文献翻译－胸腰椎骨折－胸腰椎骨折短节段固定原理
发布于 2010-10-05 · 浏览 1.1 万 · IP 浙江浙江
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Surgical Management of Thoracolumbar Fractures: Rationale for Short Fixation
Justin S. Smith, MD, PhD,* and Vincent Arlet, MD*
胸腰椎骨折的外科治疗：短节段固定原理
Series of cases from our own practice as a means of reviewing the basic principles for the treatment of thoracolumbar fractures are presented in this article. Although there are no widely accepted evidence-based standards to guide surgeons in choosing treatment approaches, several basic and logical principles may be applied to each case to first decidewhether a patient is best managed nonoperatively or with surgical treatment. If operativemanagement is indicated, the surgeon must decide whether decompression and/or stabilization is indicated, whether surgery should be done from an anterior and/or posterior approach, the timing of surgery, the surgical technique, and how extensive the instrumentation should be. Through a series of case example, the authors emphasize the principles of short fixation for most cases to preserve spinal motion. Successful surgery for thoracolumbar fracture can be achieved for most cases with short anterior or posterior fixation.Semin Spine Surg 22:20-32 © 2010 Elsevier Inc. All rights reserved.
KEYWORDS spine, thoracolumbar fracture burst
本文通过我们临床中的一系列病例来复习胸腰椎骨折治疗的基本原则，虽然还没有被广泛接受的循证标准来指导外科医师如何选择治疗，有一些基本的合理原则适用于每一个病人，用来初步决定是手术好还是非手术好。如果有手术指征，医师要决定是否减压和/或固定，选择前路还是后路，手术时机，手术技巧，以及器械的长度等。通过一系列的病例，作者强调短节段固定原则适用于大多数病例，以保留脊柱活动。短节段前路或后路固定可以成功治疗大多数胸腰椎骨折。
关键词：脊柱，胸腰椎骨折，爆裂。
Although up to 90% of all spinal fractures occur in the thoracolumbar region, there are currently no widely accepted evidence-based standards to guide surgeons in choosing treatment approaches. The surgeon must first decide whether the injury can be treated conservatively with a brace or cast or whether it requires an operation. If an operation is indicated, the surgeon must decide whether a decompression is necessary. The surgeon must also decide the optimal surgical approach, whether it is anterior, posterior, or combined. The effect of early vs delayed decompression and surgical stabilization on neurological recovery remains controversial. In the absence of evidence-based standards, surgeons are left to rely on classification systems that are mechanistic or descriptive. Three major classifications systems are used: Denis classification with the 3 column theory, 1 the Magerl/Aebi classification (also known as the AOclassification) with its 3main different types (A: flexion compression with intact posterior elements, B: flexion distraction with disruption of the posterior elements, and C: translation rotation or shear injury),2 and more recently the thoracolumbar severity score3 that has integrated the degree of neurologic injury in what was the former AO classification. For the clarity of the present article, we will use the AO classification and its 3major subgroups to explain the rationale of treatment of each fracture type.
虽然90％的脊柱骨折发生于胸腰段，但目前还没有被广泛接受的循证标准用于指导医生选择治疗方法。医生必须首先决定这个损伤是采用石膏或支具保守治疗还是手术治疗。如果有；手术指征，医生还必须决定是否需要减压；最好的手术入路是前路、后路、还是前后联合入路。早期或者延期减压固定对神经恢复的效果还有争论。由于缺乏循证标准，医生们只能依靠机械性或描述性的分类系统。正在使用的三个主要分型系统是：Denis三柱理论系统；Magerl/Aebi分型（也就是AO系统），该系统分为三个主要类型（A：屈曲压缩，后侧结构完整，B：屈曲牵伸，后侧结构损伤，C：旋转或剪切损伤）；以及最近的把神经损伤的程度与AO分型相结合的胸腰椎严重度评分系统。为清晰起见，我们采用AO分型的三个主要亚型来阐述每一种骨折的治疗原理。
Type A Fracture With Minimal Burst Component: Nonoperative Management Case 1
A 15-year-old boy presented with low back pain after a rollover all-terrain vehicle (ATV) accident. He was neurologically intact. Plain radiographs and subsequent computed tomography (CT) imaging demonstrated an L1 burst fracture with approximately 30% loss of anterior vertebral bodyheight, minimal canal compromise, and preserved spinal alignment (Fig. 1). The posterior ligamentous complex (PLC)was judged to be intact, as there was no incongruency of the facets, and the interspinous distance was preserved. This represents a type A fracture with minimal burst component in the Magerl classification. Because he was neurologically intact and lacked evidence of spinal instability, the patient was managed conservatively with a thoracolumbosacral orthosis.Plain anteroposterior (AP) and lateral standing radiographs demonstrated a stable fracture pattern when the patient was upright in a thoracolumbosacral orthosis. At 1 month follow-up he remained neurologically intact, and AP and lateral radiographs showed stable alignment and no significant increase in sagittal plane deformity.
病例1：A型骨折，轻微爆裂：非手术治疗
15岁男孩，全地形车（ATV）事故后下腰痛。神经情况完好。平片和CT证实L1椎体骨折，前柱高度压缩约30％，椎管轻微受累，脊柱排列良好（图1）。由于小关节协调、棘突间距正常，推断后侧韧带复合体（PLC）完好。按Magerl分型，这是一个轻微爆裂的A型骨折。由于神经情况完好，没有不稳定的表现，该病人采用胸腰骶支具保守治疗。支具保护下站立前后位和侧位平片证实是一个稳定的骨折。1个月随访，神经情况仍然完好，前后位和侧位片显示排列稳定，矢状面上畸形没有明显的增加。
As illustrated in Case 1, most patients with thoracolumbar burst fractures, intact PLC, and without neurologic compromise can be managed nonoperatively. In determining whether such a patient is a candidate for nonoperative treatment, several factors should be considered, including the neurologic status of the patient, the degree of canal compromise, the deformity of the fracture, and the status of the PLC, as pointed out initially in the Magerl classification.2 In a consensus panel review recently reported by Vaccaro et al,4 all expert members agreed that a neurologically intact patient with an intact PLC rarely requires surgical treatment. They give a more anatomic description of the PLC than the initial AO classification, specifically that the PLC includes the supraspinous and interspinous ligaments, the ligamentum flavum, and the facet joint capsules.
正如病例1所示，大多数PLC完好、没有神经受累的胸腰椎爆裂骨折可以采用保守治疗。在决定是否采用非手术治疗时，要考虑以下几个因素：病人的神经状态、椎管的受累程度、骨折的畸形程度、PLC的状态等，正如最初Magerl分型中指出的那样。在最近Vaccaro等报道的专家小组意见中，所有的专家都同意，没有神经受累、同时PLC完好的病人很少需要手术治疗。他们对PLC进行了较原始AO分型更详尽的解剖定义：包括棘上韧带、棘间韧带、黄韧带、以及小关节关节囊。
Patients with a thoracolumbar fracture who are deemed suitable candidates for conservative treatment are typically treated with bracing (hyperextension-type brace) or casting with early mobilization, barring limitations of other injuries.5,6 Braces are typically worn at all times, except when bathing, for 3-6 months, while casts are worn continuously. Although bracing facilitates better hygiene and is typically preferred by patients, casting does offer a form of “forced” compliance that may be favorable in the setting of a less reliable patient. As thoracolumbar compression and burst fractures heal, the natural history includes an increased degree of kyphosis over the first few weeks.5 Bracing and casting are intended to limit the progression of this kyphotic deformity during the healing process. Multiple studies have shown that with bracing or casting,the residual sagittal plane deformity is typically similar to or slightly greater than the initial deformity, 5,7-11 with no significant difference between casting and bracing.12,13 It has even been suggested that bracing and casting, although useful for initial pain control,may not prevent collapse of the vertebrae and may not change long-term results. 13
除非有其他损伤，采用保守治疗的胸腰椎骨折病人多以支具（过伸支具）或石膏固定，以早期活动。支具一直穿戴3-6个月，洗澡时可取下，石膏则一直穿戴。虽然支具比较好搞卫生，病人也更愿意用，但石膏对于一些不太可靠的人有“强制”作用。在胸腰椎骨折愈合过程中，在开始的数周，有后凸畸形加重的趋势。支具和石膏可以减少这种趋势。有多项研究表明，支具或石膏固定后，残留的矢状面畸形与最初的畸形相似或轻微加重，石膏与支具之间没有明显差别。虽然支具或石膏对控制初始疼痛很有用，但不能阻止塌陷，也不能改变其长期结果。
Although nonoperative management is frequently employed for neurologically intact patients with a thoracolumbar burst fracture, this approach only recently regained favor. In the early 1980s, Denis et al 14 reported a retrospective review of 52 patients with acute thoracolumbar burst fracture without neurologic deficit at presentation. Of the 39 patients treated nonoperatively, 17% subsequently developed neurologic problems(parapareses and/or radicular pain), 25% were unable to return to work full-time, contrasting with no neurologic problems, and 100% full-time employment among the 13 patients treated operatively. This report, coupled with concurrent rapid advancements in spinal instrumentation, strongly favored the surgical approach over conservative management. However, the majority of subsequent studies,5,7-9,12,13,15-20 including a prospective randomized study,21 have since reported successful outcomes with nonoperative treatment, providing firm support for this approach. A notable exception is a recent report of a multicenter randomized prospective trial comparing operative versus nonoperative treatment for thoracolumbar burst fracture. This study suggested that patients treated operatively have better functional outcome scores, have less kyphotic deformity at the end of follow-up, and are more likely to return to their original jobs.22
虽然非手术疗通常用于没有神经损害的胸腰椎爆裂骨折，但这也是最近才重获亲睐。早在1980年，Denis等做了回顾性研究，报道了52例没有神经损害的胸腰椎新鲜爆裂骨折。39例采用保守治疗，17％继发出现神经问题（下肢轻瘫或神经根痛），25％无法恢复全时工作，而13例手术治疗者，100％恢复全时工作。这个报告结合当前快速进步的脊柱器械，强烈倾向于手术治疗。但后来的大多数研究，包括前瞻性随机研究都报道了非手术治疗取得成功的结果，为保守治疗提供了有力的支持。值得注意的是，最近的一项胸腰椎爆裂骨折的多中心前瞻性随机对照研究认为，手术治疗者的功能评分更佳，最终随访时的后凸畸形更少，更容易恢复其原来的工作。
Figure 1 Imaging for case 1 (see text). AP (A) and lateral (B) radiographs show fracture of the L3 vertebral body.Reconstructed sagittal CT (C) and axial CT (D) imaging show an L3 burst fracture with minimal canal compromise.
图1：病例1图片（见正文）。AP（A）位和侧位（B）平片显示L3椎体骨折。矢状面CT重建（C）和轴位CT(D)显示，L3椎体爆裂骨折，椎管轻微受累。
Proponents of operative treatment advance 3 main arguments. The first relates to a presumed increase in risk of neurologic deterioration without surgical stabilization.Except for the article by Denis et al,14 the article fails to support such an increased risk, with most authors reporting either rare or no initial neurologic deterioration in neurologically intact patients.7,8,10,17-19 In addition, bony remodeling has been shown to reduce residual canal compromise due to retropulsed fragments by more than 50%over the course of a year,9 restoring much of the normal canal space for neural elements. The second argument advances that surgery provides correction of the kyphosis,resulting in reduced pain. Surgery can result in improved kyphosis, but this correction is frequently lost,23-26 and the degree of kyphosis has not been shown to correlate with clinical results, 5,7-10,19 even when the kyphosis is greaterthan 30°.13 The third argument is that surgery allows earlier mobilization, resulting in decreased complications and costs from prolonged bed rest. However, the article supports protocols with early mobilization in a brace and early discharge from the hospital. 7-10 In addition, when including the cost of surgery, reports of hospital charges have been consistently and considerably less for nonoperative treatment.16,27,28
手术治疗存在很大的争议。支持手术治疗的第一个理由是是非手术治疗有增加神经损害的风险。除了Denis的那篇论文（也不支持会增加这种风险），大多数作者报道神经功能完好的病人，很少或不会出现神经功能减退。而且，在1年后，超过50％的病人会出现椎管重塑，减少后突骨块压迫引起的椎管狭窄，恢复正常椎管容量。第二个论点是手术可以矫正畸形，减少疼痛。手术可以矫正畸形，但矫正度常常会丢失，而且后凸的角度与临床结果不相关，即便是后凸角度超过30°时。第三个论点是手术可以早期活动，减少并发症和长期卧床的花费。但用支具也可以早期活动并提早出院。而且，加上手术费用，非手术治疗费用要少得多。
Type A Fracture With Incomplete Neurologic Injury:Short-Segment Posterior Instrumentation and Fusion
Case 2
病例2：A型骨折，不完全脊髓损伤，后路短节段固定融合
A 44-year-old woman presented 3 hours after a fall from a height of 8 feet. She had severe dysesthesia and significant diffuse motor weakness (2/5) in her lower extremities, but had preserved rectal tone and sphincter contraction. Imaging demonstrated an L1 burst fracture, with approximately 50% loss of vertebral body height and approximately 60% canal compromise due to retropulsed vertebral body fragments in the spinal canal (Figs. 2A-D). Magnetic resonance imaging (MRI) demonstrated injury to the conus, evidenced by T2 signal change (Fig. 2E). However, the PLC appeared to be intact. This is therefore a type A burst in the Magerl classification (or A3). Given the presence of an incomplete neuro logical deficit and canal compromise, the patient was urgently taken to the operating room for surgical intervention.At the same time, high-dose steroids were administered in accordance with spinal cord injury protocols. An internal fixator with pedicle screws was placed bilaterally at T12 and L2 (Schanz screws, Universal Spine System (USS) Fracture System, Synthes, West Chester, PA). Rods were secured into place, crosslinked, and used to induce lordosis and then distraction through the Schanz screws. Arthodesis of T12-L2 was performed using allograft and recombinant human bone morphogenetic protein 2 (Medtronic Sofamor Danek). Postoperative imaging demonstrated excellent alignment and canal decompression through distraction (Figs. 2F-H), obviating the immediate need for an anterior reconstruction.Within 2 days the patient was ambulating with dramatic improvement of motor strength and continued preservation of bowel and bladder function. At 2 month follow-up, her motor strength continued to improve and her spinal construct remained intact with excellent spinal alignment.
44岁女性，8英尺高处坠落后3小时。双下肢感觉麻木严重，运动减弱。但直肠张力和括约肌收缩存在。影像证实L1爆裂骨折，椎体高度丢失约50％，后突的骨块侵占椎管约60％（图2A-D）。MRI 可见T2信号改变，证实圆锥损伤（图2 E）。PLC完好。因此，这是一个Margerl分型中的A型骨折（A3）。由于神经不完全损伤、椎管占位，患者被送入手术室进行急诊手术。同时采用大剂量激素治疗并做脊髓损伤记录。在T12和L2进行双侧椎弓根钉内固定(Schanz 螺钉, 通用脊柱系统 (USS)，骨折系统， Synthes, West Chester, PA)。置入连接棒、横联，再通过Schanz钉产生脊柱前凸，再撑开。以自体骨和BMP(Medtronic Sofamor Danek)融合T12-L2。术后影像证实脊柱序列及椎管恢复良好(图 2F-H)，不必再进行前路重建。2天内，患者恢复行走并恢复直肠和膀胱功能。2个月随访，患者的肌力仍在进步，内固定保持良好，脊柱序列正常。
Case 2 illustrates the management of a thoracolumbar burst fracture in the setting of an incomplete neurological deficit with evidence of persistent compression of neural elements. Conservative management was not deemed appropriate for this patient, as decompression of the neural elements and fracture reduction with spinal fixation offered the chance of improved neurological outcome. The recent consensus panel review reported by Vacarro et al4 favors anterior decompression and reconstruction in the setting of an incomplete or cauda equina injury in which the PLC is intact. Complications of the anterior and posterior approaches have been reviewed, and the anterior approach has been suggested to have significantly greater morbidity,29 in terms of blood loss, operating room time, and chest complications. Minimally invasive approaches, in experienced hands, may result in less morbidity.30-34 In choosing the posterior approach for the patient in Case 2, we reasoned that a posterior reduction would provide indirect decompression of the conus through ligamentotaxis and adequate stabilization of the spine while the fractured vertebral body healed. Such posterior surgery can be carried out within 2 hours of patient admission with minimal resources, compared with an anterior approach to the spine that is more readily performed during daylight hours when resources are more easily available. Postoperative imaging demonstrated excellent restoration of vertebral body height at the fractured level and restoration of the lateral walls of the vertebral body (Fig. 2I) that will prevent loss of correction despite the void in the central part of the vertebral body (Fig. 2H).
病例2是一个神经受压、不完全神经损伤的胸腰椎爆裂骨折病例。保守治疗不合适，而神经减压、骨折复位内固定可为神经恢复创造机会。Vacarro等报道的专家小组意见中，对于PLC完好的不完全脊髓损伤或马尾损伤倾向于前路减压与重建。对比前后路手术并发症发现，前路手术的失血量、手术时间、胸腔并发症等发生率均明显高于后路。微创手术对于有经验的人来说，并发症可以很低。病例2选用后路，主要考虑后路可以通过韧带复位间接减压圆锥，当骨折愈合后，可提供足够的稳定性。这种后路手术可以在入院后2小时进行，不需要很多的条件。而如果是前路手术，则多要安排在白天、资源充足的情况下进行。术后影像证实骨折椎体的高度和侧壁恢复完美(Fig. 2I)，不会因为中央的空隙而复位丢失(Fig. 2H).。
Conventionally, short-segment posterior fixation refers to fusion from 1 vertebral level above to 1 vertebral level below the fractured vertebra. Although several early studies reported suboptimal outcomes with short-segment posterior fixation,23,35-37 more recent studies have demonstrated good clinical results.26,38,39 In our experience, short-segment posterior fixation enables excellent spinal reduction, decompression of the neural elements, and spinal reconstruction in the majority of cases of thoracolumbar compression and burst fracture that warrant surgery. Exceptions include cases in which the integrity of the anterior column is compromised to the point that anterior reconstruction is necessary for anterior column support. Other exceptions include cases of incomplete neurological deficit in which a posterior approach may not provide adequate exposure for decompression, including a canal that is extensively obliterated with bone fragments, or the presence of a reverse cortical sign (see Case 5).
通常，后路固定融合骨折上下各一椎体。虽然后路短节段固定的早期的报道疗效欠佳，但近来更多的报道认为效果良好。按我们的经验，后路短节段固定对大多数压缩骨折、爆裂骨折需要手术者，都可以获得良好的复位、减压和脊柱重建。例外的情况包括：前柱的损伤已到了需要前柱支撑的程度者，不完全神经损伤后路无法充分暴露减压者、椎管被骨块完全闭塞者、有皮质翻转征者（见病例5）。
Sasso et al 26 reported a retrospective review of anterioronly vs short-segment posterior fixation for unstable thoracolumbar burst fractures in 53 patients. The only significant difference they reported between the 2 groups was increased loss of sagittal plane correction (only 6°) in the posterior fixation group compared with the anterior group. However, at the last follow-up there did not seem to be any clinically relevant difference between the 2 groups in the amount of “final kyphosis” (11.6° in the posterior group vs 9.2° in the anterior group). The fact that the final kyphosis is similar in the anterior and posterior groups can be explained by the difficulty of completely restoring spinal alignment at the time of surgery with the anterior approach, compared with the posterior approach. The posterior fixation group had no instances of pseudoarthrosis or hardware failure and no cases requiring reoperation,while nearly 10%of the anterior group required either early or delayed supplemental posterior thoracolumbar arthrodesis with instrumentation for hardware failure or pseudoarthrosis.
Sasso等对53例不稳定胸腰椎爆裂骨折病人分别采用前路和后路短节段固定，进行回顾性分析。两组仅在矢状面矫正度丢失上有明显的不同，后路较前路大（只有6°）。然而最终随访结果显示临床结果与“最终后凸程度”无关（后路为11.6°，而前路为9.2°）。前后路最终后凸角度相似的原因在于前路手术时难以完全恢复脊柱序列。后路手术组没有假关节、内固定失败、或再手术者，而前路手术组有近10％因为假关节或内固定失败而需要进行早期或延期后路胸腰椎融合固定。Clinical investigation of high-dose steroids for spinal cord injury has provided conflicting results, and the evidence to substantiate their routine use is poor.40-46 On the contrary,evidence of deleterious effects continues to mount. 40,43,47 However, steroids continue to be given at many institutions for spinal cord injury, primarily motivated by peer pressure and fear of litigation, as it was done in this case.
大剂量激素治疗脊髓损伤的临床调查结果是矛盾的，而常规剂量的效果很差。相反，其副作用不断被报道。对于这种脊髓损伤的病人，激素在很多机构仍在使用，其原因主要源于同行的压力和担心被起诉。
Figure 2 Imaging for case 2 (see text). AP (A) and lateral (B) radiographs show fracture of the L1 vertebral body.Reconstructed sagittal CT (C) and axial CT (D) imaging show an L1 burst fracture with approximately 60% canal compromise. (E) T2-weighted sagittalMR imaging demonstrates abnormal T2 signal in the conus, reflecting injury. AP(F) and lateral (G) radiographs and reconstructed sagittal CT imaging (H) following T12 to L2 posterior fixation. Note the restoration of normal L1 vertebral body height and segmental lordosis achieved through ligamentotaxis. Also note the length and the divergent position of the pedicle screws to increase the biomechanics of the construct. No complementary anterior surgery is necessary despite the void in the vertebral body (observed in H) as the 2 lateral walls of thevertebral body have been restored by ligamentotaxis (I) (only right lateral wall represented in the slide).
图2 病例2图片（见正文）。AP（A）和侧位（B）片显示L1椎体骨折。矢状面重建CT（C）和轴位CT(D)显示L1爆裂骨折，近60％椎管受累。（E）T2加权MR证实圆锥部异常信号，表明损伤。T12－L2固定术后的AP（F）位和侧位（G）平片和矢状面CT重建（H）。注意，通过韧带牵开，恢复了L1椎体高度和生理前凸，同时注意椎弓根钉的长度和叉开的位置，增加了内固定的机械性能。由于椎体的两侧壁均已通过韧带恢复，尽管椎体中央有空隙（见于图H），也不必再进行前方手术（I）(片上只有右侧壁)。
Type B Fracture, Predominantly Osseous: Temporary Posterior Internal Fixation
Case 3
病例3：B型骨折，主要为骨性损伤，临时性后路内固定
A 16-year-old boy presented 3 days after a motor vehicle accident in which he was an unrestrained driver. He was initially managed conservatively at a surrounding hospital for a diagnosis of L3 compression fracture, but pain and right lower extremity weakness with mobilization prompted transfer to our institution. He presented with motor weakness of the right hamstring (3/5) and quadriceps (3/5) muscles, and repeat imaging demonstrated an L3 flexion distraction type of injury or Chance fracture (Figs. 3A-C). This is a Magerl type B fracture with rupture of the posterior element but predominantly osseous. His weakness in the right quadriceps can be explained by the compression observed at the level of the L3 foramen as seen on the MRI (Fig. 3D). The L3 nerve is compressed between the fracture of the posteriorwall and the buckling of the ligamentum flavum. The patient was taken to the operating room where bilateral L2 and L4 pedicle screws were placed (Schanz screws, USS Fracture System, Synthes) and decompression of the right L3 nerve root was performed. Reduction of the fracture was achieved through the manipulation of the Schanz screws in lordosis and compression (Figs. 3E and F). No segmental arthrodesis was performed intentionally. At 5 months after surgery, once the L3 vertebral body fracture was healed, he underwent hardware removal. Two weeks after hardware removal, flexion and extension radiographs demonstrated preservation of motion between L2 and L4 (Figs. 3G-I). He demonstrated stable radiographs and progressive improvement of motor strength at 10 months after initial injury.
16岁男孩，超速行驶引起的交通事故后3天。在附近医院诊断为L3压缩性骨折，并做了适当的处理。但由于疼痛和右下肢肌力减退使其转入我们医院。右侧腘绳肌(3/5)、股四头肌(3/5)肌力减退。重新拍片显示L3屈曲牵伸型损伤或Chance骨折(图. 3A-C)。这属于Magerl B型骨折，主要为骨性损伤。MRI上，L3节段椎间孔受压可以解释其右侧股四头肌肌力减弱(图. 3D)。L3神经根被压于后壁骨折块与皱曲的黄韧带之间。患者被送入手术室，行L2和L4椎弓根钉固定(Schanz screws, USS Fracture System, Synthes)，右侧L3神经根减压。通过Schanz螺钉进行脊柱前凸和加压，复位骨折(图. 3E and F)。有意不做节段融合。术后5个月，骨折愈合后，取出内固定。内固定物取出后2周，过伸过屈位位片证实，L2和L4之间的活动存在(图. 3G-I)。损伤后10个月，影像证实稳定，肌力明显增加。
Case 3 illustrates a case of flexion distraction injury, according to the Magerl classification, that would be a type B injury involving the bone and not the PLC. Such a fracture can be treated conservatively with a hyperextension cast and will heal uneventfully, as opposed to the flexion distraction injuries that involve the PLC that will not heal with this approach. However, in this specific case, a posterior surgical approach was chosen to enable decompression of the L3 nerve root, and the short-segment posterior instrumentation without arthrodesis provided adequate stability to allow the fracture to heal. The concept of “temporary internal bracing” for a bony Chance fracture was recently reported by Beringer et al 48 who performed it through percutaneous incisions and minimal access surgery.
病例3为屈曲牵伸型损伤，根据Magerl分型为B型，骨性损伤，没有PLC损伤。这种骨折可以采用过伸石膏进行保守治疗，但如果是伴有PLC损伤的屈曲牵伸损伤，用这种方法就不会愈合。在这个特殊病例中，采用后路手术减压L3神经根，同时短节段固定而不融合，以提供足够的稳定，利于骨折愈合。“临时性内固定”的概念是最近Beringer等提出的，他们采用微创手术治疗这种骨性Chance骨折。
Figure 3 Imaging for case 3 (see text). AP (A) and lateral (B) radiographs show a typical flexion distraction Chance fracture through the bone. (C) Reconstructed sagittal CT imaging and axial MRI (D) explain the L3 radiculopathy with the narrowing of the right L3/L4 foramen due to the buckling of the ligamentum flavum and the posterior wall disruption (arrows). AP (E) and lateral (F) radiographs following L2 to L4 instrumentation with placement of bilateral L2 and L4 pedicle screws, rods, and crosslink. Neutral (G), flexion (H), and extension (I) standing radiographs, following removal of hardware 5 months after initial surgery, demonstrate healing of the L3 Chance fracture and restoration of mobility.
图3：病例3图片（见正文）。AP（A）位和侧位(B)平片显示经骨的典型的屈曲牵伸型Chance骨折。矢状面CT重建（C）和轴位CT（D）显示由于黄韧带皱缩，后壁破裂，导致L3/L4右神经根管狭窄（箭头）。 AP（E）和侧位(F)平片为L2、L4椎弓根钉、连接棒、横联固定术后。初次手术后5个月，去除内固定术后，站立中立位（G）、屈曲位(H)、过伸位(I)证实，L3骨折愈合，活动度存在。
Type B Fracture, Predominantly Ligamentous: Posterior Monosegmental Fixation
Case 4
病例4：B型骨折，主要韧带损伤，后路单节段固定
A 30-year-old Olympic athlete presented following a heavy weight blow to the back during training. He was neurologically intact except for mild to moderate (4/5) weakness of the right extensor hallucis longus. Imaging demonstrated an L1 compression fracture, with anterolisthesis of T12 on L1 and bilateral perched facets (Figs. 4A-D). This is a flexion–distraction injury involving predominantly the PLC (type B predominantly ligamentous in theMagerl classification). An MRI was performed urgently (not shown) to check for any possible posterior disc disruption that would have made the posterior reduction and compression dangerous.49,50 In the absence of posterior disc herniation, a posterior approach was chosen. The patient was taken to the operating room for open reduction of the dislocation, followed by placement of bilateral T12 and L1 pedicle screws (Schanz screws, USS Fracture System, Synthes). Rods were secured into place and crosslinked, and used to induce compression and lordosis over the Schanz screws (Figs. 4E and F). Arthodesis of T12-L1 was performed using autograft. At 3 years follow-up, the spinal reconstruction remains intact (Fig. 4G), and the patient continues to be a competitive Olympic athlete. Despite the patient being almost neurologically intact, the instability of this injury necessitated surgical intervention. A posterior approach was selected to enable reduction of the perched facets and restore spinal alignment. To minimize the number of fusion levels in this elite athlete, only the fracture level and the level above were instrumented, thereby avoiding fusion of the L2 level. This was possible due to the limited compromise of the L1 vertebral body and the angling of the L1 pedicle screws caudally to capture the intact portion of the L1 vertebral body.
30岁运动员，训练进重物砸伤背部所致。右侧足拇长伸肌肌力轻－中度减退（4/5），其余神经功能良好。影像证实L1压缩性骨折伴有T12向前脱位，小关节跳跃（图4A-D）。这是一个屈曲牵伸型病例，以PLC损伤为主（Margerl分型中B型，韧带损伤为主）。急诊MR检查（未显示）看是否有后方椎间盘破裂，如有，可对后路复位和减压造成危险。由于没有椎间盘突出，采用后路手术治疗。开放复位，T12/L1双侧椎弓根螺钉固定（Schanz 螺钉, USS 骨折系统, Synthes）。连接棒安全植入并以横联相连，通过Schanz螺钉加压、脊柱前凸进行复位（图4E、F）。T12-L1间自体植骨融合。3年随访，脊柱重建保持良好（图4G）。病人仍在进行奥林匹克运动。虽然几乎没有神经损伤，由于损伤的不稳定，需要手术干预。选择后路可使跳跃的小关节复位，恢复脊柱序列。为减少这个运动精英的融合节段，只在骨折椎及其上方椎进行固定，这样就避免了融合到L2水平。由于L1椎体受损较少，将L1的椎弓根螺钉向尾侧成角放置，以抓持住L1椎体的完整部分。
Figure 4 Imaging for case 4 (see text). (A-C) Reconstructed sagittal CT images demonstrate an L1 compression fracture with anterolisthesis of T12 on L1 and bilateral perched facets. (D) Axial CT image at the L1 vertebral level does not demonstrate disruption of the posterior aspect of the L1 body. AP (E) and lateral (F) radiographs following monosegmental fixation from T12 to L1. Note that the trajectory of the L1 pedicle screws is such to maximize bony purchase in the unfractured portion of the vertebral body and to maximize pull-out strength. (G) At 3 years follow-up, the spinalreconstruction remains intact.
图4，病例4 的图片（见正文）。(A-C)矢状位CT重建显示L1椎体压缩性骨折，T12向前滑脱，小关节跳跃。(D)轴位CT显示L1椎体后壁未破损。 AP (E)和侧位(F)为T12到L1单节段固定术后。注意L1椎弓根钉朝向非骨折部位，以获得最大的抗拔力。(G)3年随访，脊柱重建依然良好。
Type B Fracture With Anterior Dislocation and Reverse Cortical Sign: Treatment Through an Anterior Approach
Case 5
病例5 ：B型骨折伴有向前脱位和皮质翻转征：前路手术。
A 34-year-old man presented after an ATV accident. On examination, he had a sensory level at T12 and no motor function below this level. His rectal tone was diminished, but there was some patchy sensory preservation in his medial thighs bilaterally. Imaging demonstrated an L1 burst fracture with anterior dislocation (Figs. 5A-E). There was significant canal narrowing due to dislocation and retropulsion of abony fragment into the spinal canal. On the CT scan, this fragment seems to be flipped 180°, referred to as the reverse cortical sign (Figs. 5C and E). Given the partial preservation of sensory function, urgent surgical decompression was undertaken, including left thoracotomy and retroperitoneal approach for L1 vertebrectomy, expandable intervertebral cage placement (Synthes expandable cage), and anterolateral fusion from T12 to L2 (Medtronic Sofamor Danek, Antares anterior fixation system) (Figs. 5F and G). At 6 months follow-up, the patient continues to have neurologic improvement and demonstrates an L5 sensory level bilaterally, excellent quadriceps function on the left and trace function on the right. His construct remains intact.
34岁男性，ATV事故。感觉平面位于T12，该平面以下运动功能消失。直肠张力减弱，双侧大腿内侧残余少量感觉。影像证实L1爆裂骨折伴有前方脱位（图5A-E），由于脱位和后方骨块的压迫，椎管明显狭窄。在CT片上，骨块翻转了180°（皮质翻转征）（图5C和E）。由于保留了部分感觉，急诊进行手术减压，采用左侧经胸腹膜后L1椎体切除，可撑开椎间融合器植入（Synthes可撑开椎间融合器），T12-L2前外侧融合（Medtronic Sofamor Danek，Antares前路固定系统）（图5F、G），6个月随访，患者的神经功能仍在进步，感觉平面位于L5水平，左侧股四头肌功能良好，右侧也有轻度恢复。内固定保持良好。
Case 5 illustrates a case with significant canal compromise due to a dislocation of the spine with an accompanied retropulsed fragment in the canal that is flipped (Fig. 5E). Although the patient had sustained a near-complete neurologic injury, evidence of some residual function prompted urgent decompression. The anterior surgery is necessary in such a case, as a posterior reduction with ligamentotaxis will not address the flipped cortical piece and may induce further neurologic damage. The anterior approach will directly address the neural compression and will allow anterior column reconstruction. The use of an expandable cage along with a double rod system allows excellent anatomic reduction.
病例5由于脱位和后方骨块翻转压迫，椎管有明显的占位（图5E），虽然接近神经完全损伤，由于残余少量功能，提示急诊减压。由于后方韧带复位对于皮质翻转骨块已不可能，且可能造成神经进一步损伤，因此需要前路手术。前路可进行神经直接减压并进行前柱重建。应用可扩张cage加上双棒系统可以达到解剖复位。
Figure 5 Imaging for case 5 (see text). AP (A) and lateral (B) radiographs show fracture of the L1 vertebral body with T12-L1 dislocation. (C) Sagittally reconstructed CT and MRI (D) images show the dislocation and significant retropulsion of a bone fragment that appears to be flipped into the spine canal (arrow). (E) Axial CT image showing the reverse cortical sign (arrows, see text). AP (F) and lateral (G) radiographs following L1 corpectomy, expandable intervertebral cage placement, and anterolateral fusion from T12 to L2. Case images courtesy of Dr Jeffrey Elias
(Department of Neurosurgery, University of Virginia).
图5 病例5图片（见正文）。AP（A）位和侧位（B）显示L1椎体骨折伴有T12-L1脱位。矢状面CT重建（C）和MRI（D）显示脱位，后突的骨块突入椎管并翻转（箭头）。轴位CT（E）显示皮质翻转征（箭头，见正文）。L1椎体切除术后AP位（F）和侧位(G)片显示，可扩张椎间融合器置入，从T12至L2进行前外侧融合。病人片子得到 Dr Jeffrey Elias(Department of Neurosurgery, University of Virginia)允许。
Type C Fracture (Rotation Translation Injury With Shear):Short-Segment Fixation Via Posterior Approach Followed by Complementary Anterior Column Support
Case 6
病例6：C型骨折（旋转剪切损伤）：后路加前柱支撑、短节段固定A 16-year-old girl presented after a roll-over ATV accident with significant lower extremity weakness. She lacked any demonstrable motor function in her lower extremities, except for flickers of movement in her toes bilaterally and limited resistance to gravity (4/5) in her right quadriceps. An L3 compression fracture with near obliteration of the spinal canal due to retropulsed fragments was identified on imaging (Figs. 6A-E). On the AP view one can see the translation and rotation of the spine. These lesions, according to Magerl, would be classified as type C and are extremely unstable.Given the incomplete neurologic injury with significant canal compromise and the highly unstable pattern of this fracture, she was taken urgently to the operating room where bilateral L2 and L4 pedicle screws were placed (Schanz screws, USS Fracture System). An L3 decompressive laminectomy and partial L3 corpectomy were performed. Rods were secured into place, crosslinked, and used to induce distraction and lordosis (Fig. 6F). An intraoperative myelogram was done and confirmed excellent decompression of the spinal canal.Arthrodesis from L2 to L4 was done using autologous iliaccrest bone graft. During the same hospitalization, the patient was returned to the operating room for an L3 corpectomy and anterior cage (SynMesh cage, Synthes) reconstruction with local bone grafting and anterior instrumentation (AOUSS type 2) (Figs. 6G and H). At 1 year follow-up the patient has a stable spinal reconstruction and has significant improvement in lower extremity strength such that she is
able to walk with only the assistance of a cane.
16岁女孩，ATV事故后双下肢明显无力，双侧足拇可轻微活动，右侧股四头肌可抗重力（4/5）,其他肌力均为0级。影像可见L3椎体压缩骨折，后突的骨块几乎将椎管湮没（图6A-E）.前后位上可见脊柱移位并旋转。根据Margerl分型为C型，极不稳定。由于神经不完全损伤，椎管严重占位，脊柱极不稳定，急诊入手术室进行双侧L2、L4椎弓根固定(Schanz screws, USS Fracture System)，L3椎板减压，L3部分椎体切除。连接棒安全植入、横联连接、撑开、脊柱前凸固定。术中脊髓造影显示椎管减压充分。采用自体髂骨移植进行L2-L4融合。在住院期间，患者以再回手术室进行了L3椎体切除、前路cage(SynMesh cage, Synthes)重建、局部骨移植、前路内固定(AO USS type 2) (图. 6G and H)。1年随访，重建的脊柱稳定，下肢肌力明显增加，扶单拐可以行走。
Case 6 is an example of a fracture with significant canal compromise with neurologic deficit. As opposed to Cases 2 and 5, where one can argue to perform anterior or posterior surgery, such cases with a rotational component or translation should be treated with posterior surgery, because reduction of the alignment is very difficult with anterior surgery alone. A posterior approach was first done to decompress the canal and foramen, to realign the spine, and to provide spinal fixation. To achieve adequate decompression of the canal and neural foramen, it was necessary to perform a partial transpedicular corpectomy. Postoperative imaging demonstrated a lack of anterior column support that prompted anterior reconstruction of the anterior column. McCormack et al 51 described a load-sharing classification of spine fractures. They presented 28 patients who had 3-column spinal fractures surgically stabilized by short-segment instrumentation with screws and plates and autograft. Ten of these patients subsequently presented with broken screws. A point system (the load-sharing classification) was devised based on the amount of damaged vertebral body, the spread of fragments at the fracture site, and the amount of corrected traumatic kyphosis. This point system was then used preoperatively to help predict which 3-column fractures can be effectively treated with short-segment posterior fusion vs those in need of an anterior reconstruction.
病例6为椎管明显受压伴神经损伤的骨折。与病例2和5不同，那两例可能还会讨论是前路还是后路手术，这种旋转或平移损伤应该采用后路手术治疗，因为单纯前路手术很难恢复脊柱的序列。先进行后路椎管和椎间孔减压，恢复脊柱排列，再进行固定。为使椎管和椎间孔减压充分，经椎弓根椎体部分切除是必须的。术后的影像证实前柱缺损，提示需要进行前柱重建。McCormack等报道了一种脊柱骨折的载荷分担系统。他们报道了28例三柱骨折采用短节段固定自体植骨术，其中10例出现螺钉断裂。根据椎体的损害程度、骨块移位程度、需要矫正的角度等他们发明了载荷分担分型系统，以便在术前进行预测，三柱骨折是采用短节段后路固定还是前路重建。
Figure 6 Imaging for case 6 (see text). AP (A) and lateral (B) radiographs show fracture of the L3 vertebral body. (C) Axial CT image at the level of L3 shows significant spinal canal compromise due to retropulsion of bony fragments. T2-weighted sagittal (D) and axial (E) MR imaging demonstrate significant spinal canal compromise at the L3 level. (F)Reconstructed sagittal CT image following L2 to L4 fusion with placement of bilateral L2 and L4 pedicle screws, rods,and crosslink. Note the defects in the L3 vertebral body, resulting from both the injury and the need to perform a partial corpectomy for decompression. AP (G) and lateral (H) radiographs following an anterior approach for L3 corpectomy and reconstruction。
图6，病例6的图片。（见正文）。AP位（A）和侧位（B）显示L3椎体骨折。轴位CT(C)显示L3节段由于骨块后突造成明显的椎管占位。T2加权（D）和轴位MR(E)证实L3水平椎管明显占位。L2-L4双侧椎弓根钉、连接棒、横联固定融合后的矢状面CT重建（F），注意由于损伤和椎体部分切除减压后造成的L3椎体缺损。前路L3椎体切除重建术后AP位（G）和侧位（H）。Type C Fracture of the Thoracic Spine (Rotation Translation Injury): Treatment With Long Posterior Fixation
Case 7
A 40-year-old patient who fell off a ladder was initially seen in a local hospital and “cleared for any spine fracture.” The patient was seen 3 weeks later at the spine clinic for persisting pain. Radiographs showed a dislocation with translation rotation of the spine at T7-T8 with significant kyphosis. The patient was neurologically intact. Such an injury is very unstable and is classified as a type C lesion in the Magerl classification (Figs. 7A and B). Here, as opposed to the other cases where short fixations were performed, a long fixation is favored for the following reasons. The reduction in spinal mobility introduced by a long fusion of the thoracic spine is not as clinically significant as a long fusion in the thoracolumbar or lumbar spine. Also, the reduction of such fractures is difficult and requires a long lever arm and careful surgical placement of the pedicle screws. 52 Moreover, even reduced, these fractures remain highly unstable, necessitating longer instrumentation.
病例7：C型胸椎骨折，（旋转剪切损伤）：采用长节段后路固定。
40岁患者，从楼梯上摔下，就诊于地方医院，“排除任何脊柱骨折”。3周后康拜因持续疼痛就诊于脊柱门诊。平片显示T7-8旋转脱位伴有明显后凸。神经功能完整。该病人按Magerl分类为C型损伤，属于极不稳定型（图7A/B）。这里不该用短节段固定，长节段固定更合适，原因如下。胸椎长节段融合后，脊柱活动丢失不如胸腰段或腰段明显。这种骨折的复位困难，需要较长的力臂和小心置入椎弓根钉。而且，如果减少节段，骨折会很不稳定，需要长的器械固定。
Figure 7 Imaging for case 7 (see text). AP (A) and lateral (B) radiographs show rotation between T7 and T8 and lateral translation between T7 and T9. A severe kyphosis can be observed on the lateral x-rays. AP (C) and lateral (D) radiographs following correction of the thoracic dislocation with a long posterior instrumentation. Note the 2crosslinks in this highly unstable rotatory fracture dislocation.
图7 病例7的图片（见正文）。AP位（A）和侧位（B）显示T7和T8之间旋转，T7与T9之间侧方移位。侧位片上可以见到严重的后凸畸形。后路长节段复位胸椎脱位术后AP位（C）和侧位（D）。注意这种高度不稳定的旋转骨折脱位上用了两个横联。
Conclusions
Through this review of case examples classified in the AO classification system, one can propose a schematic treatment algorithm that must be modulated based on whether neurologic decompression is necessary.
结论
通过按AO分型的病案复习，可以得出根据是否需要神经减压进行调整的治疗纲要。
● Type A fractures without accompanying neurologic deficit, in most cases, can be treated conservatively, provided there is no progression of the deformity.
A型骨折不伴有神经损伤者，大多数可以保守治疗，畸形不会进展。
● Type A fractures with accompanying neurologic deficit should be treated surgically. It is the authors’ preference to perform these cases with a posterior approach and ligamentotaxis. Anterior surgery may be preferred by others.
伴有神经损伤的A型骨折要手术治疗，作者推荐后路韧带复位，有些作者喜欢前路。
● Type B fractures should be, in most cases, treated surgically regardless of neurologic status. In our practice we treat most of these injuries through a posterior approach to restore the posterior tension band. A postoperative CT scan will determine the need of further anterior decompression of neurologic structures or anterior column support. Some surgeons prefer an anterior approach for type B fractures.
B型骨折大多需要手术治疗，不管有没有神经损伤。我们多数采用后路重建张力带。术后CT可以决定是否需要再行前路减压或前柱支撑。有些医生喜欢前路治疗B型骨折。● Type C fractures require posterior reduction fixation,usually long (2 levels above and 2 levels below) in the thoracic spine, and short in the lumbar spine (1 above 1 below) to preserve mobility and function.In most cases, the goals of fracture care are to restore function, both neurologic and spinal column function, and to maintain mobility. Therefore, we are strong proponents of short fixation of fractures to preserve range of motion of the spine and to prevent late degenerative changes, late spinal stenosis under the construct, or late charcot spine under long instrumentation in the paraplegic. The exceptions are the thoracic dislocations, which often require longer fixation (2 above and 2 below) and patients with osteoporosis. The need for anterior column support remains an issue that requires a careful analysis of the fracture and its reduction on the post operative CT scan. Advanced instrumentation techniques have rendered anterior column support less necessary as it used to be.
C型骨折需要后路复位固定，胸椎通常采用长节段固定（上下各两各节段），腰椎通常采用短节段固定（上下各一节段），以保留活动和功能。大多数骨折的治疗目的在于恢复脊柱和神经功能，保全生命。因此，我们强烈推荐短节段固定以保留脊柱活动，防止迟发退行性改变、继发性椎管狭窄、截瘫长节段固定后的夏科氏关节等。例外的情况是胸椎脱位（通常需要上下各两个节段）和骨质疏松患者。是否需要前柱支撑，需要术后CT进行详细分析骨折和复位情况。器械的进步已使前柱支撑不像以前那么需要了。
References
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Justin S. Smith, MD, PhD,* and Vincent Arlet, MD*
胸腰椎骨折的外科治疗：短节段固定原理
Series of cases from our own practice as a means of reviewing the basic principles for the treatment of thoracolumbar fractures are presented in this article. Although there are no widely accepted evidence-based standards to guide surgeons in choosing treatment approaches, several basic and logical principles may be applied to each case to first decidewhether a patient is best managed nonoperatively or with surgical treatment. If operativemanagement is indicated, the surgeon must decide whether decompression and/or stabilization is indicated, whether surgery should be done from an anterior and/or posterior approach, the timing of surgery, the surgical technique, and how extensive the instrumentation should be. Through a series of case example, the authors emphasize the principles of short fixation for most cases to preserve spinal motion. Successful surgery for thoracolumbar fracture can be achieved for most cases with short anterior or posterior fixation.Semin Spine Surg 22:20-32 © 2010 Elsevier Inc. All rights reserved.
KEYWORDS spine, thoracolumbar fracture burst
本文通过我们临床中的一系列病例来复习胸腰椎骨折治疗的基本原则，虽然还没有被广泛接受的循证标准来指导外科医师如何选择治疗，有一些基本的合理原则适用于每一个病人，用来初步决定是手术好还是非手术好。如果有手术指征，医师要决定是否减压和/或固定，选择前路还是后路，手术时机，手术技巧，以及器械的长度等。通过一系列的病例，作者强调短节段固定原则适用于大多数病例，以保留脊柱活动。短节段前路或后路固定可以成功治疗大多数胸腰椎骨折。
关键词：脊柱，胸腰椎骨折，爆裂。
Although up to 90% of all spinal fractures occur in the thoracolumbar region, there are currently no widely accepted evidence-based standards to guide surgeons in choosing treatment approaches. The surgeon must first decide whether the injury can be treated conservatively with a brace or cast or whether it requires an operation. If an operation is indicated, the surgeon must decide whether a decompression is necessary. The surgeon must also decide the optimal surgical approach, whether it is anterior, posterior, or combined. The effect of early vs delayed decompression and surgical stabilization on neurological recovery remains controversial. In the absence of evidence-based standards, surgeons are left to rely on classification systems that are mechanistic or descriptive. Three major classifications systems are used: Denis classification with the 3 column theory, 1 the Magerl/Aebi classification (also known as the AOclassification) with its 3main different types (A: flexion compression with intact posterior elements, B: flexion distraction with disruption of the posterior elements, and C: translation rotation or shear injury),2 and more recently the thoracolumbar severity score3 that has integrated the degree of neurologic injury in what was the former AO classification. For the clarity of the present article, we will use the AO classification and its 3major subgroups to explain the rationale of treatment of each fracture type.
虽然90％的脊柱骨折发生于胸腰段，但目前还没有被广泛接受的循证标准用于指导医生选择治疗方法。医生必须首先决定这个损伤是采用石膏或支具保守治疗还是手术治疗。如果有；手术指征，医生还必须决定是否需要减压；最好的手术入路是前路、后路、还是前后联合入路。早期或者延期减压固定对神经恢复的效果还有争论。由于缺乏循证标准，医生们只能依靠机械性或描述性的分类系统。正在使用的三个主要分型系统是：Denis三柱理论系统；Magerl/Aebi分型（也就是AO系统），该系统分为三个主要类型（A：屈曲压缩，后侧结构完整，B：屈曲牵伸，后侧结构损伤，C：旋转或剪切损伤）；以及最近的把神经损伤的程度与AO分型相结合的胸腰椎严重度评分系统。为清晰起见，我们采用AO分型的三个主要亚型来阐述每一种骨折的治疗原理。
Type A Fracture With Minimal Burst Component: Nonoperative Management Case 1
A 15-year-old boy presented with low back pain after a rollover all-terrain vehicle (ATV) accident. He was neurologically intact. Plain radiographs and subsequent computed tomography (CT) imaging demonstrated an L1 burst fracture with approximately 30% loss of anterior vertebral bodyheight, minimal canal compromise, and preserved spinal alignment (Fig. 1). The posterior ligamentous complex (PLC)was judged to be intact, as there was no incongruency of the facets, and the interspinous distance was preserved. This represents a type A fracture with minimal burst component in the Magerl classification. Because he was neurologically intact and lacked evidence of spinal instability, the patient was managed conservatively with a thoracolumbosacral orthosis.Plain anteroposterior (AP) and lateral standing radiographs demonstrated a stable fracture pattern when the patient was upright in a thoracolumbosacral orthosis. At 1 month follow-up he remained neurologically intact, and AP and lateral radiographs showed stable alignment and no significant increase in sagittal plane deformity.
病例1：A型骨折，轻微爆裂：非手术治疗
15岁男孩，全地形车（ATV）事故后下腰痛。神经情况完好。平片和CT证实L1椎体骨折，前柱高度压缩约30％，椎管轻微受累，脊柱排列良好（图1）。由于小关节协调、棘突间距正常，推断后侧韧带复合体（PLC）完好。按Magerl分型，这是一个轻微爆裂的A型骨折。由于神经情况完好，没有不稳定的表现，该病人采用胸腰骶支具保守治疗。支具保护下站立前后位和侧位平片证实是一个稳定的骨折。1个月随访，神经情况仍然完好，前后位和侧位片显示排列稳定，矢状面上畸形没有明显的增加。
As illustrated in Case 1, most patients with thoracolumbar burst fractures, intact PLC, and without neurologic compromise can be managed nonoperatively. In determining whether such a patient is a candidate for nonoperative treatment, several factors should be considered, including the neurologic status of the patient, the degree of canal compromise, the deformity of the fracture, and the status of the PLC, as pointed out initially in the Magerl classification.2 In a consensus panel review recently reported by Vaccaro et al,4 all expert members agreed that a neurologically intact patient with an intact PLC rarely requires surgical treatment. They give a more anatomic description of the PLC than the initial AO classification, specifically that the PLC includes the supraspinous and interspinous ligaments, the ligamentum flavum, and the facet joint capsules.
正如病例1所示，大多数PLC完好、没有神经受累的胸腰椎爆裂骨折可以采用保守治疗。在决定是否采用非手术治疗时，要考虑以下几个因素：病人的神经状态、椎管的受累程度、骨折的畸形程度、PLC的状态等，正如最初Magerl分型中指出的那样。在最近Vaccaro等报道的专家小组意见中，所有的专家都同意，没有神经受累、同时PLC完好的病人很少需要手术治疗。他们对PLC进行了较原始AO分型更详尽的解剖定义：包括棘上韧带、棘间韧带、黄韧带、以及小关节关节囊。
Patients with a thoracolumbar fracture who are deemed suitable candidates for conservative treatment are typically treated with bracing (hyperextension-type brace) or casting with early mobilization, barring limitations of other injuries.5,6 Braces are typically worn at all times, except when bathing, for 3-6 months, while casts are worn continuously. Although bracing facilitates better hygiene and is typically preferred by patients, casting does offer a form of “forced” compliance that may be favorable in the setting of a less reliable patient. As thoracolumbar compression and burst fractures heal, the natural history includes an increased degree of kyphosis over the first few weeks.5 Bracing and casting are intended to limit the progression of this kyphotic deformity during the healing process. Multiple studies have shown that with bracing or casting,the residual sagittal plane deformity is typically similar to or slightly greater than the initial deformity, 5,7-11 with no significant difference between casting and bracing.12,13 It has even been suggested that bracing and casting, although useful for initial pain control,may not prevent collapse of the vertebrae and may not change long-term results. 13
除非有其他损伤，采用保守治疗的胸腰椎骨折病人多以支具（过伸支具）或石膏固定，以早期活动。支具一直穿戴3-6个月，洗澡时可取下，石膏则一直穿戴。虽然支具比较好搞卫生，病人也更愿意用，但石膏对于一些不太可靠的人有“强制”作用。在胸腰椎骨折愈合过程中，在开始的数周，有后凸畸形加重的趋势。支具和石膏可以减少这种趋势。有多项研究表明，支具或石膏固定后，残留的矢状面畸形与最初的畸形相似或轻微加重，石膏与支具之间没有明显差别。虽然支具或石膏对控制初始疼痛很有用，但不能阻止塌陷，也不能改变其长期结果。
Although nonoperative management is frequently employed for neurologically intact patients with a thoracolumbar burst fracture, this approach only recently regained favor. In the early 1980s, Denis et al 14 reported a retrospective review of 52 patients with acute thoracolumbar burst fracture without neurologic deficit at presentation. Of the 39 patients treated nonoperatively, 17% subsequently developed neurologic problems(parapareses and/or radicular pain), 25% were unable to return to work full-time, contrasting with no neurologic problems, and 100% full-time employment among the 13 patients treated operatively. This report, coupled with concurrent rapid advancements in spinal instrumentation, strongly favored the surgical approach over conservative management. However, the majority of subsequent studies,5,7-9,12,13,15-20 including a prospective randomized study,21 have since reported successful outcomes with nonoperative treatment, providing firm support for this approach. A notable exception is a recent report of a multicenter randomized prospective trial comparing operative versus nonoperative treatment for thoracolumbar burst fracture. This study suggested that patients treated operatively have better functional outcome scores, have less kyphotic deformity at the end of follow-up, and are more likely to return to their original jobs.22
虽然非手术疗通常用于没有神经损害的胸腰椎爆裂骨折，但这也是最近才重获亲睐。早在1980年，Denis等做了回顾性研究，报道了52例没有神经损害的胸腰椎新鲜爆裂骨折。39例采用保守治疗，17％继发出现神经问题（下肢轻瘫或神经根痛），25％无法恢复全时工作，而13例手术治疗者，100％恢复全时工作。这个报告结合当前快速进步的脊柱器械，强烈倾向于手术治疗。但后来的大多数研究，包括前瞻性随机研究都报道了非手术治疗取得成功的结果，为保守治疗提供了有力的支持。值得注意的是，最近的一项胸腰椎爆裂骨折的多中心前瞻性随机对照研究认为，手术治疗者的功能评分更佳，最终随访时的后凸畸形更少，更容易恢复其原来的工作。
Figure 1 Imaging for case 1 (see text). AP (A) and lateral (B) radiographs show fracture of the L3 vertebral body.Reconstructed sagittal CT (C) and axial CT (D) imaging show an L3 burst fracture with minimal canal compromise.
图1：病例1图片（见正文）。AP（A）位和侧位（B）平片显示L3椎体骨折。矢状面CT重建（C）和轴位CT(D)显示，L3椎体爆裂骨折，椎管轻微受累。
Proponents of operative treatment advance 3 main arguments. The first relates to a presumed increase in risk of neurologic deterioration without surgical stabilization.Except for the article by Denis et al,14 the article fails to support such an increased risk, with most authors reporting either rare or no initial neurologic deterioration in neurologically intact patients.7,8,10,17-19 In addition, bony remodeling has been shown to reduce residual canal compromise due to retropulsed fragments by more than 50%over the course of a year,9 restoring much of the normal canal space for neural elements. The second argument advances that surgery provides correction of the kyphosis,resulting in reduced pain. Surgery can result in improved kyphosis, but this correction is frequently lost,23-26 and the degree of kyphosis has not been shown to correlate with clinical results, 5,7-10,19 even when the kyphosis is greaterthan 30°.13 The third argument is that surgery allows earlier mobilization, resulting in decreased complications and costs from prolonged bed rest. However, the article supports protocols with early mobilization in a brace and early discharge from the hospital. 7-10 In addition, when including the cost of surgery, reports of hospital charges have been consistently and considerably less for nonoperative treatment.16,27,28
手术治疗存在很大的争议。支持手术治疗的第一个理由是是非手术治疗有增加神经损害的风险。除了Denis的那篇论文（也不支持会增加这种风险），大多数作者报道神经功能完好的病人，很少或不会出现神经功能减退。而且，在1年后，超过50％的病人会出现椎管重塑，减少后突骨块压迫引起的椎管狭窄，恢复正常椎管容量。第二个论点是手术可以矫正畸形，减少疼痛。手术可以矫正畸形，但矫正度常常会丢失，而且后凸的角度与临床结果不相关，即便是后凸角度超过30°时。第三个论点是手术可以早期活动，减少并发症和长期卧床的花费。但用支具也可以早期活动并提早出院。而且，加上手术费用，非手术治疗费用要少得多。
Type A Fracture With Incomplete Neurologic Injury:Short-Segment Posterior Instrumentation and Fusion
Case 2
病例2：A型骨折，不完全脊髓损伤，后路短节段固定融合
A 44-year-old woman presented 3 hours after a fall from a height of 8 feet. She had severe dysesthesia and significant diffuse motor weakness (2/5) in her lower extremities, but had preserved rectal tone and sphincter contraction. Imaging demonstrated an L1 burst fracture, with approximately 50% loss of vertebral body height and approximately 60% canal compromise due to retropulsed vertebral body fragments in the spinal canal (Figs. 2A-D). Magnetic resonance imaging (MRI) demonstrated injury to the conus, evidenced by T2 signal change (Fig. 2E). However, the PLC appeared to be intact. This is therefore a type A burst in the Magerl classification (or A3). Given the presence of an incomplete neuro logical deficit and canal compromise, the patient was urgently taken to the operating room for surgical intervention.At the same time, high-dose steroids were administered in accordance with spinal cord injury protocols. An internal fixator with pedicle screws was placed bilaterally at T12 and L2 (Schanz screws, Universal Spine System (USS) Fracture System, Synthes, West Chester, PA). Rods were secured into place, crosslinked, and used to induce lordosis and then distraction through the Schanz screws. Arthodesis of T12-L2 was performed using allograft and recombinant human bone morphogenetic protein 2 (Medtronic Sofamor Danek). Postoperative imaging demonstrated excellent alignment and canal decompression through distraction (Figs. 2F-H), obviating the immediate need for an anterior reconstruction.Within 2 days the patient was ambulating with dramatic improvement of motor strength and continued preservation of bowel and bladder function. At 2 month follow-up, her motor strength continued to improve and her spinal construct remained intact with excellent spinal alignment.
44岁女性，8英尺高处坠落后3小时。双下肢感觉麻木严重，运动减弱。但直肠张力和括约肌收缩存在。影像证实L1爆裂骨折，椎体高度丢失约50％，后突的骨块侵占椎管约60％（图2A-D）。MRI 可见T2信号改变，证实圆锥损伤（图2 E）。PLC完好。因此，这是一个Margerl分型中的A型骨折（A3）。由于神经不完全损伤、椎管占位，患者被送入手术室进行急诊手术。同时采用大剂量激素治疗并做脊髓损伤记录。在T12和L2进行双侧椎弓根钉内固定(Schanz 螺钉, 通用脊柱系统 (USS)，骨折系统， Synthes, West Chester, PA)。置入连接棒、横联，再通过Schanz钉产生脊柱前凸，再撑开。以自体骨和BMP(Medtronic Sofamor Danek)融合T12-L2。术后影像证实脊柱序列及椎管恢复良好(图 2F-H)，不必再进行前路重建。2天内，患者恢复行走并恢复直肠和膀胱功能。2个月随访，患者的肌力仍在进步，内固定保持良好，脊柱序列正常。
Case 2 illustrates the management of a thoracolumbar burst fracture in the setting of an incomplete neurological deficit with evidence of persistent compression of neural elements. Conservative management was not deemed appropriate for this patient, as decompression of the neural elements and fracture reduction with spinal fixation offered the chance of improved neurological outcome. The recent consensus panel review reported by Vacarro et al4 favors anterior decompression and reconstruction in the setting of an incomplete or cauda equina injury in which the PLC is intact. Complications of the anterior and posterior approaches have been reviewed, and the anterior approach has been suggested to have significantly greater morbidity,29 in terms of blood loss, operating room time, and chest complications. Minimally invasive approaches, in experienced hands, may result in less morbidity.30-34 In choosing the posterior approach for the patient in Case 2, we reasoned that a posterior reduction would provide indirect decompression of the conus through ligamentotaxis and adequate stabilization of the spine while the fractured vertebral body healed. Such posterior surgery can be carried out within 2 hours of patient admission with minimal resources, compared with an anterior approach to the spine that is more readily performed during daylight hours when resources are more easily available. Postoperative imaging demonstrated excellent restoration of vertebral body height at the fractured level and restoration of the lateral walls of the vertebral body (Fig. 2I) that will prevent loss of correction despite the void in the central part of the vertebral body (Fig. 2H).
病例2是一个神经受压、不完全神经损伤的胸腰椎爆裂骨折病例。保守治疗不合适，而神经减压、骨折复位内固定可为神经恢复创造机会。Vacarro等报道的专家小组意见中，对于PLC完好的不完全脊髓损伤或马尾损伤倾向于前路减压与重建。对比前后路手术并发症发现，前路手术的失血量、手术时间、胸腔并发症等发生率均明显高于后路。微创手术对于有经验的人来说，并发症可以很低。病例2选用后路，主要考虑后路可以通过韧带复位间接减压圆锥，当骨折愈合后，可提供足够的稳定性。这种后路手术可以在入院后2小时进行，不需要很多的条件。而如果是前路手术，则多要安排在白天、资源充足的情况下进行。术后影像证实骨折椎体的高度和侧壁恢复完美(Fig. 2I)，不会因为中央的空隙而复位丢失(Fig. 2H).。
Conventionally, short-segment posterior fixation refers to fusion from 1 vertebral level above to 1 vertebral level below the fractured vertebra. Although several early studies reported suboptimal outcomes with short-segment posterior fixation,23,35-37 more recent studies have demonstrated good clinical results.26,38,39 In our experience, short-segment posterior fixation enables excellent spinal reduction, decompression of the neural elements, and spinal reconstruction in the majority of cases of thoracolumbar compression and burst fracture that warrant surgery. Exceptions include cases in which the integrity of the anterior column is compromised to the point that anterior reconstruction is necessary for anterior column support. Other exceptions include cases of incomplete neurological deficit in which a posterior approach may not provide adequate exposure for decompression, including a canal that is extensively obliterated with bone fragments, or the presence of a reverse cortical sign (see Case 5).
通常，后路固定融合骨折上下各一椎体。虽然后路短节段固定的早期的报道疗效欠佳，但近来更多的报道认为效果良好。按我们的经验，后路短节段固定对大多数压缩骨折、爆裂骨折需要手术者，都可以获得良好的复位、减压和脊柱重建。例外的情况包括：前柱的损伤已到了需要前柱支撑的程度者，不完全神经损伤后路无法充分暴露减压者、椎管被骨块完全闭塞者、有皮质翻转征者（见病例5）。
Sasso et al 26 reported a retrospective review of anterioronly vs short-segment posterior fixation for unstable thoracolumbar burst fractures in 53 patients. The only significant difference they reported between the 2 groups was increased loss of sagittal plane correction (only 6°) in the posterior fixation group compared with the anterior group. However, at the last follow-up there did not seem to be any clinically relevant difference between the 2 groups in the amount of “final kyphosis” (11.6° in the posterior group vs 9.2° in the anterior group). The fact that the final kyphosis is similar in the anterior and posterior groups can be explained by the difficulty of completely restoring spinal alignment at the time of surgery with the anterior approach, compared with the posterior approach. The posterior fixation group had no instances of pseudoarthrosis or hardware failure and no cases requiring reoperation,while nearly 10%of the anterior group required either early or delayed supplemental posterior thoracolumbar arthrodesis with instrumentation for hardware failure or pseudoarthrosis.
Sasso等对53例不稳定胸腰椎爆裂骨折病人分别采用前路和后路短节段固定，进行回顾性分析。两组仅在矢状面矫正度丢失上有明显的不同，后路较前路大（只有6°）。然而最终随访结果显示临床结果与“最终后凸程度”无关（后路为11.6°，而前路为9.2°）。前后路最终后凸角度相似的原因在于前路手术时难以完全恢复脊柱序列。后路手术组没有假关节、内固定失败、或再手术者，而前路手术组有近10％因为假关节或内固定失败而需要进行早期或延期后路胸腰椎融合固定。Clinical investigation of high-dose steroids for spinal cord injury has provided conflicting results, and the evidence to substantiate their routine use is poor.40-46 On the contrary,evidence of deleterious effects continues to mount. 40,43,47 However, steroids continue to be given at many institutions for spinal cord injury, primarily motivated by peer pressure and fear of litigation, as it was done in this case.
大剂量激素治疗脊髓损伤的临床调查结果是矛盾的，而常规剂量的效果很差。相反，其副作用不断被报道。对于这种脊髓损伤的病人，激素在很多机构仍在使用，其原因主要源于同行的压力和担心被起诉。
Figure 2 Imaging for case 2 (see text). AP (A) and lateral (B) radiographs show fracture of the L1 vertebral body.Reconstructed sagittal CT (C) and axial CT (D) imaging show an L1 burst fracture with approximately 60% canal compromise. (E) T2-weighted sagittalMR imaging demonstrates abnormal T2 signal in the conus, reflecting injury. AP(F) and lateral (G) radiographs and reconstructed sagittal CT imaging (H) following T12 to L2 posterior fixation. Note the restoration of normal L1 vertebral body height and segmental lordosis achieved through ligamentotaxis. Also note the length and the divergent position of the pedicle screws to increase the biomechanics of the construct. No complementary anterior surgery is necessary despite the void in the vertebral body (observed in H) as the 2 lateral walls of thevertebral body have been restored by ligamentotaxis (I) (only right lateral wall represented in the slide).
图2 病例2图片（见正文）。AP（A）和侧位（B）片显示L1椎体骨折。矢状面重建CT（C）和轴位CT(D)显示L1爆裂骨折，近60％椎管受累。（E）T2加权MR证实圆锥部异常信号，表明损伤。T12－L2固定术后的AP（F）位和侧位（G）平片和矢状面CT重建（H）。注意，通过韧带牵开，恢复了L1椎体高度和生理前凸，同时注意椎弓根钉的长度和叉开的位置，增加了内固定的机械性能。由于椎体的两侧壁均已通过韧带恢复，尽管椎体中央有空隙（见于图H），也不必再进行前方手术（I）(片上只有右侧壁)。
Type B Fracture, Predominantly Osseous: Temporary Posterior Internal Fixation
Case 3
病例3：B型骨折，主要为骨性损伤，临时性后路内固定
A 16-year-old boy presented 3 days after a motor vehicle accident in which he was an unrestrained driver. He was initially managed conservatively at a surrounding hospital for a diagnosis of L3 compression fracture, but pain and right lower extremity weakness with mobilization prompted transfer to our institution. He presented with motor weakness of the right hamstring (3/5) and quadriceps (3/5) muscles, and repeat imaging demonstrated an L3 flexion distraction type of injury or Chance fracture (Figs. 3A-C). This is a Magerl type B fracture with rupture of the posterior element but predominantly osseous. His weakness in the right quadriceps can be explained by the compression observed at the level of the L3 foramen as seen on the MRI (Fig. 3D). The L3 nerve is compressed between the fracture of the posteriorwall and the buckling of the ligamentum flavum. The patient was taken to the operating room where bilateral L2 and L4 pedicle screws were placed (Schanz screws, USS Fracture System, Synthes) and decompression of the right L3 nerve root was performed. Reduction of the fracture was achieved through the manipulation of the Schanz screws in lordosis and compression (Figs. 3E and F). No segmental arthrodesis was performed intentionally. At 5 months after surgery, once the L3 vertebral body fracture was healed, he underwent hardware removal. Two weeks after hardware removal, flexion and extension radiographs demonstrated preservation of motion between L2 and L4 (Figs. 3G-I). He demonstrated stable radiographs and progressive improvement of motor strength at 10 months after initial injury.
16岁男孩，超速行驶引起的交通事故后3天。在附近医院诊断为L3压缩性骨折，并做了适当的处理。但由于疼痛和右下肢肌力减退使其转入我们医院。右侧腘绳肌(3/5)、股四头肌(3/5)肌力减退。重新拍片显示L3屈曲牵伸型损伤或Chance骨折(图. 3A-C)。这属于Magerl B型骨折，主要为骨性损伤。MRI上，L3节段椎间孔受压可以解释其右侧股四头肌肌力减弱(图. 3D)。L3神经根被压于后壁骨折块与皱曲的黄韧带之间。患者被送入手术室，行L2和L4椎弓根钉固定(Schanz screws, USS Fracture System, Synthes)，右侧L3神经根减压。通过Schanz螺钉进行脊柱前凸和加压，复位骨折(图. 3E and F)。有意不做节段融合。术后5个月，骨折愈合后，取出内固定。内固定物取出后2周，过伸过屈位位片证实，L2和L4之间的活动存在(图. 3G-I)。损伤后10个月，影像证实稳定，肌力明显增加。
Case 3 illustrates a case of flexion distraction injury, according to the Magerl classification, that would be a type B injury involving the bone and not the PLC. Such a fracture can be treated conservatively with a hyperextension cast and will heal uneventfully, as opposed to the flexion distraction injuries that involve the PLC that will not heal with this approach. However, in this specific case, a posterior surgical approach was chosen to enable decompression of the L3 nerve root, and the short-segment posterior instrumentation without arthrodesis provided adequate stability to allow the fracture to heal. The concept of “temporary internal bracing” for a bony Chance fracture was recently reported by Beringer et al 48 who performed it through percutaneous incisions and minimal access surgery.
病例3为屈曲牵伸型损伤，根据Magerl分型为B型，骨性损伤，没有PLC损伤。这种骨折可以采用过伸石膏进行保守治疗，但如果是伴有PLC损伤的屈曲牵伸损伤，用这种方法就不会愈合。在这个特殊病例中，采用后路手术减压L3神经根，同时短节段固定而不融合，以提供足够的稳定，利于骨折愈合。“临时性内固定”的概念是最近Beringer等提出的，他们采用微创手术治疗这种骨性Chance骨折。
Figure 3 Imaging for case 3 (see text). AP (A) and lateral (B) radiographs show a typical flexion distraction Chance fracture through the bone. (C) Reconstructed sagittal CT imaging and axial MRI (D) explain the L3 radiculopathy with the narrowing of the right L3/L4 foramen due to the buckling of the ligamentum flavum and the posterior wall disruption (arrows). AP (E) and lateral (F) radiographs following L2 to L4 instrumentation with placement of bilateral L2 and L4 pedicle screws, rods, and crosslink. Neutral (G), flexion (H), and extension (I) standing radiographs, following removal of hardware 5 months after initial surgery, demonstrate healing of the L3 Chance fracture and restoration of mobility.
图3：病例3图片（见正文）。AP（A）位和侧位(B)平片显示经骨的典型的屈曲牵伸型Chance骨折。矢状面CT重建（C）和轴位CT（D）显示由于黄韧带皱缩，后壁破裂，导致L3/L4右神经根管狭窄（箭头）。 AP（E）和侧位(F)平片为L2、L4椎弓根钉、连接棒、横联固定术后。初次手术后5个月，去除内固定术后，站立中立位（G）、屈曲位(H)、过伸位(I)证实，L3骨折愈合，活动度存在。
Type B Fracture, Predominantly Ligamentous: Posterior Monosegmental Fixation
Case 4
病例4：B型骨折，主要韧带损伤，后路单节段固定
A 30-year-old Olympic athlete presented following a heavy weight blow to the back during training. He was neurologically intact except for mild to moderate (4/5) weakness of the right extensor hallucis longus. Imaging demonstrated an L1 compression fracture, with anterolisthesis of T12 on L1 and bilateral perched facets (Figs. 4A-D). This is a flexion–distraction injury involving predominantly the PLC (type B predominantly ligamentous in theMagerl classification). An MRI was performed urgently (not shown) to check for any possible posterior disc disruption that would have made the posterior reduction and compression dangerous.49,50 In the absence of posterior disc herniation, a posterior approach was chosen. The patient was taken to the operating room for open reduction of the dislocation, followed by placement of bilateral T12 and L1 pedicle screws (Schanz screws, USS Fracture System, Synthes). Rods were secured into place and crosslinked, and used to induce compression and lordosis over the Schanz screws (Figs. 4E and F). Arthodesis of T12-L1 was performed using autograft. At 3 years follow-up, the spinal reconstruction remains intact (Fig. 4G), and the patient continues to be a competitive Olympic athlete. Despite the patient being almost neurologically intact, the instability of this injury necessitated surgical intervention. A posterior approach was selected to enable reduction of the perched facets and restore spinal alignment. To minimize the number of fusion levels in this elite athlete, only the fracture level and the level above were instrumented, thereby avoiding fusion of the L2 level. This was possible due to the limited compromise of the L1 vertebral body and the angling of the L1 pedicle screws caudally to capture the intact portion of the L1 vertebral body.
30岁运动员，训练进重物砸伤背部所致。右侧足拇长伸肌肌力轻－中度减退（4/5），其余神经功能良好。影像证实L1压缩性骨折伴有T12向前脱位，小关节跳跃（图4A-D）。这是一个屈曲牵伸型病例，以PLC损伤为主（Margerl分型中B型，韧带损伤为主）。急诊MR检查（未显示）看是否有后方椎间盘破裂，如有，可对后路复位和减压造成危险。由于没有椎间盘突出，采用后路手术治疗。开放复位，T12/L1双侧椎弓根螺钉固定（Schanz 螺钉, USS 骨折系统, Synthes）。连接棒安全植入并以横联相连，通过Schanz螺钉加压、脊柱前凸进行复位（图4E、F）。T12-L1间自体植骨融合。3年随访，脊柱重建保持良好（图4G）。病人仍在进行奥林匹克运动。虽然几乎没有神经损伤，由于损伤的不稳定，需要手术干预。选择后路可使跳跃的小关节复位，恢复脊柱序列。为减少这个运动精英的融合节段，只在骨折椎及其上方椎进行固定，这样就避免了融合到L2水平。由于L1椎体受损较少，将L1的椎弓根螺钉向尾侧成角放置，以抓持住L1椎体的完整部分。
Figure 4 Imaging for case 4 (see text). (A-C) Reconstructed sagittal CT images demonstrate an L1 compression fracture with anterolisthesis of T12 on L1 and bilateral perched facets. (D) Axial CT image at the L1 vertebral level does not demonstrate disruption of the posterior aspect of the L1 body. AP (E) and lateral (F) radiographs following monosegmental fixation from T12 to L1. Note that the trajectory of the L1 pedicle screws is such to maximize bony purchase in the unfractured portion of the vertebral body and to maximize pull-out strength. (G) At 3 years follow-up, the spinalreconstruction remains intact.
图4，病例4 的图片（见正文）。(A-C)矢状位CT重建显示L1椎体压缩性骨折，T12向前滑脱，小关节跳跃。(D)轴位CT显示L1椎体后壁未破损。 AP (E)和侧位(F)为T12到L1单节段固定术后。注意L1椎弓根钉朝向非骨折部位，以获得最大的抗拔力。(G)3年随访，脊柱重建依然良好。
Type B Fracture With Anterior Dislocation and Reverse Cortical Sign: Treatment Through an Anterior Approach
Case 5
病例5 ：B型骨折伴有向前脱位和皮质翻转征：前路手术。
A 34-year-old man presented after an ATV accident. On examination, he had a sensory level at T12 and no motor function below this level. His rectal tone was diminished, but there was some patchy sensory preservation in his medial thighs bilaterally. Imaging demonstrated an L1 burst fracture with anterior dislocation (Figs. 5A-E). There was significant canal narrowing due to dislocation and retropulsion of abony fragment into the spinal canal. On the CT scan, this fragment seems to be flipped 180°, referred to as the reverse cortical sign (Figs. 5C and E). Given the partial preservation of sensory function, urgent surgical decompression was undertaken, including left thoracotomy and retroperitoneal approach for L1 vertebrectomy, expandable intervertebral cage placement (Synthes expandable cage), and anterolateral fusion from T12 to L2 (Medtronic Sofamor Danek, Antares anterior fixation system) (Figs. 5F and G). At 6 months follow-up, the patient continues to have neurologic improvement and demonstrates an L5 sensory level bilaterally, excellent quadriceps function on the left and trace function on the right. His construct remains intact.
34岁男性，ATV事故。感觉平面位于T12，该平面以下运动功能消失。直肠张力减弱，双侧大腿内侧残余少量感觉。影像证实L1爆裂骨折伴有前方脱位（图5A-E），由于脱位和后方骨块的压迫，椎管明显狭窄。在CT片上，骨块翻转了180°（皮质翻转征）（图5C和E）。由于保留了部分感觉，急诊进行手术减压，采用左侧经胸腹膜后L1椎体切除，可撑开椎间融合器植入（Synthes可撑开椎间融合器），T12-L2前外侧融合（Medtronic Sofamor Danek，Antares前路固定系统）（图5F、G），6个月随访，患者的神经功能仍在进步，感觉平面位于L5水平，左侧股四头肌功能良好，右侧也有轻度恢复。内固定保持良好。
Case 5 illustrates a case with significant canal compromise due to a dislocation of the spine with an accompanied retropulsed fragment in the canal that is flipped (Fig. 5E). Although the patient had sustained a near-complete neurologic injury, evidence of some residual function prompted urgent decompression. The anterior surgery is necessary in such a case, as a posterior reduction with ligamentotaxis will not address the flipped cortical piece and may induce further neurologic damage. The anterior approach will directly address the neural compression and will allow anterior column reconstruction. The use of an expandable cage along with a double rod system allows excellent anatomic reduction.
病例5由于脱位和后方骨块翻转压迫，椎管有明显的占位（图5E），虽然接近神经完全损伤，由于残余少量功能，提示急诊减压。由于后方韧带复位对于皮质翻转骨块已不可能，且可能造成神经进一步损伤，因此需要前路手术。前路可进行神经直接减压并进行前柱重建。应用可扩张cage加上双棒系统可以达到解剖复位。
Figure 5 Imaging for case 5 (see text). AP (A) and lateral (B) radiographs show fracture of the L1 vertebral body with T12-L1 dislocation. (C) Sagittally reconstructed CT and MRI (D) images show the dislocation and significant retropulsion of a bone fragment that appears to be flipped into the spine canal (arrow). (E) Axial CT image showing the reverse cortical sign (arrows, see text). AP (F) and lateral (G) radiographs following L1 corpectomy, expandable intervertebral cage placement, and anterolateral fusion from T12 to L2. Case images courtesy of Dr Jeffrey Elias
(Department of Neurosurgery, University of Virginia).
图5 病例5图片（见正文）。AP（A）位和侧位（B）显示L1椎体骨折伴有T12-L1脱位。矢状面CT重建（C）和MRI（D）显示脱位，后突的骨块突入椎管并翻转（箭头）。轴位CT（E）显示皮质翻转征（箭头，见正文）。L1椎体切除术后AP位（F）和侧位(G)片显示，可扩张椎间融合器置入，从T12至L2进行前外侧融合。病人片子得到 Dr Jeffrey Elias(Department of Neurosurgery, University of Virginia)允许。
Type C Fracture (Rotation Translation Injury With Shear):Short-Segment Fixation Via Posterior Approach Followed by Complementary Anterior Column Support
Case 6
病例6：C型骨折（旋转剪切损伤）：后路加前柱支撑、短节段固定A 16-year-old girl presented after a roll-over ATV accident with significant lower extremity weakness. She lacked any demonstrable motor function in her lower extremities, except for flickers of movement in her toes bilaterally and limited resistance to gravity (4/5) in her right quadriceps. An L3 compression fracture with near obliteration of the spinal canal due to retropulsed fragments was identified on imaging (Figs. 6A-E). On the AP view one can see the translation and rotation of the spine. These lesions, according to Magerl, would be classified as type C and are extremely unstable.Given the incomplete neurologic injury with significant canal compromise and the highly unstable pattern of this fracture, she was taken urgently to the operating room where bilateral L2 and L4 pedicle screws were placed (Schanz screws, USS Fracture System). An L3 decompressive laminectomy and partial L3 corpectomy were performed. Rods were secured into place, crosslinked, and used to induce distraction and lordosis (Fig. 6F). An intraoperative myelogram was done and confirmed excellent decompression of the spinal canal.Arthrodesis from L2 to L4 was done using autologous iliaccrest bone graft. During the same hospitalization, the patient was returned to the operating room for an L3 corpectomy and anterior cage (SynMesh cage, Synthes) reconstruction with local bone grafting and anterior instrumentation (AOUSS type 2) (Figs. 6G and H). At 1 year follow-up the patient has a stable spinal reconstruction and has significant improvement in lower extremity strength such that she is
able to walk with only the assistance of a cane.
16岁女孩，ATV事故后双下肢明显无力，双侧足拇可轻微活动，右侧股四头肌可抗重力（4/5）,其他肌力均为0级。影像可见L3椎体压缩骨折，后突的骨块几乎将椎管湮没（图6A-E）.前后位上可见脊柱移位并旋转。根据Margerl分型为C型，极不稳定。由于神经不完全损伤，椎管严重占位，脊柱极不稳定，急诊入手术室进行双侧L2、L4椎弓根固定(Schanz screws, USS Fracture System)，L3椎板减压，L3部分椎体切除。连接棒安全植入、横联连接、撑开、脊柱前凸固定。术中脊髓造影显示椎管减压充分。采用自体髂骨移植进行L2-L4融合。在住院期间，患者以再回手术室进行了L3椎体切除、前路cage(SynMesh cage, Synthes)重建、局部骨移植、前路内固定(AO USS type 2) (图. 6G and H)。1年随访，重建的脊柱稳定，下肢肌力明显增加，扶单拐可以行走。
Case 6 is an example of a fracture with significant canal compromise with neurologic deficit. As opposed to Cases 2 and 5, where one can argue to perform anterior or posterior surgery, such cases with a rotational component or translation should be treated with posterior surgery, because reduction of the alignment is very difficult with anterior surgery alone. A posterior approach was first done to decompress the canal and foramen, to realign the spine, and to provide spinal fixation. To achieve adequate decompression of the canal and neural foramen, it was necessary to perform a partial transpedicular corpectomy. Postoperative imaging demonstrated a lack of anterior column support that prompted anterior reconstruction of the anterior column. McCormack et al 51 described a load-sharing classification of spine fractures. They presented 28 patients who had 3-column spinal fractures surgically stabilized by short-segment instrumentation with screws and plates and autograft. Ten of these patients subsequently presented with broken screws. A point system (the load-sharing classification) was devised based on the amount of damaged vertebral body, the spread of fragments at the fracture site, and the amount of corrected traumatic kyphosis. This point system was then used preoperatively to help predict which 3-column fractures can be effectively treated with short-segment posterior fusion vs those in need of an anterior reconstruction.
病例6为椎管明显受压伴神经损伤的骨折。与病例2和5不同，那两例可能还会讨论是前路还是后路手术，这种旋转或平移损伤应该采用后路手术治疗，因为单纯前路手术很难恢复脊柱的序列。先进行后路椎管和椎间孔减压，恢复脊柱排列，再进行固定。为使椎管和椎间孔减压充分，经椎弓根椎体部分切除是必须的。术后的影像证实前柱缺损，提示需要进行前柱重建。McCormack等报道了一种脊柱骨折的载荷分担系统。他们报道了28例三柱骨折采用短节段固定自体植骨术，其中10例出现螺钉断裂。根据椎体的损害程度、骨块移位程度、需要矫正的角度等他们发明了载荷分担分型系统，以便在术前进行预测，三柱骨折是采用短节段后路固定还是前路重建。
Figure 6 Imaging for case 6 (see text). AP (A) and lateral (B) radiographs show fracture of the L3 vertebral body. (C) Axial CT image at the level of L3 shows significant spinal canal compromise due to retropulsion of bony fragments. T2-weighted sagittal (D) and axial (E) MR imaging demonstrate significant spinal canal compromise at the L3 level. (F)Reconstructed sagittal CT image following L2 to L4 fusion with placement of bilateral L2 and L4 pedicle screws, rods,and crosslink. Note the defects in the L3 vertebral body, resulting from both the injury and the need to perform a partial corpectomy for decompression. AP (G) and lateral (H) radiographs following an anterior approach for L3 corpectomy and reconstruction。
图6，病例6的图片。（见正文）。AP位（A）和侧位（B）显示L3椎体骨折。轴位CT(C)显示L3节段由于骨块后突造成明显的椎管占位。T2加权（D）和轴位MR(E)证实L3水平椎管明显占位。L2-L4双侧椎弓根钉、连接棒、横联固定融合后的矢状面CT重建（F），注意由于损伤和椎体部分切除减压后造成的L3椎体缺损。前路L3椎体切除重建术后AP位（G）和侧位（H）。Type C Fracture of the Thoracic Spine (Rotation Translation Injury): Treatment With Long Posterior Fixation
Case 7
A 40-year-old patient who fell off a ladder was initially seen in a local hospital and “cleared for any spine fracture.” The patient was seen 3 weeks later at the spine clinic for persisting pain. Radiographs showed a dislocation with translation rotation of the spine at T7-T8 with significant kyphosis. The patient was neurologically intact. Such an injury is very unstable and is classified as a type C lesion in the Magerl classification (Figs. 7A and B). Here, as opposed to the other cases where short fixations were performed, a long fixation is favored for the following reasons. The reduction in spinal mobility introduced by a long fusion of the thoracic spine is not as clinically significant as a long fusion in the thoracolumbar or lumbar spine. Also, the reduction of such fractures is difficult and requires a long lever arm and careful surgical placement of the pedicle screws. 52 Moreover, even reduced, these fractures remain highly unstable, necessitating longer instrumentation.
病例7：C型胸椎骨折，（旋转剪切损伤）：采用长节段后路固定。
40岁患者，从楼梯上摔下，就诊于地方医院，“排除任何脊柱骨折”。3周后康拜因持续疼痛就诊于脊柱门诊。平片显示T7-8旋转脱位伴有明显后凸。神经功能完整。该病人按Magerl分类为C型损伤，属于极不稳定型（图7A/B）。这里不该用短节段固定，长节段固定更合适，原因如下。胸椎长节段融合后，脊柱活动丢失不如胸腰段或腰段明显。这种骨折的复位困难，需要较长的力臂和小心置入椎弓根钉。而且，如果减少节段，骨折会很不稳定，需要长的器械固定。
Figure 7 Imaging for case 7 (see text). AP (A) and lateral (B) radiographs show rotation between T7 and T8 and lateral translation between T7 and T9. A severe kyphosis can be observed on the lateral x-rays. AP (C) and lateral (D) radiographs following correction of the thoracic dislocation with a long posterior instrumentation. Note the 2crosslinks in this highly unstable rotatory fracture dislocation.
图7 病例7的图片（见正文）。AP位（A）和侧位（B）显示T7和T8之间旋转，T7与T9之间侧方移位。侧位片上可以见到严重的后凸畸形。后路长节段复位胸椎脱位术后AP位（C）和侧位（D）。注意这种高度不稳定的旋转骨折脱位上用了两个横联。
Conclusions
Through this review of case examples classified in the AO classification system, one can propose a schematic treatment algorithm that must be modulated based on whether neurologic decompression is necessary.
结论
通过按AO分型的病案复习，可以得出根据是否需要神经减压进行调整的治疗纲要。
● Type A fractures without accompanying neurologic deficit, in most cases, can be treated conservatively, provided there is no progression of the deformity.
A型骨折不伴有神经损伤者，大多数可以保守治疗，畸形不会进展。
● Type A fractures with accompanying neurologic deficit should be treated surgically. It is the authors’ preference to perform these cases with a posterior approach and ligamentotaxis. Anterior surgery may be preferred by others.
伴有神经损伤的A型骨折要手术治疗，作者推荐后路韧带复位，有些作者喜欢前路。
● Type B fractures should be, in most cases, treated surgically regardless of neurologic status. In our practice we treat most of these injuries through a posterior approach to restore the posterior tension band. A postoperative CT scan will determine the need of further anterior decompression of neurologic structures or anterior column support. Some surgeons prefer an anterior approach for type B fractures.
B型骨折大多需要手术治疗，不管有没有神经损伤。我们多数采用后路重建张力带。术后CT可以决定是否需要再行前路减压或前柱支撑。有些医生喜欢前路治疗B型骨折。● Type C fractures require posterior reduction fixation,usually long (2 levels above and 2 levels below) in the thoracic spine, and short in the lumbar spine (1 above 1 below) to preserve mobility and function.In most cases, the goals of fracture care are to restore function, both neurologic and spinal column function, and to maintain mobility. Therefore, we are strong proponents of short fixation of fractures to preserve range of motion of the spine and to prevent late degenerative changes, late spinal stenosis under the construct, or late charcot spine under long instrumentation in the paraplegic. The exceptions are the thoracic dislocations, which often require longer fixation (2 above and 2 below) and patients with osteoporosis. The need for anterior column support remains an issue that requires a careful analysis of the fracture and its reduction on the post operative CT scan. Advanced instrumentation techniques have rendered anterior column support less necessary as it used to be.
C型骨折需要后路复位固定，胸椎通常采用长节段固定（上下各两各节段），腰椎通常采用短节段固定（上下各一节段），以保留活动和功能。大多数骨折的治疗目的在于恢复脊柱和神经功能，保全生命。因此，我们强烈推荐短节段固定以保留脊柱活动，防止迟发退行性改变、继发性椎管狭窄、截瘫长节段固定后的夏科氏关节等。例外的情况是胸椎脱位（通常需要上下各两个节段）和骨质疏松患者。是否需要前柱支撑，需要术后CT进行详细分析骨折和复位情况。器械的进步已使前柱支撑不像以前那么需要了。
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