthavebeendevel-
oped,buttherehavebeenfewstud-
iesoftheirefficacy.Long-termstabil-
itycanbeachievedwithfusionofthe
strutgraft.
















重建通常包括两方面内容：及时稳定和重建正常脊柱序列。及时的稳定可以通过不同的器材达到，例如cage、钉棒和钉板装置以及外固定架。最初充当支撑移植骨是髂棘自体移植骨，但是最近已经开始使用胫骨和肱骨同种异基因移植骨。包含自体松质骨的复测cage得到进一步发展，但是对于他们的有效性只有很少的研究。支撑骨的融合可以获得长期的稳定。
Implanttypescommonlyusedan-
teriorlyforfractureindicationsin-
cludebothrigidandnonrigidplate-
and-screwandrodconstructs.Most
studiesreporttheuseofeitherrigid
16,17
orrigid
screwandrodconstructs
18
Semirigidordy-
plateconstructs.
namizedconstructsusingscrewsand
rodshavebeenreportedwithsatis-
19
Implantsshould
factoryoutcomes.
beplacedlaterallytoavoidcontact
withtheaortabecausesuchcontact
hasbeenreportedtocauselatevas-
20
Inad-
culardisruptionanddeath.
dition,toavoidproblemswiththeil-
iacvessels,anteriorplate-and-screw
orrod-and-screwconstructsshould
notbeusedbelowL4.

























用于骨折的前路植入物类型通常包括刚性和非刚性钉板和钉棒系统，很多研究报道使用刚性钉棒系统或者钉板系统。运用螺钉和圆棒的半刚性或者动态系统有报道达到满意结果。植入物应置于侧面避免接触主动脉，因为有报道称这些接触可引起晚期的血管破裂甚至死亡。另外，为了避免造引起髂总静脉的问题，前路钉板和钉棒系统不应用于L4一下。
BiomechanicsofAnterior
Reconstruction
Thebiomechanicsofanteriorrecon-
structionhavebeenstudiedinava-
rietyofmodels,includinganimal
(bothinvi***ndinvitro),cadaveric,
andbiomechanicalsynthetic.Devic-
esusedanteriorlycanbedividedinto
twocategories:interpositionaland
splinting.Interpositionaldevices,
whichsubstitutefortheanteriorand
middlecolumns,areusuallybiolog-
ic(eg,iliaccreststrut).Splintingde-
vicesareusedtostabilizethecon-
structduringbiologicincorporation
oftheinterpositionaldevice.Themul-
tifactorialnatureofthebiomechan-
icalpropertiesofthesedevicesmakes
comparisonofdifferentstudiesdif-
?cult.Constructstrengthandstiffness
areaffectedbybiologicvariabilityin
patientsizeandbonedensity,pur-
chasestrengthoftheanchors(usual-
lyscrews),loadsharingwiththegraft,
andthemechanicalpropertiesoftheimplants.Biologicvariabilitybetween
individualpatientsmustbeconsid-
eredwhenplanningreconstruction
aftercorpectomy.Althoughlittlehas
beenpublishedaboutthepurchase
strengthofanchors,bicorticalpur-
chasehasbeenshowntoincrease
screwpulloutstrengthoverunicor-
ticalpurchase;however,theeffectis
lesspronouncedwhenbonemineral
21
densityislow.
Syntheticmodels
standardizedbytheAmericanSoci-
etyforTestingandMaterialsprovide
amethodforcomparingimplantstiff-
nessandfatiguestrengthwithoutthe
confoundingvariablesintroducedby
biologicvariability,specimenavail-
ability,andanchorpurchasefail-
22
ure.













































前路重建的生物力学机制：前路重建的生物力学机制在不同的模型中进行研究，包括动物（活体内或者活体外），尸体，生物力学模型。前路器械可被分为两类：椎体间装置和夹板固定装置。用于代替前柱和中柱功能的椎体间装置通常具有生物学特点。当椎体间装置发生生物学融合的过程中夹板装置发挥固定结构作用。结构的强度和硬度受患者身高和骨密度的生物学多样性、螺钉的把持力、移植骨的分担负荷以及植入物的力学特性影响。一旦计划重建必须考虑不同患者的生物学多样性。尽管关于螺钉的把持力的报道很少，但是双皮质固定在增加螺钉把持力方面优于单皮质固定，然而骨密度低时效果不是很明显。由美国材料与测试协会制定的生物学模型标准提供一种对照研究植入物硬度和疲劳强度的方法，无需混淆由生物学多样性、样本的可用性以及螺钉把持失败所致的变量。
Theloadsharingofthegraftmay
contributetostability,dependingon
23
re-
theconstructchosen.Leeetal
porteddifferencesinstabilitytesting
dependingontheanteriorreconstruc-
tionmethodused.Theycompareda
polymethylmethacrylateblock,iliac
crestbonegraft,twosmallcages,and
onelargecage.Thelargecagewassu-
periorinaxialrotationandsagittal
motion,andthetwosmallcagesand
iliaccrestbonegraftweresuperiorin
lateralbending.ThePMMAblock
wasapproximatelythesameasiliac
crestbonegraftinallmodestested
exceptlateralbending,whereitwas
inferior.


















移植骨所承担的负荷有助于促进稳定，应依据结构不同选择。Leeetal报道不稳定测试依据前路重建的方法不同。他们对比了聚甲基丙烯酸甲酯块、髂棘移植骨、两个小型cage以及一个大型cage。大型cage在轴向旋转和冠状面运动具有优势，两个小型cage和髂棘移植骨在侧向弯曲方面具有优势。聚甲基丙烯酸甲酯（PMMA）块除了在侧向弯曲方面存在劣势，其余在所有模型中与髂棘移植骨相比大约一致。
Manysurgeonsuseinternal?xa-
ioninadditiontoanteriorcolumnre-
onstruction.Thepropertiesofthein-
erpositionalandinternal?xation
devicesmaybecombinedforim-
provedoverallstability.Inanolder
nvitrostudy,theKanedadevice
DePuyAcromed,Raynham,MA,
ormerlyAcromed)wasfoundtore-
toretorsionalstiffnessaswellasa
posteriorCotrel-Duboussetcon-
24
andbetterthanHarrington
truct
odsortheAO?xateurinterne(nei-
25
Oth-
herofwhichisusedanymore).
rauthorsemphasizedtheimpor-
anceofconnectingparallelrodsused
26
nanteriororposteriorconstructs.
nacaninestudy,thefusionratewashigherwiththeKanedadeviceand
graft(86%)thanwithgraftalone
27
Ax-
(29%)at24weeks(P =0.028).
ial,?exural,andtorsionalstiffness
weretested;onlytorsionalstiffness
wasfoundtobesigni?cantly(P <
0.05)strongerintheinstrumentedfu-
sions.Otherstudieshaveincluded
comparisonsofdifferentdevicesin
animalorcadavericinvitromodels,
withvaryingresults.Themodelsus-
ingstabilitytestingfavortheKaneda
deviceoverplate-and-screwcon-
structsingeneral,especiallyin
28-30
Resultsofstabilitytesting
torsion.
usingasyntheticmodelhavefavored
plateoverrodconstructs,withtheex-
ceptionoftheZ-plate(ZPLATE-ATL;
MedtronicSofamor-Danke,Mem-
phis,TN),whichtendstobetheleast
31
Theuse
stiffofallconstructstested.
ofsyntheticmodelstendstofavor
screwanchorsoverbolt-typeanchors,
whichmayhavehadsomeeffecton
theresults.




















































很多外科医生除了前路重建以外还要使用内固定器。椎体间植入结构和内固定器的特定可以联合用于改善整体稳定性。在老的离体实验研究中，发现金田装置和后路C-D系统具有相同扭转硬度，但优于哈氏棒和AO内固定器（它们现在已不被使用）。其他一些学者强调在前路和后路固定固定结构重视平行连接棒的重要性。在犬科动物模型试验中，在24周内统联合骨移植的融合率高于单纯骨移植，前者为86％，后者为29％。测试轴向，屈曲，扭曲强度在器械融合中仅发现扭曲强度明显加强。其他一些研究在动物或者尸体体外模型上进行不同器械的对比研究，取得不同结果。通常，进行稳定性测试的模型显示金田系统优于钉板结构，尤其在弯曲状态下。在人造生物模型上进行稳定性测试显示钉板系统优于钉棒系统，Z型钢板除外，它是所有测试系统装置中硬度最低。在人造生物学模型中螺钉式固定优于优于螺栓式固定，这可能对临床疗效有一些影响。
Thematerialusedinmanufactur-
ingtheimplantaffectsitsstiffnessand
strength.Therearefewdirectcom-
31
compared
parisondata.Kotanietal
Kanedadevicesmadeoftitaniumandofstainlesssteel.Thesedevicesareas
sumedtohavesimilardimensiona
tolerances.Thetitaniumimplantwa
foundtohavebothgreaterbending
strengthandhigherstiffnessthanthe
stainlesssteelimplant.











人工内植入物的材料影响它的硬度和强度。只有少量直接对照资料。Kotanietal对照研究了钛合金的金田装置和不锈钢的金田装置。这些器械呈现出相似的二维耐受力。发现钛合金器械与不锈钢器械相比不进有较大的弯曲强度而且有较高的硬度。
Theimportanceofsubtledifferenc-
esinstiffnessremainstobeseen.Clin-
icalstudiesofalldevicesdemonstrate
highfusionratesandgoodperfor-
mance,probablymakingthesubtle
differencesinbiomechanicalproper-
tiesunimportant.Inaddition,the
stiffnessneededineachplaneappears
tobedifferent.Oneclinicalstudywith
animplantconstructthatalloweddy-
namicaxialcompressionshowedthat
nopatientshadpseudarthrosis,and
kyphosisworsenedbyonly4!aatlong
termfollow-up(mean,42months;
19
Although
range,24to84months).
therequireddegreeofstiffnessre-
mainsunclear,itappearsthatanyre-
constructiontechniquethatprovides
rotationalstiffnessequaltoorgreat-
erthanthatoftheintactspinewill
provideastableconstructthatleads
tofusion.























在硬度方面细微差别的重要性仍然被重视。所有器械的临床研究显示高的融合比率和优良的性能使得生物力学方面细微的差别不再重要。另外，每一平面所需要硬度不同。一项关于允许轴向加压内植入器械的研究显示长期随访（平均42个月；一般范围：24-48个月）没有出现假关节现象，后突畸形只加重4°。尽管所需的硬度仍不清楚，任意重建技术所提供的旋转硬度等于或者强于正常脊柱所能提供的，稳定的结构能引起融合发生。
Inyoungpatientswithqualitative-
lygoodbonequality,abiologicstrut(eg,iliaccrestbonegraft)isoptimal
foranteriorcolumnsupport.Alterna-
tively,anappropriatelysizedallograft
canbeused.Whenpreparingtheend
plates,acuretteshouldbeusedtore-
movethecartilaginousendplateto
bleedingbone.Thisremoveslessof
thesubchondralboneandthusreduc-
esthechanceofgraftsettling.Ifthe
bonequalityispoor,orifthepatient
preferstoavoidthediscomfortof
graftharvest,atibialallograftpro-
videsabroadbaseofcontactbetween
thegraftandvertebrae.Eithertype
ofgraftcanbesupplementedwith
cancellousbonefromthevertebrec-
tomy.Alow-pro?leplateconstructto
augmentthereconstructionisplaced
laterally,awayfromtheaorta,avoid-
ingthepotentialforlateerosionofthe
aorta(Fig.1).





















在有较好的骨量的年轻患者，生物学支撑（髂棘移植骨）是最佳前柱支撑。或者合适大小的同种异体骨移植。当进行终板准备时，应用刮匙将终板软骨刮去直至骨头出血。这样可以移除少量的软骨下骨从而减少移植骨下沉发生几率。如果骨质不理想，或者患者想要避免移植骨采取后的不舒服，胫骨异体骨在移植骨和椎骨之间提供较大的接触面积。任何类型的移植骨都可以附加椎体切除后的松质骨。用于重建的低侧钢板应置于侧面，远离动脉，避免晚期的血管破裂。
ClinicalResults
Becauseofthehighlyvariablenature
ofthoracolumbarburstfracturesand
thelackofrandomizedprospective
studies,clinicalresultsafterdirectan-
teriordecompressionaredifficulttocomparewiththoseofothertech
1
re
niques.However,McAfeeetal
portedthat37of42patientstreated
withanteriordecompressionata
meanof60daysafterinitialinjury
hadsomedegreeofneurologicim
provement.Ofthe37patients,30pre
operativelyhadmotorstrengtho
grade3orless.Fourteenofthese30
patientsbecamecommunityambula
tors;9othersregainedfunctionad
equateforhouseholdambulation,al
thoughsomerequiredshortleg
bracesand/orcrutches.Radiograph
icresultsindicatedthat12ofthe42
patientsdevelopedkyphosis>20
16
report
postoperatively.Kanedaetal
edaseriesof150patientswithburs
fracturesandshowedcomparablere
sultsin78withneurologicde?citwho
underwentanteriordecompression
supplementedwithanterior?xation
Thetimefrominjurytodecompres
sionvariedfrom<48hoursto>1year
Seventy-twopercentoftheneurolog
icallycompromisedpatients(56/78
recoveredcompletely.Eighty-sixper
centofallpatientswhohadbeenem
ployedpreinjury(112/130)returned
16
Nopatientineithe
totheirjobs.
1,16
wasmadeneurologically
study
worse,andthosewiththemostin
completede?citsrecoveredone
Frankelgradeormore.Inbothstud
ies,CTdoneafterdecompression
demonstratedadequatedecompres
sioninallbuttwocases.

















































临床结果：由于爆裂性骨折高度多变性以及缺乏随机前瞻性研究，直接前路减压后临床结果很难与其他方法进行比较。尽管，McAfeeetal报道接受前路减压的42名患者中有37名在最初损伤后平均60天有一定程度神经功能改善。37名患者中有30名患者术前肌力3级或者更低。30名患者中有14名可以在社区走动；其它9人重新达到的功能足够在卧室走动，尽管一些需要短的腿部支具或者手杖。X线检查结果显示42名患者中12名术后后突畸形加重至大于20°。Kanedaetal报道了一系列150名胸腰椎爆裂性骨折患者，并发表78名有神经功能障碍患者行前路减压并前路固定术后的对照研究结果。从受到损伤到减压的时间变化范围从48小时到1年。72％伴有神经受压的患者得到完全恢复。所有患者中86％重新回到受伤前工作岗位上。在两项研究中没有发现患者神经系统功能加重并且那些有不完全性神经功能障碍恢复至Frankel一级或者更好。在这两项研究中减压后CT显示除两病例外其余患者减压都已充分。
Comparativestudiesbetweenan-
teriorandposteriorapproachesare
few,usemultiplesurgicaltechniques,
andhaverelativelysmallnumbersof
32
patientsineachgroup.Essesetal
compared18patientstreatedwithan-
teriordecompression,iliacstrut,and
Kostuik-Harringtonanterior?xation
with22patientswhohadposterior
distractioninstrumentationwiththe
?xateurinterneandposterolateralfu-
sion.PostoperativeCTdemonstrated
bettercanaldecompressionwiththe
anteriorapproach,butthisdidnot
correlatewithneurologicrecovery,
whichwasnodifferentbetweenthe
33
com-
groups.SchneeandAnsellpared14patientstreatedwithante-
riordecompression,allograftstrut,
andplate?xationwith9patientswho
underwentcombinedanteriorde-
compressionandposterior?xation
and2patientswhohadtranspedic-
ulardecompression,fusion,and?x-
ation.Choiceoftechniqueapparent-
lywasrelatedtotheseverityofinjury
tothespinalcolumn.Theauthors
concludedthatanteriordecompres-
sioniscriticaltosuccessinmanag-
ingfractureswithsigni?cantverte-
34
braldestruction.BeenandBouma
studied27patientstreatedwithan-
teriordecompressionandiliacstrut
combinedwithposterior?xationand
comparedthemwith19patientstreat-
edwiththeAO?xateurinternefor
posteriordistractionandstabiliza-
tion.Therewasnostatisticaldiffer-
encebetweenthetwogroups;neuro-
logicrecoveryofmorethanone
Frankelgradeoccurredin10of10pa-
tientsintheanteriorgroupand7of
8intheposteriorgroup.Bladderre-
coverywasobtainedin3of7inthe
anteriorgroupandin1of3inthepos-
teriorgroup.Painreliefoccurredin
85%oftheanteriorgroupand79%
oftheposteriorgroup.Complications
occurredin15%oftheanteriorgroup
and26%intheposteriorgroup.




















































前路手术和后路手术对照研究很少，每一研究小组运用复杂外科技术，病人数量相对比较少。Essesetal将18名行前路减压、髂骨支撑以及Kostuik-Harrington内固定器固定的患者与22名伴有内固定器和后侧融合的后路撑开装置。术后CT检查显示前路减压后可以达到较好的椎管减压，但是与神经功能恢复无相关性，这在两个对照组中无区别。Schnee和Ansell将14名行前路减压、异体移植骨支撑以及钢板固定的患者与9名联合前路减压和后路固定的患者进行对照研究，并且两名患者行跨椎弓根的减压、融合以及固定。显然方法的选择与脊柱受损的严重程度有关。作者总结处理伴有明显椎体毁损骨折的关键是前路减压。Been和Bouma将27名行前路减压和髂骨支撑联合后路固定的患者与19名运用AO内固定器行后路撑开和固定的患者进行对照研究。这两个对照组没有统计学上差别；神经系统功能恢复到frankel一级以上，10名前路手术组患者中有10名达到，8名后路手术组中有7名达到。前路手术组中7名患者中有3名获得膀胱功能恢复，后路手术组中3名患者有1名获得膀胱功能恢复。前路手术组中85％有疼痛缓解，后路手术组有79％有疼痛缓解。前路手术组中有15％患者出现并发症，后路手术组中26％患者出现并发症。
SurgicalTechnique
Thersidedapproachisusedfor
upperthoracicburstfracturesto
avoidtheaorticarch,commoncarot-
idartery,esophagus,andtrachea


.
Thoracicfractures(T6throughT11)
canbeapproachedfromtheright,al-
thoughaleft-sidedapproachispos-
siblebecausetheaortaiseasilymo-
bilized.Theleftsideispreferredfor
thoracolumbarfracturesrequiringa
thoracoabdominal(T12-L1)orretro-
peritoneal(L2-3)approach;this
avoidstheapproachbeingobscured
bytheliverorhavingtomobilizethe
venacava.However,aright-sidedap-
proachcanbeusedforthoracolum-
barfractures,ifnecessary.Lowerlum-barfractures(L4andL5)usuallyare
approachedposteriorly,although
rarelytheymayrequirereconstruc-
tionoftheanteriorcolumnthrough
aretroperitoneal(L4)ortransperito-
neal(L5)approach.[/color]ight-
外科技术：高位胸椎爆裂性骨折使用右侧入路，以避开主动脉弓、颈总动脉、食道以及气道。T6至T11骨折可以采用右侧入路，由于主动脉脉较易移动左侧入路也是可能的。胸腰椎骨折需要胸腹联合（T12-L1）或者腹膜后（L2-L3）入路可以选择左侧入路，这样可以避免肝脏对手术入路的妨碍以及移动腔静脉。然而，如果需要对于胸腰椎骨折患者可以采用右侧入路。低位腰椎（L4-L5）骨折通常采用后路手术，他们很少需要经腹膜后（L4）或者跨腹膜后（L5）进行前柱重建。
Thepatientshouldbeplacedinthe
truelateralpositiontohelpthesur-
geonmaintainorientationofthever-
tebralbody.Theregionofthefracture
ispositionedoverthebreakintheta-
blebecause?exingthetablewillim-
proveexposure.Forafractureatthe
thoracolumbarjunction(T12-L2),an
obliqueincisionismadeeitheralong
the12thrib(T12-L1)orjustinferior
toit(L1-L2)extendingtowardthe
umbilicusforaretroperitonealap-
proach.ForT11andsomeT12frac-
tures,especiallywheninternal?xa-
tionisplanned,a10thor11thrib
approachisused.Specialattentionis
requiredintheseexposurestoremain
extrapleural,andmeticulousrepairis
neededwhenthediaphragmisin-
cised.Whensuchanincisionisneed-
ed,itisimportanttoleaveapproxi-
mately1to2cmoftheperiphery
attachedtothechestwallforlaterre-
pair.Suturesmaybeplacedtomark
normalanatomiclocationsaround
theperipherytoaidanatomicclosure
afterreconstruction.Fora12thribex-
posure,theribisexcisedandtheret-
roperitoneumidenti?edwherethe
transversalisfascia,pleura,anddia-
phragmmeetnearthetipofthe12th
rib.Incisionoftheabdominalmus-
clesprovidesaccesstotheretroperi-
toneum.Theperitoneum,retroperi-
tonealfat,andkidneysarere?ected
anteriorlyusingbluntdissection,
therebyexposingthequadratuslum-
borumandpsoasmajormuscles.The
levelofthefractureisidenti?edand
thepsoasgentlyelevatedfromthean-
teriorportionofthevertebralbody.
Thesegmentalvesselsthenareiden-
ti?edbetweenthediskspacesonthe
vertebralbodyandareligatedanddi-
vided.Subperiostealdissectionof
thesestructuresallowsexposure
nearlytotheoppositepedicle.A
Finochiettoribretractororotherself-retainingretractorisplacedbetween
the11thribandtheiliaccrest.
















































患者体位应置于正中侧位，有助于外科医生确定椎体的方位。骨折椎体区域应置于手术床裂缝可弯曲处，因为调整手术床的弯曲度有助于手术视野的暴露。对于胸腰连接处（T12-L2）骨折，可以沿着第12肋骨（T12-L1）或者沿其下方（L1-L2）行斜形切口并向脐方向延伸，达到腹膜后入路。对于T11和一些T12骨折的患者，尤其是计划使用内固定器的患者，要使用沿第10或者11肋骨的入路。这些手术入路需要特别注意停留在胸膜外以及当膈肌切开时需要小心的修复。做这样切口后，重要的是留下大约1-2厘米的边缘附属于胸腔，以便于随后修复。暴露第12肋骨，切除肋骨，在腹膜后确认腹横筋膜、胸膜以及膈肌在第12肋骨顶端的交汇处。通过腹肌切口到达腹膜后，腹膜、腹膜后脂肪以及肾脏需要钝性分离至前方，从而可以暴露腰方肌和腰大肌。确定伤椎水平，从椎体前部将腰肌轻轻挑起。确认分割椎体的椎间盘之间的阶段血管并分离结扎。骨膜下分离允许暴露至椎弓根附近。Finochietto肋骨牵开器或者其它一些自动牵开器应置于第11肋骨和髂嵴之间。
Decompressionisaccomplished
withtheaidofloupemagni?cation
anda?beropticheadlight.Diskecto-
myisdoneaboveandbelowthefrac-
uredvertebra,followedbycorpec-
1
Bone
omyforthedecompression.
removedwithrongeursissavedfor
aterusetosupplementthestrutgraft
withcancellousbone.Directvisual-
zationofthedurathroughthepedi-
cleresectionandthediskectomysites
helpsavoidprematurepenetrationof
heposteriorwallofthevertebraand
njurytothedura.Thetransverse
widthofthevertebralbody,asnoted
hroughthediskectomysites,serves
asaguidefortheextentofthedecom-
pression.Themedialwallofthecon-
ralateralpedicleisthelandmarkfor
headequacyofthedecompression.
Acommonmistakeisnottodecom-
pressacrossthevertebralbodytothe
contralateralpedicle.Thedurawill
resumeitsnormalcontourafterde-
compression.


























减压的完成需要借助于放大显微镜和纤维光学头灯。在椎体次全切减压完成后应在骨折椎体上方和下方切除椎间盘。咬骨钳移除的骨头应保留，随后补充用于支撑移植的松质骨。通过切除椎弓根以及切除了椎间盘的部位可以直接清洗看到硬膜囊，从而避免仓促穿透椎体的后壁造成对硬膜囊的损伤。椎体的横向宽度（注意通过切除椎间盘部位了解）可以指导减压的程度。对侧椎弓根的内侧壁是减压充分的标志。减压后硬膜囊会恢复至正常形态。
Somemodi?cationsofthistech
niqueareneededforthoracicfrac
tures.Adouble-lumenendotrachea
tubeoftenisusedbecausesomepa
tientsdonottoleratepackingofth
lungforexposure.Theribaboveth
fracturecanbeusedasthelandmar
fortheapproach.Somesurgeonsre
movetherib;othersusethecostalin
terspacefortheexposure.Removalo
theribhasthedisadvantageofin
creasedpain,butitprovidessomelo
calautograftandamuchwiderex
posure.Theribheadattachmentt
thefracturedvertebraisremovedt
exposethepedicleandforamen.















这种改良技术也可用于胸椎骨折。由于一些患者不能耐受暴露过程中对肺脏的压迫，经常要使用双腔气官导管。骨折椎体阶段以上的肋骨可当做手术入路的标志。一些外科医生将肋骨移去；其他医生经肋间隙进行显露。移除肋骨有增加疼痛的缺点，但是这呢狗狗提供一些自体移植骨，并且显露的视野更加广泛。与伤椎连接的肋骨头应切除，以显露椎弓根和椎间孔。
Ifthespineisnotalreadyinad-
equatesagittalalignmentafterdecom-
pression,pressureontheskinposte-
riorlyatthelevelofinjuryand/or
distractionwithinthecorpectomyde-
fect,usingalargelaminarspreader
orimplantinstrumentation,canhelp
restorenormalalignment.Theverte-
bralendplatesshouldbepreparedby
removingthecartilaginousendplate
withacuretteorbur.Acompromisemustbemadebetweenobtainingad-
equatebleedingboneforvascularsup-
plytothegraftandremovingsomuch
ofthesubchondralbonethattheme-
chanicalsupportforthegraftisde-
creased.Somesurgeonsprefertomake
indentationsorseatingholesintothe
vertebralbodiestoaccommodatethe
endsofthegraft,butgenerallythis
shouldbecombinedwithadditional
support(eg,internal?xation)topre-
ventgraftimpactionandkyphosis.
Measurementsaremadefortheheight
andwidthofthegraft,whichthenare
appliedtoshapingtheiliaccrestau-
tograft,allografttibiaorfemur,orcage
device.Thegraftisimpactedintopo-
sitionwithdirectvisualizationofthe
duratoavoidimpingement.Placing
thetricorticalportionofthegrafton
thecontralateralsidecanhelpprevent
settlingandcoronaldeformitywhen
internal?xationisused.Thebreakin
theoperatingtableisthenremoved,
therebyeliminatingthelateralbend-
inginducedinthespinebyposition-
ingthepatient.Thistendstolockthe
graftinplaceandpreventsthespine
frombeingleftwithacoronalplane
deformity.Ifimplantsarebeingused,
theyareappliedaccordingtoman-
ufacturerrecommendations.Afterin-
strumentation,acheckshouldbedone
tomakesurethehardwaredoesnot
impingeonvascularorvisceralstruc-
tures.













































如果减压后脊柱的已经发生矢状序列恢复不充分，使用大型椎板撑开器或者植入器械，在后面皮肤上加压或者在椎体切除缺损处撑开，这样有助于恢复正常的序列。使用刮匙或者磨钻除去终板软骨组织进行椎体终板准备。一个妥协折中的方案是：达到椎体骨充分出血从而为移植骨提供融合的血管，移除足够多的软骨下骨以至于支撑移植骨的生物力学降低。一些外科医生倾向于选择在椎体上做一些凹槽或者座位空，从而为移植骨末端提供足够空间，但是通常这样需要联合附加的支撑（内固定器）来防止移植骨受压或者后突畸形的发生。测量所需要移植骨的高度和宽度，然后据此修正髂嵴自体移植骨、胫骨和股骨的异体骨以及cage装置。将移植骨植入时英直视硬膜囊以防止其受到侵犯。将移植骨的三面部分置于对侧，有助于防止在植入内固定时发生下沉和冠状面畸形。然后将手术床的折弯处恢复，从而可以消除由于患者体位所致脊柱侧向弯曲。这样可以将移植骨锁定在合适的位置并且可以防止朝向左侧的冠状面畸形。如果使用内固定物，应遵循制造商的建议。内固定植入完毕后应检查并确保植入器材没有侵犯血管或者内脏结构。
Anatomicclosureofthewoundis
doneafterinsertionofanappropri-
atedrainorthoracostomytube.Ifthe
pleuralcavitywasinvolvedintheex-
posure,clinicalandradiographic
monitoringforpneumothoraxshould
bedonepostoperatively.Thoracosto-
mytubesgenerallyareremoved
whenthereisnopneumothoraxon
radiographandnoairleakandwhen
drainagehassubsided.Inpatients
whodevelopapostoperativeileus,
dietshouldberestrictedand/orna-
sogastricsuctionuseduntilthereturn
ofbowelsounds.Externalsupport
withatotal-contactorthoracolum-
bosacralorthosisoftenisused,and
ambulationisbegunoncebrace?t-tingisaccomplished(usually48
hourspostoperatively).Progressive
exercisesforrehabilitationoflumbar
andabdominalmusclesarebegunap-
proximately3monthspostoperative-
lyand,whennecessary,followedby
workhardeningprograms.























插入合适引流管或者胸腔引流管后，按解剖层次闭合伤口。如果在显露的过程中累计胸膜腔，术后应进行气胸的临床和影像学监测。当影响学检查没有气胸现象或者漏气现象以及引流已经开始减少时可以拔出胸腔引流管。患者如果出现术后肠梗阻，应限制饮食，并进行鼻胃管减压直至肠鸣音恢复。经常要使用全接触式支具或者胸腰骶支具提供外部支撑，支具完成（通常术后48小时）即应开始下床活动。术后3个月开始逐步锻炼腰肌和腹部肌肉，如有必要，应按照强化方案进行锻炼。
Complications
Causesofcomplicationscanbe
groupedintothreegeneralcategories:
surgicalapproach,decompression,
35
andstructural(reconstruction).
Complicationsmayoccurasaresult
ofusingtheretroperitonealorthora-
coabdominalapproachtothespine.
Pneumothorax,recognizedintraoper-
ativelyandonpostoperativeradio-
graphs,ismanagedwithinsertionof
achesttube.Atelectasis,andocca-
sionallypostoperativepneumonia,
canoccurandappearsinthecon-
tralateralordependentlungin3%to
35
Super?cialanddeep
5%ofpatients.
woundinfectionsarerare;mostre-
spondtoantibiotictherapy.Infections
unresponsivetoinitialantibioticther-
apymayrequiresurgicald¤?bride
ment,usuallywithretentionofthere-
construction.Genitofemoralnerve
injury,nerveroot(eg,lumbarplexus)
tractioninjury,andinjurytothesym-
patheticplexusoccurinapproximate-
1,16,35
Intraop-
ly2%to4%ofpatients.
erativelacerationoftheinferiorvena
cavahasbeenreported.Bloodlossis
variable,buttheneedfortransfusion
shouldbeanticipated.Ileusiscom-
monwithretroperitonealapproach-
esbutgenerallyresolveswithin24
hours.Reported,butrare,complica-
tionsincludeperitonealentry,dam-
agetotheureter,interruptionof
lymphaticchannelswithresulting
chylothoraxorchylousleak,and
splenicrupture.Latecomplications
fromtheretroperitonealapproach
alsomayincludeincisionalhernia
andpermanentabdominalswelling
onthesideoftheapproach.














































并发症：并发症的诱因有三个种类：手术入路、减压、结构方面（重建）。采用腹膜后或者胸腹联合的入路到达椎体可能会引起并发症。手术中和术后X线发现的气胸需要插入胸腔引流管。3％-5％的患者对侧肺组织或者肺底会出现或者发生肺不张和术后偶发性肺炎。浅表或者深处伤口感染很少发生，很多对抗生素治疗有反应。对最初抗生素治疗无反应的感染可能需要清创，通常保留原有重建。大约2％-4％患者会出现生殖股神经损伤、神经根牵拉伤（例如腰丛）、交感神经丛损伤。有报道发现术中损伤下腔静脉的现象。失血量变化比较大，但是应提前做好输血准备。腹膜后入路会发生肠梗阻，但是通常术后24小时会有缓解。有报道显示的并发症有误入腹腔，输尿管损伤，淋巴管中断导致乳糜胸或者乳糜漏，脾脏破裂，但是很少发生。腹膜后入路的晚期并发症可能包括切口疝和手术入路侧永久切口膨胀。
Complicationsrelatedtodecom-
pressionarerelativelyuncommon.Iatrogenicneurologicinjuryisnotr
portedinmajorseries,likelybecaus
ofthesafetyresultingfromdirectan
teriorvisualizationofthethecalsa
Iatrogenicdurallacerationsshouldb
isolatedandclosed,ifpossible.Sub
arachnoiddrainageshouldbeconsid
eredforpersistentcerebrospinal?u
idleak.









关于减压的并发症相对少见。在较大的对照组中未发现医源性神经损伤的报道，可能是由于前路能直接清除看到硬膜囊所致安全性较大。医源性原因所致硬膜囊撕裂，如果可能应该分离缝合关闭。对于反复出现的脑脊液漏应考虑采用蛛网膜下腔引流。

Kyphosisandpseudarthrosisare
themainstructuralcomplicationsof
anteriorarthrodesis.Withoutinternal
?xation,kyphosisoccursinapprox-
4
Thishasnot
imately25%ofpatients.
beenfelttobedetrimentaltothere-
coveryofneurologicfunctionbecause
thekyphosisresultsfromsettlingof
thegraftwithoutcompressionofthe
neuralelements.Instrumentationcan
reducethisrateofkyphosistobe-
29
Ratesofpseud-
tween5%and10%.
arthrosisaregenerally5%to10%and
appeartobeatthelowerendofthis
16,17,32,35
rangewhen?xationisused.
Painattheiliaccrestdonorsiteisre-portedinapproximately5%ofcases,
althoughthismaybeanarti?cially
15,17,35
lowestimate.























前路固定融合的主要结构性并发症是畸形和假关节现象。没有使用内固定器，大约25％的患者会发生畸形。还没有发现畸形不利于神经功能的恢复，由于移植骨的下沉所致畸形不会发生神经组织受压。内固定器可将畸形的发生率降至5％-10％。假关节现象的发生率为5％-10％，当使用内固定器时发生率低于这个范围的最低值。5％的患者会出现髂棘采集移植骨处的疼痛，尽管这可能估计的较低。
Implantcomplicationsaredevice-
18
Device-related
ortechnique-related.
complicationsincludescreworbolt
breakageandrodorinterconnection
failure,bothofwhichareassociated
withprogressivekyphosis.Inonese-
riesusingthe?rst-generationKane-
dadevicein20patients,threescrew
failuresandonepseudarthrosis
17
Implanttechniquecom-
occurred.
plicationsarerarelyreported,but
concernexistsregardingcanalpen-
etrationandvascularinjurytothe
vesselsonthecontralateralside.In-
adequateexposureofthesuperior
endvertebramaypreventproper
placementofthescreworbolt?ush
againstthevertebralbody,complicat-
ingproperplacementoftheplate.Al-
thoughtheprominenceofimplants
isapotentialprobleminthethoracic
spine,theanteriorpositionoftheaor-taandtheoverlyingpsoasmajo
muscleeliminatesthisconcernatth
thoracolumbarjunction.



























植入物的并发症与器械或者技术有关。器械有关的并发症包括螺钉或者螺栓的断裂以及圆棒或者连接棒的失效，这些都会导致进行性畸形。一组使用最初金田装置的20名患者，三枚螺钉失效并出现一例假关节现象。植入物技术相关的并发症很少有报道，但是存在的担心是关于破入椎管以及造成对侧血管的损伤。椎体的上端暴露不足会妨碍螺钉和螺栓嵌入椎体的适当位置以及钢板的合适位置的选择。尽管植入物的突起在胸椎是一个潜在问题，主动脉的前方位置以及覆盖在上面的腰大肌在胸腰结合处消除这种担心。
Summary
Theanteriorapproachforthora-
columbarfracturesmaybepreferred
inpatientswithincompleteneurolog-
icde?citfromburstfractureswith-
outsubstantialposteriorelementin-
jury.Excellentvisualizationofthe
anteriorduramaterallowssafede-
compressionandleadstosomede-
greeofneurologicrecoveryinmost
patients.Reconstructiongenerallyin-
cludestheuseofiliaccreststrutgraft,
cages,orallograft.Supplementation
withinternal?xationcanimprove
biomechanicalstabilityandmaylead
toimprovedfusionratesandreduc-
tioninultimatekyphosis.Complica-
tionsarerareanddonotgenerallyaf-
fectlong-termoutcome.


















总结：胸腰椎骨折前路手术治疗首选爆裂性骨折有不完全性神经功能损伤的患者，同时不存在后方重要组织损伤。硬膜囊前方清晰地暴露允许安全的减压，在一些患者中有助于神经功能的恢复。重建通常包括使用髂棘支撑骨、cages、异体骨。附加内固定器固定有助于改善生物力学的稳定性，并致使融合几率提高，减小畸形的程度。并发症极少，通常不影响远期结果。