胸腰椎骨折专题文献译文发布帖—胸腰椎爆裂性骨折治疗回顾

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——hotstone

A review of the management of thoracolumbar burst fractures
胸腰椎爆裂性骨折治疗回顾

Abstract Background: Burst fractures account for more than half of all thoracolumbar fractures, which often cause a neurologic deficit and present a significant economic burden to the family and society. Accepted methods of treatment of thoracolumbar burst fractures include conservative therapy, posterior reduction and instrumentation, and anterior decompression and instrumentation. However, the management of thoracolumbar burst fractures has been the subject of much controversy. Methods: Publications reporting clinical data relating to the thoracolumbar burst fractures were reviewed. These articles were determined via review of the results of PubMed searches and articles gathered through compilation of references from those articles.
Results: There exist different criteria for the choice of the management based on the severity of kyphotic deformity, canal compromise, vertebral height loss, and neurologic status. To our knowledge, none of the existing criteria for the treatment of thoracolumbar burst fractures are generally accepted. Conclusions: In thoracolumbar burst fractures without a neurologic deficit, there is no superiority of conservative therapy over operative therapy. When the neurologic involvement is significant, the choice of operative management is advised. Also, there is no obvious superiority of one approach over the other.
D 2007 Elsevier Inc. All rights reserved.

Keywords: Thoracolumbar spine; Burst fractures; Treatment

摘要：背景：所有胸腰椎骨折中超过一半以上为爆裂性骨折，爆裂性骨折经常会导致神经功能障碍，给家庭和社会带来沉重的经济负担。通常胸腰椎爆裂性骨折的治疗方法包括：保守治疗、后路复位和器械固定、以及前路减压和器械固定。然而胸腰椎爆裂性骨折治疗方法仍然是有很多争议的话题。
方法：对报道胸腰椎爆裂性骨折临床资料的刊物进行回顾性研究。通过回顾PubMed研究结果来决定这些文章，从那些文章中的参考资料编写出文章。
结果：治疗方法选择存在不同的标准，依据后突畸形的严重程度、椎管受压的情况、椎体高度丢失程度以及神经系统的功能状态。依据我们的知识，目前胸腰椎爆裂性骨折的治疗标准没有一种被广泛接受。
结论：对于不伴有神经功能障碍的胸腰椎爆裂性骨折的患者，保守治疗与手术治疗相比没有优势。当神经系统的症状很严重，建议选择手术治疗。同时各种手术、方法相比没有明显的优势。
关键词：胸腰椎骨折 爆裂性骨折 治疗





1. Introduction

The term bburst fractureQ was first defined by Holds- worth [51] as a fracture caused by axial load leading to herniation of the nucleus pulposus of the vertebral disk through the upper end plate, resulting in the disruption of the vertebra from within. In 1983, Denis [32] redefined the burst fracture in his 3-column theory as a compression fracture of the anterior and middle vertebral columns, which causes retropulsion of a posterior vertebral body fragment into the spinal canal, the radiographic hallmark of the burst fracture [24,25,76,78,103]. Nearly 90% of all spinalfractures occur in the thoracolumbar region, and burst fractures compose approximately 10% to 20% of such injuries [32,39,58,79]. Although it is such a common fracture, there are various therapeutic options regarding the ideal management. The advantages of surgery include better correction of kyphotic deformity, greater initial stability, an opportunity to perform direct or indirect decompression of neural elements, decreased requirements for external immobilization, and an earlier return to work [3,23,35]. However, conservative management of thoraco- lumbar burst fractures in neurologically intact patients with bracing or casting would avoid a surgical intervention with its attendant morbidity. Therefore, it is controversial whether surgical or conservative treatment is more effective in the treatment of thoracolumbar burst fractures, especially in fractures without neurologic deficit. Also, the question as to how these fractures should be approached and stabilized (anteriorly, posteriorly, or combined anteroposteriorly), has been the subject of debate for a long time.

正文：
1.简介：Holds-worth首先将爆裂性骨折定义为轴向负荷造成骨折，导致椎间盘髓核由终板上极疝出，并引起椎体由内部的破裂。1983年Denis运用三柱理论将爆裂性骨折重新定义为椎体前柱和中柱粉碎性骨折，造成椎体后部的爆裂性骨块突入椎管，以及X线存在爆裂性骨折的特征。将近90％骨折发生在胸腰椎阶段，然而爆裂性骨折占到大约10％-20％。尽管这是一种常见骨折，关于理想治疗方法有多种选择。手术治疗的优势在于：较好纠正后突畸形，初期坚强的稳定，有机会对神经组织进行直接或者间接地减压，降低外固定的需求，以及早期回到工作岗位。然而对于神经功能正常的胸腰椎爆裂性骨折的患者采取支具或者石膏外固定的保守治疗，可以避免外科干预所伴有的并发症。因此，对于胸腰椎爆裂性骨折外科治疗和保守治疗那一种是更为有效的治疗方法仍旧存在争议，尤其是对于不伴有神经功能障碍骨折类型。同时，对于这些骨折采取何种手术入路以及固定的问题是长时间以来不断争论的话题。


2. Concept of stability

Various studies in the literature have dealt with the issue of radiologic analysis of stability in burst fractures. How- ever, the concept of stability, which is the most important determinant for the choice of treatment method, is still debated. Holdsworth [51] considered the burst fractures to be stable because the anterior and middle columns may be squashed down, whereas the posterior usually remains mechanically intact. Radiographic examination does show an obligatory laminar crack at the site of the burst fracture, but the important surrounding ligaments and muscles remain whole, thus conferring stability on the posterior column [12]. However, Denis [31] concluded that all thoracolumbar burst fractures would be unstable. He stated that the involvement of the middle column was a sufficient criterion for instability without any relation to type or direction of forces acting on the spinal column [31,32]. Krompinger et al [60] defined burst fractures without neurologic deficit as stable if the kyphotic angle was less than 308 and spinal canal narrowing was less than 50%. In the study of Reid et al [85], fractures with kyphosis less than358 and anterior height loss less than 60% were accepted as stable. Cantor et al [15] stated that fractures without neurologic deficit, with kyphosis less than 308 and height loss less than 50%, were defined as stable.

2.稳定性概念：各种不同的文献资料研究已经解决了对爆裂性骨折的稳定性进行放射学分析的问题。然而，决定治疗方法选择的最重要因素即稳定系概念仍旧存在争议。Holdsworth认为爆裂性骨折是稳定骨折，因为前柱和中柱可能粉碎塌陷，然而后柱通常保持机械性完整状态。X线检查在爆裂性骨折的部位确实存在椎板断裂，但是周围重要韧带和肌肉保持完整，因此认为后柱存在稳定性。然而Denis总结认为所有爆裂性骨折是不稳定骨折。他认为涉及中柱是判定骨折不稳定的充足理由，与作用在脊柱上外力方向和骨折类型无关。Krompinger等人认为不伴有神经功能损害并且后突角度小于30°以及椎管受压面积小于50％的爆裂性骨折是稳定性骨折。在Reid等人研究中后突畸形小于35°以及前柱高度丢失小于60％的骨折被认为稳定性骨折。Cantor等人认为不伴有神经功能障碍、后突畸形小于30°以及高度丢失小于50％骨折为稳定性骨折。

As described previously, although many radiologic para- meters such as local kyphotic angle, anterior vertebral height, posterior vertebral height, and canal compromise were defined to evaluate the stability, it is difficult to define the critical values of these parameters that may be required for determin- ing the stability of a burst fracture [12,60,86]. Neurologic status of patients seems to be another important determinative factor for stability for these fractures [80,92,102]. Therefore, the b3-column theoryQ described by Denis [32] may be the most widely accepted concept in use today. Denis described instability as mechanical instability (first degree), neurologic instability (second degree), and combined mechanical and neurologic instability (third degree).

如以前描述，尽管许多放射学参数例如局部后突角度、椎体前部高度、椎体后部高度以及椎管受压情况用于评估稳定性，然而很难去定义这些用于判定爆裂性骨折稳定性的参数的重要价值。患者神经功能状态被认为是定义骨折稳定性的另一个决定行因素。因此，由Denis所阐述三柱理论在今天可能是被广泛接受和使用的概念。Denis这样描述不稳定性：机械性不稳定（一级），神经系统不稳定（二级），神经系统和机械性不稳定并存（三级）

Recently, MRI has brought out a new dimension in the
stability concept and leads us to consider the importance of the posterior ligamentous complex. It is advocated that the evaluation of the posterior ligamentous complex on MRI is essential before a decision of instability is made. Burst fractures can be described as unstable if there is associated posterior ligamentous complex injury proved by MRI

最近，MRI对关于稳定性概念提出新的内容，促使我们考虑后方韧带群的重要性。提倡在做出不稳定判断前要通过MRI评估后方韧带群。如果MRI检查证实爆裂性骨折伴有后方韧带群的损伤，则被认为不稳定性骨折。

3. Nonoperative treatment
3.1. Indications
Initially, some series have reported poor outcomes from nonoperative management [7,29,33]. Denis et al [33] reported 6 cases of neurologic deterioration in 29 cases (ofor no neurologic deterioration in initially neurologically39 cases originally examined), and nonoperative treatment was then believed to multiply the risk of neurologic deterioration. However, most investigators have foundrareintact patients [15,21,56,80,102], and neither was neurologic deterioration noted in the reported series

3.非手术治疗
3.1.指征：最初，一系列研究报道了非手术治疗的不良结果。Denis等报道29例患者（最初是39例患者接受检查）中有6例神经系统功能恶化，然后非手术治疗被认为有增加神经系统功能恶化的风险。尽管，很多调查研究人员已经发现在最初神经系统功能正常患者中极少或者不存在神经系统功能恶化的现象，并且在一系列的报道中没有发现神经系统功能恶化。


]Nonoperative treatment is most commonly indicated for a relatively stable burst fracture. Agus et al [2] concluded that neurologically intact 2- and 3-column injured Denis type A, B, and C thoracolumbar burst fractures with intact facet joints could be treated nonoperatively. Wood et al [105] and Tropiano et al [98] believed that nonoperative management is a safe method in treating neurologically intact patients with thoracolumbar burst fractures because of its acceptable functional and radiographic results. Similarly, Shen et al [91] demonstrated that neurologically intact patients with single-level closed burst fracture and no fracture dislocations or pedicle fractures can be treated nonoperatively. In these studies, radiographic parameters such as posterior column involvement, kyphotic angle, and degree of canal compromise were not used as indications for nonoperative treatment. However, these radiographic parameters were considered for the choice of the treatment in other studies. Hitchon et al [50] claimed that recumbency was generally adopted in fractures with an angular deformity less than 208, a residual canal exceeding 50% of normal, and an anterior vertebral body height greater than50% of the posterior height. In addition, the posterior ligament complex should be evaluated before a decision of management is made. Tezer et al [95] suggested that conservative management should only be considered if there is no neurologic deficit and the ligaments are intact.

非手术治疗通常最适宜用于相对稳定的爆裂性骨折。Agus等总结认为神经系统功能正常，Denis分型中A、B、C三类胸腰椎爆裂性骨折中2柱以及3柱损伤，小关节完整的患者可以采取非手术治疗。Wood等以及Tropiano等相信非手术治疗在治疗神经系统功能正常的胸腰椎爆裂性骨折的患者中是一种安全的方法，因为它能够达到可以接受的功能和X线结果。同样，Shen等证实单一平面的闭合性爆裂骨折，不存在骨折脱位或者椎弓根骨折以及神经系统功能正常的患者可以接受非手术治疗。在这些研究中，X线参数诸如是否涉及后柱、后突畸形的角度、椎管受压的程度并没有作为非手术治疗的指征。然而，在其他研究中这些X线参数用于选择治疗方法。Hitchon等对于骨折伴有后突畸形小于20°，残留的椎管面积超过正常50％，椎体的前部高度高于后部的50％的患者通常要采取斜躺卧床治疗。另外后组韧带群在做出治疗决定前应该进行评估。Tezer等建议保守治疗应该考虑只用于没有神经系统功能障碍以及韧带结构完整的患者。

There is a growing consensus that posttraumatic kyphotic deformity may cause back pain from the soft tissue surrounding the spinal deformity [67,99] and alterations in the biomechanical characteristics of the neighboring motion segments [44,62,81], so some authors plan the management based on the severity of kyphotic deformity. Reid et al [86] concluded that nonoperative treatment is indicated for neurologically intact patients with kyphotic angle less than
358. In an effort to quantify the risk for late kyphosis progression in burst fractures, the SI was defined to help in assessing the segmental deformity at the level of the fracture [41]. The SI is a measurement of the kyphotic segmental deformity corrected for the normal sagittal contour at the level of the deformed segment. Farcy et al [41] proposed that nonoperative treatment would be indicated if the SI did not exceed 158.

大家不断取得一致意见认为：创伤后后突畸形造成脊柱周围软组织畸形以及邻近阶段的生物力学特点改变从而导致后背部疼痛，因此一些作者依据后突畸形的严重程度制定治疗方案。Reid等总结认为非手术治疗适应于神经系统功能正常并且后突畸形的角度小于35°的患者。为了量化爆裂性骨折中晚期畸形进展的风险，确定SI有助于评估骨折平面阶段畸形的程度。SI是在畸形阶段平面，测量阶段后突畸形矫正至正常矢状平面的角度的一种方法。Farcy等建议SI不超过15°可以采取非手术治疗。

Load sharing classification is a reliable and easy-to-use classification for the conservative treatment. Aligizakis et al [6] suggested that conservative management should be limited to neurologically intact patients with load sharing scoring of 6 or less.

负荷分享分型是用于选择保守治疗的一种可以信赖并且容易使用的分类方法。Aligizakis建议保守治疗应该限定用于神经系统功能正常同时负荷分享小于6分的患者。

3.2. Canal remodeling and its clinical significance
Spontaneous remodeling of the spinal canal succeeding thoracolumbar burst fractures has been recognized as an entity after the advent of 3-dimensional imaging technologies [42]. The mechanism of canal remodelingafter burst fractures is resorption of the intracanal bone fragments, rather than subsequent changes in the position of those fragments. Therefore, remodeling is shown to occur in patients treated either operatively or nonoperatively [30,48,53,80,89,94,107]. The degree of canal remodeling has been reported by authors regarding either nonoperative or operative approaches [15,25,39,64,80,92,102]. It raises one question: Is operative treatment beneficial to canal remodeling? Yazici et al [107] reported that the resorption of retropulsed fragments was less favorable in nonoperatively treated patients, although spinal canal remodeling occurred in both operatively and nonoperatively treated patients. However, in another study, Dai [25] found that there were no differences of the percentage of remodeling between patients who were untreated and those treated nonoper- atively and operatively.

3.2.椎管重塑以及其临床意义

在三维图像重建技术出现后，胸腰椎爆裂性骨折后椎管自发性重塑被认为是实实在在存在的。爆裂性骨折后椎管重塑的机制是椎管内骨折块的吸收而致，并非骨折部位骨折块位置随后改变而致。因此，重塑表现出可发生于手术治疗患者或者非手术治疗患者。据一些作者报道椎管重塑的程度依据非手术治疗或者手术治疗方法而不同。这就提出一个问题：是否手术治疗有益于椎管重塑？Yazici等报道尽管椎管重塑可发生于手术治疗和非手术治疗患者中，爆裂性骨块吸收情况在非手术治疗患者中不是很满意。然而，在另一项研究中，戴等发现接受手术治疗和非手术治疗的患者与没有接受手术治疗的患者相比重塑的百分比没有不同。



It has been demonstrated that transpedicular intracorpor- eal grafting in the treatment of burst fractures did not havea detectable effect on canal remodeling [4]. The sequelae of remodeling seemed correlated with the initial canal encroachment [17,25]. Willen et al [104] demonstrated fragment resorption to some degree in 51% patients (20/39) who had initial canal narrowing of less than 50%, whereas larger fragments narrowing the spinal canal more than
50% did not appear to resorb. However, Mumford et al [80]
reported significant remodeling in virtually all canals with greater than 50% compromise. Nonoperative treatment may be a choice for thoracolumbar burst fractures with canal encroachment without significant neurologic deficit regard- less of the relation between remodeling and canal en- croachment, because there was no correlation between the degree of canal compromise and any clinical symptoms. However, the choice of nonoperative management often means giving up decompression of the neural elements and poorer prognosis when the neurologic involvement is significant [25].

已经证实经椎弓根椎体内植骨在治疗爆裂性骨折中对于椎管重塑没有可以发现的效果。重塑的结果看起来与椎管最初受侵的情况有关。Willen等证实在最初椎管狭窄程度小于正常50％的51％患者中出现一定程度的骨折块吸收，相反较大的骨折块造成椎管狭窄程度大于正常的50％没有表现出吸收情况。然而，Mumford等报道有意义的重塑实际上发生在椎管受压超过50％的患者中。非手术治疗可以作为胸腰椎爆裂性骨折伴有椎管受侵不存在严重神经功能障碍患者治疗的选择，而不管椎管重塑与椎管受侵的关系，因为椎管受压的程度与任何临床症状之间没有关系。然而，选择非手术治疗经常意味着放弃对神经组织的减压，当神经系统功能症状明显时会发生不良预后。

3.3. Treatment modality
Conservative treatment consists of postural reduction, bed rest, body cast/orthosis, functional rehabilitation, or a combination of these. Although numerous authors have reported excellent results after nonoperative management without reduction [7,14,15,29,43,80,91,92,102], we claim to attempt to restore sagittal alignment by fracture reduction because a positive association was observed between kyphotic deformity and back pain. The duration of recumbency after fracture still remains controversial. Some authors recommended recumbency for 4 to 12 weeks followed by gradual mobilization, although some did suggest bed rest for a shorter time. Cantor et al [15] and Tropiano et al [98] reported satisfactory results from conservative treatment of neurologically intact burst frac- tures with early ambulation in a TLSO or casting. In addition, prolonged bed rest carries a risk of thromboem- bolism, decubitus ulceration, pulmonary complications, and patient deconditioning [15,98], and Willen et al [104] found no relationship between duration of bed rest and increase in gibbus angle in their series of 54 conservatively managed burst fractures. It seems that prolonged bed rest in these patients is unnecessary. Mumford et al [80] proposed standard treatment of 4 weeks of bed rest followed by 12 weeks of bracing for thoracolumbar burst fractures not accompanied by neurologic deficits.

保守治疗包括体位复位、卧床休息、躯体石膏和支具、功能康复或者这些治疗的联合。尽管很多学者已经报道不用复位的保守治疗后的良好结果，我们主张试图通过骨折复位来恢复序列矢状面完整性，因为发现后突畸形与背部疼痛的明确关系。骨折后斜躺卧位的时间仍旧存在争议。一些作者推荐4-12周的斜躺卧床，并逐渐进行肢体活动，然而一些作者建议缩短卧床休息的时间。Cantor等以及Tropiano等报道神经功能正常爆裂性骨折保守治疗并运用TLSO或者支具早期下床活动获得满意结果。另外，延长卧床休息时间带来血栓栓塞的风险、褥疮溃疡、肺部疾病并发症以及患者去适应现象，Willen等在他们54例爆裂性骨折的保守治疗系列研究中发现卧床休息时间与驼背角度之间没有关系。这看起来延长卧床休息时间对这些患者没有必要。Mumford等建议胸腰椎爆裂性骨折不伴有神经系统功能障碍患者进行卧床休息4周同时戴支具12周的规范治疗。

3.4. Clinical outcome

Clinical outcome of conservative treatment of thoraco- lumbar burst fractures is summarized in Table 1. Although conservative treatment can lead to good clinical outcomes in neurologically intact patients with thoracolumbar burst fractures, it appears that the kyphosis progresses and vertebral body collapses gradually over time. Mumford et al [80] reported that kyphosis progressed 78 and anterior body collapsed a further 6% at an average follow-up of
2 years. Similarly, Willen et al [104] noted an average increase in kyphosis of 68 and a 7% increase in anterior body compression in a series of 54 patients at 6 months after fractures, whereas changes in both measurements were small 1 year after injury, suggesting stabilization of the deformity. Krompinger et al [60] reported that 36% of thoracolumbar burst fractures progressed 108 or more at follow-up. However, the remaining residual deformity was not correlated with symptoms at follow-up.

3.4.临床结果
胸腰椎爆裂性骨折保守治疗的临床结果总结于表一。尽管保守治疗对于胸腰椎爆裂性骨折神经系统功能正常患者可获得较好的临床结果，但是表现出随着时间延长，畸形进行性加重以及椎体逐渐塌陷。Mumford等报道平均随访2年中，发现后突畸形加重7°，椎体前部塌陷超过6％。同样，Willen等54例患者在骨折6个月后后突畸形平均加重6°，椎体前部受压程度增加7％，相反这两项测量结果变化都是在受伤后少于1年时间，暗示畸形的稳定性。Krompinger等报道在随访患者中36％胸腰椎爆裂性骨折后突畸形角度加重10°或者更严重。然而在随访患者中残留畸形和患者症状没有关系。


3.5. Nonoperative vs operative treatment
Clinical outcome of conservative treatment vs operative treatment of thoracolumbar burst fractures is summarized in Table 2. In general, patients with neurologic deficit are treated operatively, whereas the management of thoraco- lumbar burst fractures without neurologic deficit remains a operatively, Denis et al [33] found that all patients treatedmatter of controversy. In a retrospective analysis of 104 cases of thoracolumbar burst fractures in the absence of neurologic deficit treated either operatively or non-surgically had no unrelated disability and returned to full- time work, whereas 25% of the patients treated non- operatively were unable to return to work full time and
17% developed neurologic problems. This suggests the significant advantages of operative treatment over conser- vative management of thoracolumbar burst fractures without neurologic deficit. Theoretically, decompression, fracture reduction, and stabilization through surgery lead to optimal outcomes in terms of neurologic function and back pain [13,35]. However, most authors demonstrated that operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurologic examination provided comparable functional outcomes at long-term follow-up as compared with nonoperative treatment [25,37,58,91,105], although operative treatment may pro- vide partial kyphosis correction and earlier pain relief [91]. In a prospective, randomized study comparing operative and nonoperative treatment of thoracolumbar burst fractures in 47 patients without neurologic deficit, radiographic examination demonstrated no significant differences be- tween the 2 groups with respect to the fracture kyphosis on admission, after treatment, or after long-term follow-up [105]. Similarly, no significant difference was found between the 2 groups with respect to return to work and the average pain scores. In a retrospective study of
235 patients with unstable thoracolumbar fractures, Rechtine et al [84] found that there was no significant difference in the occurrence of decubitus, deep venous thromboses, pulmonary emboli, or mortality between the nonoperatively treated patients and operatively treated patients. However, we must note that the average charges related to hospitalization and treatment in patients treated operatively are much greater than those in patients treated nonoperatively. Taken together, nonoperative treatment remains a viable alternative to operative intervention in neurologically intact patients with thoracolumbar burst fractures, although there is definitely a need for ran- domized controlled trials with sufficient sample size to determine whether one treatment is more effective than the other.

3.5.非手术治疗与手术治疗对比
保守治疗与手术治疗临床结果对比总结于表2。通常，有神经功能障碍的患者应给予手术治疗，相反不伴有神经功能障碍的胸腰椎爆裂性骨折患者的治疗仍旧存在一些争议。对104例胸腰椎爆裂性骨折不伴有神经功能障碍患者的手术治疗或者非手术治疗进行回顾性分析，Denis发现所有手术治疗的患者没有相关的残疾，并且回到全职岗位，相反进行非手术治疗患者中有25％不能回到专职岗位上并且有17％神经系统问题加重。这就暗示胸腰椎爆裂性骨折不伴有神经系统功能障碍的患者手术治疗与非手术治疗相比有明显优势。理论上讲，通过手术减压复位固定对于神经系统功能和后背部疼痛的治疗能够取得最佳结果。然而，许多作者通过长期随访证实稳定性爆裂性骨折且神经系统检查正常患者进行手术治疗组与非手术治疗组对比提供相同的结果，尽管手术治疗可能会获得部分后凸畸形的矫正以及早期疼痛的缓解。通过对47例不伴有神经功能障碍胸腰椎爆裂性骨折的患者手术治疗组与非手术治疗组进行前瞻性随机对比调查研究，X线检查证实关于骨折畸形在入院后、治疗后以及长期随访中没有明显不同。同样，关于返回工作和平均疼痛得分两组没有明显不同。对于235名不稳定胸腰椎爆裂性骨折的患者进行的回顾性研究中，Reachtine等发现非手术治疗患者与手术治疗患者相比在褥疮、深静脉血栓、肺部栓子以及死亡率方面没有明显不同。然而，我们必须注意手术治疗患者的住院和治疗负担与非手术治疗患者相比要大得多。综合考虑，对于神经功能正常爆裂性骨折患者非手术治疗是切实可行的选择，然而确实需要对足够样本进行随机性可控性试验以确定是否一种治疗与其他治疗方法相比更为有效。


4. Operative treatment

The goals of surgical treatment of thoracolumbar spinal fractures include (1) decompression of the spinal canal and nerve roots to facilitate neurologic recovery, (2) restoration and maintenance of vertebral body height and alignment, (3) obtaining a rigid fixation to facilitate nursing care and to allow early ambulation and rehabilitation, (4) prevention of development of posttraumatic progressive deformity with neurologic deficit, and (5) limiting the number of instru- mented vertebral motion segments [1,18,52]. Recent trends have been toward rigid internal fixation of fractures to allow rapid mobilization of patients and decrease the complica- tions of prolonged immobilization of joints and muscles.

4.手术治疗
胸腰椎骨折外科治疗目的包括椎管和神经根减压亦有利于神经系统功能恢复，重建和维持椎体的高度和序列，获得坚强的固定以有利于护理、允许早期的离床活动和康复锻炼，预防伴有神经系统功能障碍的进行性创伤后畸形的发展，限制活动阶段椎体的固定数量。最近有一种趋势倾向于骨折的坚强固定允许患者迅速的活动，从而减少延长关节和肌肉制动所引起的并发症。


4.1. Indications
Generally, operative management is indicated in patients who present with a neurologic deficit and an unstable burst fracture. One notable exception is patients with an isolated partial nerve root deficit, which usually will improve in time with nonsurgical treatment. Reid et al [86] concluded that it is necessary to treat patients operatively with burst fractures if these patients have neurologic deficits or kyphotic angle more than 358. Benson et al [11] and Willen et al [104] concluded that operative treatment should be limited to those fractures with canal compromise more than 50%, compression rate of the anterior column exceeding 50%, and kyphotic angle more than 208. There was no correlation between the degree of canal compromise and any clinical symptoms. Thus, in the setting of a detailed neurologic examination with normal findings, no degree of canal com- promise would by itself serve as an indication for operative intervention and decompression in this fracture [105]. Nowadays, there is a growing consensus that there might be a positive association between kyphotic deformity and back pain [37,41,46], so kyphotic deformity should serve as an indication for surgical management. SI is a useful criterion to assess deformity and predict progression of segmental kyphosis. Farcy et al [41] proposed that if the SI exceeds 158, the biomechanical environment favors pro- gression of kyphosis, and surgery is indicated. In addition, if the posterior ligamentous complex is injured, surgical management should be undertaken [95].

4.1.手术指征
通常手术治疗适宜于患者表现出神经功能障碍以及不稳定性骨折。单独出现不完全性神经根功能障碍的患者是一个例外，这种患者经过及时非手术治疗会出现神经功能的恢复。Ried等总结认为，如果爆裂性骨折患者伴有神经系统功能障碍或者后突畸形角度大于35°有必要给予手术治疗。Benson等和Willen等总结认为手术治疗应限定用于骨折患者伴有椎管受压超过50％，前柱粉碎程度超过50％以及后突畸形角度大于20°。椎管受压程度和临床症状之间没有联系，因此神经系统检检查为正常所见，没有椎管受压，在这种骨折中可以作为手术干预和减压的指征。今天，逐渐达成共识：后突畸形和背部疼痛存在确定关系，因此后突畸形应作为手术治疗指征。SI是一种判断畸形角度以及预测阶段畸形进展的有用标准。Faracy等建议如果SI超过15°，生物力学环境有利于后突畸形进展，应作为手术治疗的指征。另外，如果后柱韧带群损伤，应进行手术治疗。


If patients have certain situations, such as obesity, skin conditions, multitrauma, and psychological factors, operative treatment should be considered because either casting or bracing is not feasible or surgical stabilization is advantageous.

如果患者有一些情况，例如肥胖，皮肤因素，复合伤以及心理学因素，应考虑是否手术治疗，因为要考虑石膏或者支具是否可行或者手术固定是否有利。

4.2. Operative approach

If surgical treatment of thoracolumbar burst fractures is chosen, further debate arises from the appropriate type of approach. There are 3 major approaches used in the treatment of patients with thoracolumbar burst fracture [10,13,36,61,90]. The anterior approach with a plate on the vertebral body provides good decompression and solid fusion, but the operative risk is relatively higher than that associated with the posterior approach [39,54]. The poste- rior procedure of the thoracolumbar junction is well established, with advantages such as more safety in exploring the surgical site without violating the pulmonary, visceral, and vascular structures [75] and being less technically demanding. However, instrument failure and recurrence of kyphosis have been reported when surgery is made without vertebral body reconstruction [16,38,73]. One of the treatment modalities to solve these problems is long- segment pedicle screw fixation (2 above and 2 below), but this will reduce the range of spinal motion. A combination should be approached and stabilized (anteriorly, posteriorly,of the anterior and posterior approaches may be an ideal method, but the operative time is longer and the surgical trauma is higher. The question as to how these fracturesor combined anteroposteriorly), remains controversial

4.2.手术方法
如果选择胸腰椎骨折的外科治疗，进一步争论产生于合适的手术方法。用于治疗胸腰椎爆裂性骨折方法主要有3种。使用椎体钢板的前路手术治疗可以进行充分减压以及坚固融合，但是与后路手术相比手术风险较高。已经确定胸腰结合部的后路手术治疗有很多优点，诸如手术部位的暴露更加安全，无需侵犯肺脏，腹部器官以及血管结构，并且对技术性要求较少。然而，当手术治疗没有进行椎体重建，有报道显示会发生器械固定失败和畸形复发。解决这些问题的治疗形式之一就是进行长阶段的椎弓根螺钉内固定（上方两个椎体和下方两个椎体），但是这将减少脊柱的活动程度。前后路联合手术是一种理想方法，但是手术时间较长并且手术创伤较大。关于如何对这些骨折进行显露和固定的问题（前路、后路、前后路联合）仍旧存在争议。


Anterior decompression and stabilization has been proposed for cases with severe canal compromise, vertebral comminution, and kyphotic deformity, and especially with neurologic deficit [49,72]. In cases without neurologic deficits, however, most authors recommend indirect reduc- tion with posterior transpedicular instrumentation. McCor- mack et al [71] introduced the load-sharing classification system, which is assessed to accumulate the points for a total score as determined by the vertebral fracture anatomy: (1) the amount of comminution on sagittal CT scans: 1 point for little comminution when 30% or less of the vertebral body is involved, 2 points when 30% to 60% of the body is involved, and 3 points for greater than 60% comminution of the vertebral body; (2) the amount of displacement of fracture fragments on axial CT scans: 1 point for minimal displacement, 2 points for at least 2 mm displacement less than 50% of the cross-sectional area of vertebral body, and3 points for 2 mm or greater displacement in more than 50% of the cross-sectional area; (3) the amount of correction of kyphotic deformity on lateral plain radiographs: 1 point for38 or less correction, 2 points for 48 to 98 correction, and3 points for 108 or more correction. Parker et al [83] applied this system and were able to predict which fractures could be safely treated with short-segment transpedicular posterior instrumentation with low risk of screw failure or progressive deformity. High-risk fractures should be treated in an alternative manner, using either an anterior strut graft or longer instrumentation.

对于存在严重椎管受压，椎体粉碎，后突畸形以及神经系统功能障碍的患者建议采取前路减压固定。对于不伴有神经功能障碍的患者，一些作者建议进行间接复位同时经椎弓根器械固定。McCormack等引进负荷分享分类方法，这种分类方法通过椎体骨折解剖特点来计算要点得分从而得出总分：（1）矢状位CT扫描显示骨折粉碎的程度：30％或者小于30％的椎体轻度粉碎得1分，涉及30％-60％的椎体粉碎得2分，超过60％的椎体粉碎得3分：（2）轴位CT扫描显示骨折块的移位程度：轻微移位得1分，超过小于椎体50％横截面积得2分，超过2mm的移位超过椎体横截面积50％的移位得3分：（3）侧位X线片上显示后突畸形需要矫正的程度：矫正程度为3°或者小于3°得1分，矫正程度为4°-9°得2分，矫正程度为10°或者10°以上得3分。Parker等运用这种分类方法，能够预测那种类型骨折运用经椎弓根短阶段后路固定更安全并且具有较小的螺钉固定失败以及进行性畸形风险。高风险的骨折需要变换治疗方法，采用前路移植骨支撑或者长阶段的器械固定。

4.3. Posterior surgery
Burst fractures are caused by flexion-axial loading forces and thus seem best treated posteriorly with reduction and fixation by extension and distraction. A variety of instru- mentation systems is available, and attachment can be achieved and forces applied to the spine by hooks, rods, wires, and/or screws. In general, hook-rod systems require longer moment arms over more instrumented segments than do pedicle screw constructs. The efficacy of relatively long fusions with segmental hook-rod constructs is well docu- mented. McBride [70] obtained a 93% fusion rate in 48 thoracolumbar fractures using multiple hook-rod fixation with a follow-up of 21 months. A 22% complication rate was noted because of early hardware failure, persistent pain, syrinx formation, and progression of scoliotic deformity. Sublaminar or interspinous wire fixature is rarely used in trauma patients, aside from some with complete cord injuries, because wire passage can cause additional trauma to the spinal cord, especially after fracture. Pedicle screw instrumentation systems are most commonly used today. Theoretically, pedicle screw fixation allows greater forces to be applied to the spine to reduce deformity because of its3-column fixation characteristics, which facilitate simulta- neous application of axial compression or distraction androtational forces. The improved stiffness of pedicle screw constructs may allow some burst-type fractures to be treated with very short constructs one level above and below the fracture. Markel and Graziano [68] demonstrated that some thoracolumbar burst fractures could be treated successfully with short-segment fixation in comparison with longer instrumentation and fusion. Similarly, Parker et al [83] reported a 98% fusion rate and no significant loss of lordosis with the use of short transpedicular fusion in burst fractures without extensive kyphosis or comminution. However, there was a 20% to 50% incidence of implant failure and a 50% to 90% loss in reduction of kyphosis [16,38,73,74]. Therefore, in patients with extensive com- minution and kyphosis or those who are unable to comply with postoperative bracing, alternative surgical methods may be indicated. Long-segment posterior fusion has yielded more than 90% fusion rates [70]; at least 2 levels above and below the fracture are usually instrumented. Nowadays, controversy still exists over whether short- segment pedicle instrumentation is a suitable method. In a randomized controlled trial, Tezeren and Kuru [96] reported that 5 of 9 patients treated with short-segment instrumen- tation had a correction loss of 108 with a 55% failure rate, whereas none of the patients had a correction loss of 108 in patients treated with long-segment instrumentation.

4.3.后路手术治疗
爆裂性骨折由轴向屈曲负荷应力所致，因此最好采用后路撑开装置进行复位和固定。多种器械系统可以使用，通过钩，棒，钢丝，以及螺钉力量作用于脊柱达到连接目的。通常与椎弓根螺钉固定装置相比钩棒系统需要通过较多的固定阶段来获取较长的力臂。阶段性钩棒固定装置的相对较长的融合效能已经得到很好的证明。McBride通过21个月的随访发现在48例胸腰椎骨折患者中使用多阶段的钩棒内固定装置获得93％的融合比率。由于早期金属植入物失败，持续疼痛，瘘管形成，侧弯畸形逐渐加重，注意到这中方法有22％并发症比率。除了完全性脊髓损伤患者，在创伤患者中极少使用椎板下或者棘突间钢丝固定，因为钢丝缠绕会导致对脊髓的额外损伤，尤其在骨折后。在今天椎弓根螺钉器械固定系统最常被使用。理论上讲，椎弓根螺钉允许更大的作用力作用于脊柱来纠正畸形，因为其三柱固定特点，可以减轻同时存在的轴向压力、者张力以及旋转应力。硬度得到改进的椎弓根钉可以允许一些爆裂骨折类型进行最短阶段固定，骨折椎体以上和以下一个椎体平面固定。Markel和Graziano证实一些胸腰椎爆裂性骨折患者成功应用短阶段内固定进行治疗，和长阶段器械固定融合相比取得一样的结果。同样，Parker等报道对于不伴有广发后突或者粉碎的爆裂性骨折患者进行短阶段经椎弓根融合取得98％的融合比率并且脊柱前弯角度没有明显减少。因此，对于有广泛粉碎和畸形的患者或者术后不能够应用支具的患者，适宜于改变手术方法。长阶段的后路融合取得了超过90％的融合比率；通常骨折阶段以上以下至少2个椎体水平要被固定。今天，对于短阶段的椎弓根钉固定是否是合适的方法存在争议，在一项随机控制性试验中，Tezern和Kuru报道进行短阶段固定的9名患者中有5名患者畸形矫正角度小于10°，并且有55％失败比率，相反进行长阶段固定的患者没有一个畸形矫正角度小于10°。


Spinal fusion has always been a part of the stabilizing procedure. In theory, this may result in a decreased rate of implant failure. However, in a retrospective study of28 consecutive patients who had short-segment pedicle screw fixation of thoracolumbar burst fractures without fusion performed, the implant failure rate and the clinical outcome were similar to that from series where fusion had been performed in addition to pedicle screw fixation [16,39,88]. Furthermore, bone grafting does not decrease the loss of correction after surgery [57]. It seems that bone grafting is not necessary when managing patients with thoracolumbar burst fractures by short-segment pedicle screw fixation. Potential advantages without fusion are that the facet joints are less disturbed adjacent to the fracture, with reduced surgical soft tissue stripping being required when a bed for the graft does not have to be prepared, and thoracolumbar motion is preserved

脊柱融合经常是稳定过程的一部分。理论上讲这可以降低内植物失败的比率。然而，对28名胸腰椎爆裂性骨折患者进行回顾性连续性研究中，这些进行了短阶段椎弓根钉固定而没有进行融合的患者在内植物失败比率和临床结果方面与进行椎弓根钉固定且融合的患者相比取得相似的结果。并且，骨移植并不能减少术后畸形矫正角度的丢失。当对胸腰椎爆裂性骨折患者进行短阶段的椎弓根螺钉内固定看起来没有必要进行骨移植。非融合的潜在优势在于邻近骨折部位的关节面很少受到干扰，并且减少所需要的软组织手术剥离，因为骨移植部位不需准备，还可以保留胸腰椎活动程度。

Although short-segment fixation is the most common and most simple treatment of burst fractures [59] without anterior construction, the loss of restoration will be greater because of the recollapse of the disk space. Transpedicular grafting of the injured anterior vertebral body in addition to short-segment fixation has been offered as a possible solution by Daniaux [26]. This theoretically supplements the middle column, thus decreasing the correction loss. In addition, this method decreases the bending moments on the posterior instrumentation and may result in a decreased rate of screw breakage [38]. However, a prospective trial of transpedicular intracorporeal grafting with short-segment instrumentation for thoracolumbar fractures failed to find a benefit compared with short-segment pedicle screw fixationwith only fusion, and both procedures had high failure rates of 40% to 50%, as defined as an increase of 108 or more in local kyphosis and/or screw breakage [5]. Transpedicular bone grafting has also been demonstrated not to decrease the loss of correction [57], suggesting that transpedicular grafting of the injured vertebral body is not effective in preventing correction loss and implant failure, although it appears to be a safe procedure. In addition, posterior body reinforcement with cement has been applied to restore and maintain the vertebral body and minimize implant failure in short-segment fixation. Mermelstein et al [75] found in their cadaveric burst fracture study that vertebroplasty with calcium phosphate cement reinforced the anterior column and reduced stress on the pedicle screw construct. In addition, this technique has been demonstrated relatively effective in preventing reduction loss and avoiding implant failure in clinical studies [19,20,22,63,101]. Toyone et al [97] reported a mean correction loss of 28 in their series using transpedicular hydroxyapatite grafting after indirect reduction and pedicle screw fixation, which was similar to those of the series of anterior decompression and stabiliza- tion with the Kaneda device (18) [54] and Z plate (28) [72]. Cho et al [20] reported that kyphosis correction (0.338 vs
6.28 loss) and anterior vertebral height (12.9% vs 2.3%) were achieved and maintained in fractures reinforced with PMMA cement during surgery, but not in fractures treated without PMMA vertebroplasty at about 2 years follow-up, and in the control of severe and constant pain, short- segment pedicle screw fixation combined with PMMA vertebroplasty has better clinical outcome than simply short- segment pedicle screw fixation. PMMA cement offers immediate spinal stability in patients with thoracolumbar burst fractures, as does anterior plate and screw fixation performed for anterior column repair. In addition, the increased vertebral body height and hardness achieved with the use of PMMA cement may change the loading force on the anterior column and decrease the stress on the posterior instruments [75]. That is why in patients treated with PMMA vertebroplasty, the kyphosis correction can be maintained with minimal loss of vertebral height, a low instrument failure rate, and better postoperative pain control. The vertebroplasty procedure, however, is not an absolutely safe procedure; it inherits potential risks of extravasation of PMMA. Therefore, it is important to note that not every thoracolumbar burst fracture can be treated by vertebroplasty procedure. After conservative treatment, the neurologically intact patients with thoracolumbar burst fractures had intractable pain, the fractures were limited to within the anterior and middle column, and the posterior longitudinal ligament was intact. In the above circum- stances, the vertebroplasty can be considered for treatment of burst fractures.

尽管短阶段的固定非常普通，用于治疗爆裂性骨折非常简单无需前路重建，但是由于椎间盘继续塌陷会导致重建程度更大减少。Daniaux提供一个可行的解决方法，短阶段固定外对受损的前部椎体进行经椎弓根植骨。这种方法从理论上讲补充了中柱，因此可以减少矫正角度的丢失。另外这种方法可以减少后路器械装置的弯曲应力并且减少螺钉断裂的比率。然而，一项对胸腰椎骨折进行短阶段固定并经椎弓根椎体植骨的前瞻性研究与短阶段椎弓根钉内固定并只有融合的研究进行对比。没有发现益处，并且这两种方法都存在较高的失败比率，40％-50％，表现为局部畸形程度加重10°或者更严重，或者螺钉的断裂。已经证明经椎弓根植骨不会减少纠正角度的丢失，尽管经椎弓根植骨是一种安全的方法，暗示受伤椎体经椎弓根植骨在预防纠正角度丢失和内植物断裂方面没有效果。另外，使用骨水泥强化椎体后部已经在短阶段固定中用于重建和维持椎体以及减少内植物的失败。Mermelstein等在他们尸体标本爆裂性骨折研究中发现运用磷酸钙骨水泥的椎体成形术可以加强前柱以及减小椎弓根钉的张力。另外，在临床研究中已经证明这项技术在预防复位角度的丢失以及避免内植物断裂方面相对有效。Toyone等发现间接复位以及椎弓根固定后经椎弓根羟基磷灰石植入后平均矫正角度丢失2°，结果与前路减压以及使用Kaneda器械和Z型钢板固定相似。Cho等报道通过2年随访发现手术中使用PMMA骨水泥加强的骨折病例中达到维持后突畸形矫正角度以及椎体高度的维持的作用，非PMMA骨水泥椎体成形术的病例则没有，在控制严重和持续疼痛方面，短阶段椎弓根钉内固定联合PMMA椎体成形术与单独椎弓根钉内固定相比取得更好的临床效果。PMMA骨水泥通过为胸腰椎爆裂性骨折患者提供及时的脊柱稳定性，正如前路钢板和椎弓根钉在前柱修复方面所发挥作用。另外，使用PMMA骨水泥增加的椎体高度和硬度可能会改变前柱的分享负荷以及减少后路固定装置的应力。这就是为什么使用PMMA骨水泥椎体成形术的患者后突畸形矫正同时椎体高度最小的丢失，低水平固定装置失败率，较好控制手术后疼痛。然而椎体成形术并不是一种绝对安全的方法，它依然具有PMMA骨水泥溢出的风险。因此，重要的是记住并不是每一名胸腰椎爆裂性骨折的患者适宜于椎体成形术。保守治疗后，神经功能正常爆裂性骨折患者具有难以解决的疼痛，骨折仅限于前柱和后柱以及后纵韧带完整。出现以上情况，可以使用椎体成形术治疗爆裂性骨折。

Decompression with laminectomy alone has been shown to be of no value and has been rightly abandoned because it became evident that posterior laminectomy not only failed to decompress the spinal canal, as most of the compression was anterior, but that in fact made many patients worse by destabilizing the spine, causing increased kyphosis and placing more pressure on the anterior part of the spinal cord and nerve roots.

单独椎板切除后减压已经证明没有价值，并且已经遭到肯定抛弃，因为已经证实后路椎板切除不仅不能达到椎管减压效果，因为致压因素主要来自前方，并且造成很多病人脊柱更加不稳，导致后突畸形加重以及增加脊髓和神经根前部的压力。

4.4. Anterior surgery

With the use of the computer-assisted axial tomographic scanner, it has become readily apparent that distraction rods or compression rods do not routinely decompress the bone fragments from residual impingement on the neural ele- ments in the spinal canal. In contrast to the loss of angulation after posterior instrumentation [57], some authors have reported on anterior procedures resulting in a minimal loss of sagittal alignment in clinical studies [8,49,54,77]. In addition, biomechanical studies have proven the advantage of anterior procedures, providing superior rigidity as compared with posterior instrumentation [66,93,100,108]. Thus, this has resulted in a new contro- versy regarding the necessity of anterior decompression and possibly the efficacy of anterior procedures. Currently, several authors advocate a primary anterior approach to the fractured vertebra, debridement of the fracture fragments from the anterior aspect of the spinal canal, and the use of bone grafts or anterior transvertebral-body internal fixation devices to provide stability. In most patients with thoraco- lumbar fractures, neurologic deficit is caused by impact and/ or compression to the ventral surface of the spinal cord, and the anterior approach provides optimal direct exposure for visualization of the ventral aspect of the dura mater during surgical decompression. In addition, for fracture patterns involving marked comminution with loss of support of the anterior and middle columns of the spine, the anterior approach provides excellent exposure for reconstruction with structural grafts or implants. This allows restoration of height and correction of kyphosis while limiting the number of motion segments fused. The anterior approach can be used for both management of the neurologic deficit and restoration of stability to the spine, but on the other hand, this is surgically more challenging and has a greater potential for complications.

4.4.前路手术
随着计算机辅助轴位呈像扫描使用，很容易发现撑开或者加压棒通常并不能减去骨折块对椎管内神经组织的残留侵犯。与后路固定后角度丢失对比，一些作者报道在临床研究中前路手术导致最小程度的矢状序列丢失。另外，生物力学研究已经证实前路手术的优势，与后路器械固定比较前路手术提供更好的硬度，因此，这就引起新的争议，关于前路减压的必要性以及前路手术效果的可能性。目前，许多作者提倡首先前路手术到达骨折椎体，清除椎管前方的骨折块，使用移植骨或者经椎体前方内固定器械来提供稳定性。在许多胸腰椎骨折患者中神经功能障碍是由脊髓的腹侧面受到冲击或者挤压所致，并且前路手术能为减压过程中硬膜囊腹侧面清晰显示提供最佳直接暴露。另外，对于有明显粉碎前柱和中柱失去支撑作用的骨折类型，前路手术可以为结构性植骨或者内植物重建提供清晰地显露。这就可以达到高度的恢复以及后突畸形的矫正，尽管限制了融合阶段的活动量。前路手术可以用于治疗神经功能障碍以及恢复脊柱的稳定性，但是这种手术更具有挑战性并且具有更大潜在的并发症风险。


Clinical results of the anterior instrumentation in treating thoracolumbar burst fractures have been well documented in many studies [72]. McAfee et al [69] reported that 37 of42 patients treated with anterior decompression and instrumentation at a mean of 60 days after initial injury had some degree of neurologic improvement. Of the37 patients, 30 preoperatively had motor strength of grade3 or less. Fourteen of these 30 patients became community ambulators; 9 others regained function adequate for household ambulation, although some required short leg braces and/or crutches. Radiographic results indicated that 12 of the 42 patients developed kyphosis of more than 208postoperatively. Similarly, in a retrospective study of35 patients with thoracolumbar burst fractures treated with anterior surgery, strut graft, and fixation with a Z plate, all 16 patients with neurologic deficit demonstrated at least oneFrankel grade improvement 2 years after surgery, with 11 (69%) patients demonstrating complete neurologic recovery [72]. Ghanayem and Zdeblick [47] reported on a small series of 12 patients treated with anterior instrumen- tation for thoracolumbar burst fractures, with 11 of the 12 obtaining a good or excellent functional outcome and a solid arthrodesis.

很多研究已经很好证实治疗治疗胸腰椎爆裂性骨折前路器械固定的临床疗效。McAfee等报道进行前路减压和固定治疗的42名患者中有37名在受伤后平均60天有一定程度的神经系统功能改善。37名患者中有30名手术前肌力3级或者小于3级。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°。同样，在一项对35名胸腰椎爆裂性骨折的患者行前路手术、植骨支撑、Z型钢板固定的回顾性研究中，有神经功能障碍的16名患者显示手术后2年神经功能恢复至至少Frankel一级水平，11名患者显示出完全的神经功能恢复。Ghanayem和Zdeblick报道在对12名胸腰椎爆裂性骨折前路器械固定的系列研究中，11名患者获得良好或者优秀的功能结果以及坚固的关节融合。

Comparative studies between the anterior and posterior approaches are relatively few. In a randomized prospective comparison of these 2 approaches in a population of 40 patients with a mean follow-up of 20 months, Esses et al [39] reported no particular difference between the 2 approaches in restoring normal sagittal contour, but did note 2 implant failures of 20 anterior procedures and that the blood loss was significantly higher in the patients undergo- ing anterior surgery. However, there were no complications from the thoracotomy. The limitation of this study was that their analysis was limited to the radiographic and perioper- ative parameters only. Wood et al [106] performed a randomized prospective comparison of the 2 surgical approaches in 38 patients followed up for a mean of 2 years, they reported similar patient outcomes between the 2 approaches, and that anterior fusion and instrumentation for thoracolumbar burst fractures may present fewer complications or additional surgeries. The current studies do not provide a reliable answer to whether anterior or posterior surgery is more effective in treating thoracolumbar burst fractures. High-quality randomized controlled trials are needed.

前路手术和后路手术的对照研究相对比较少。在一项对这两种方法的随机性前瞻性对照研究中，40名患者进行平均20个月的随访，Esses等报道两种方法在重建正常的矢状序列方面没有特殊差别，但是应当注意20名前路手术患者中有2例内植物失败，并且进行前路手术的失血量比较大。然而没有胸廓切开的并发症。这项研究的局限性在于他们的研究仅限定于影像学和围手术期的参数。Wood等对这两种手术方法进行一项随机性前瞻性对照研究，对38名患者进行平均2年的随访，他们报道这两种方法取得相似的临床疗效，并且前路手术可能呈现出更少的并发症或者再次手术。目前的研究不能提供一个关于治疗胸腰椎爆裂性骨折前路手术或者后路手术那一种更为有效的令人信赖的答案。仍然需要高质量随机性控制性试验。

4.5. Combined anteroposterior surgery

Some authors proposed the combined anteroposterior approach in treating thoracolumbar burst fractures. Howev- er, in a retrospective comparison of the combined anterior- posterior approach and the posterior approach alone with a follow-up of 6 years, Been and Bouma [9] reported no significant difference in neurologic outcome between the 2 approaches, although the combined anteroposterior approach yielded the best results in long-term maintenance of kyphosis correction. Posterior distraction and short- segment instrumentation was followed by loss of reduction to some degree, but the long-term kyphotic angle (48) was acceptable, and was not associated with a higher incidence of pain. Similarly, in another retrospective study of 49 patients treated with the anteroposterior procedure,anterior procedure, or posterior procedure, Danisa et al [28] reported that combined surgery required the longest total operative time and is associated with the most intraoperative blood loss, and patients treated with ante- roposterior surgery fared no better in neurologic recovery, correction of spinal deformity, fusion healing, pain relief, or work status than those treated with anterior surgery or posterior surgery. These results suggest that the combined anteroposterior approach has no obvious advantages over the anterior or posterior approach alone, but this really invokes an extensive surgical procedure. Therefore, we do not recommend combined anteroposterior surgery in treat- ing thoracolumbar fractures because better and more cost- effective results can be obtained through other procedures.

4.5.前后路联合手术
一些作者建议前后路联合手术来治疗胸腰椎爆裂性骨折。然而，在一项随访6年关于前后路联合手术和单独后路手术的回顾性对照研究中，Been和Bouma报道这两种方法在神经系统功能恢复方面没有明显不同，尽管前后路联合手术在长期畸形矫正维持方面取得最佳结果。后路撑开和短阶段的器械固定随访过程中有复位角度的丢失，但是长期4°后突畸形可以接受，并且并没有较高的疼痛发生率。同样在另一项对49名行前后路联合手术、前路手术、后路手术治疗的回顾性研究中，Danisa等报道联合手术需要最长的手术时间，并且手术中出血量最多，前后路联合治疗的患者与前路治疗或者后路治疗的患者相比并没有出现更好的神经系统功能恢复、脊柱畸形的矫正、融合、疼痛缓解以及就业状况。这些结果显示前后路联合手术与单独前路或者后路手术相比没有明显优势，但是这确实扩大了外科治疗的手段。因此我们使用前后路联合来治疗胸腰椎骨折，因为通过其他方法也可以获得更为有效和更加具有成本效益的结果。