P38。微创后路固定和双门静脉内窥镜减压治疗胸腰椎骨折伴不完全神经功能缺损的疗效：一项前瞻性观察研究

IF 2.5 Q3 Medicine

North American Spine Society Journal Pub Date : 2025-07-01 DOI:10.1016/j.xnsj.2025.100662

Manish Kumar Shah MBBS , Shivam Malaviya MBBS, DO, DNB , Bhaskar Sarkar MS, DNB, MBBS

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引用次数: 0

摘要

背景：胸腰椎骨折，特别是伴有不完全性神经功能缺损的骨折，是脊柱外科的重大挑战。这些骨折主要位于胸腰椎连接处（T10-L2），由于从僵硬的胸椎到活动的腰椎的生物力学转变，容易发生不稳定。大约25%-32%的此类骨折导致神经功能缺损，需要手术干预。传统上，开放入路固定减压是标准的，但其发病率较高。微创手术（MIS），包括后路固定和双门静脉内窥镜减压，提供了一种有希望的替代方法，减少了组织破坏，改善了视觉效果，恢复更快。然而，治疗胸腰椎骨折伴不完全神经功能缺损的最佳方法尚无定论。本研究旨在评估MIS后路固定联合双门静脉内镜减压在解决此类病例的机械稳定和神经减压方面的疗效。目的探讨微创后路固定联合双门静脉内镜减压治疗不完全神经功能缺损胸腰椎骨折的临床和影像学效果。主要目的：术后MRI通过神经结构周围清晰的蛛网膜下腔空间来评估减压的充分性。次要目的：使用ASIA运动和感觉评分评估神经恢复。分析放射学结果，包括矢状Cobb角的矫正和维持。调查医源性硬膜损伤、手术部位感染等并发症的发生率。测量术后疼痛（VAS评分），并在每个随访间隔进行比较。与接受开放手术的患者相比，评估住院时间和临床结果。研究设计/设置：这是一项前瞻性观察性研究，由Rishikesh全印度医学科学研究所（AIIMS）骨科和创伤科进行。该研究为期18个月，患者入组12个月，随访6个月。该研究坚持三级证据，包括全面的临床和放射学评估。纳入标准：胸腰椎骨折（T11-L5， AO型A/B）伴不完全神经功能缺损（ASIA分级B、C、D）。不到50%的运河受损。后韧带复合体（PLC）骨损伤。麦科马克分数&lt；4例和损伤后3周内出现的患者。排除标准：AO C型损伤、粉碎性骨折、病理性骨折或PLC韧带损伤。不适合手术或不愿同意的病人。最终样本量包括所有在创伤骨科接受MIS和双门静脉内窥镜减压的合格患者。主要结果：减压足够（术后MRI显示脑脊液边缘清晰）。次要结局：ASIA运动和感觉评分。矢状Cobb角矫正及维持。并发症的发生率。不同时间间隔的VAS评分。住院时间。方法术前评价：临床评价：ASIA评分、运动和感觉评分。•VAS疼痛评分。放射学分析：x光片、CT（椎管受损、关节面损伤）和MRI（部位和压迫程度）。术中参数：可见硬脑膜搏动作为减压的标志。从MIS到开放手术的转换率。术后评估：在2周、1、3和6个月时x线评估矢状Cobb角矫正情况。MRI证实神经减压。•ASIA评分和VAS疼痛缓解的临床评价。统计分析：描述性数据采用均数±标准差进行分析。•分类变量的？²检验和连续变量的配对t检验。•数据处理通过SPSS或EPI-Info 7.0。结果初步数据分析表明，MIS后路固定和双门静脉减压：术后MRI显示脑脊液间隙清晰，神经减压效果满意。2. 结果显著改善了神经系统，反映在亚洲运动和感觉评分上。3. 在6个月时证明了矢状Cobb角矫正的有效性，并且最小程度地损失了对齐。4. 与术前相比，术后疼痛（VAS评分）降低。5. 与开放手术相比，缩短住院时间，降低并发症发生率。并发症发生率，包括螺钉错位，是最小的和可控的。患者报告的结果显示功能恢复明显改善。结论微创后路固定联合双门静脉内窥镜减压是治疗胸腰椎骨折伴不完全性神经功能缺损安全有效的方法。与开放手术相比，该方法具有显著的优势，包括增强神经减压，改善临床和放射学结果，降低手术发病率。这些发现支持MIS技术在脊柱创伤护理中的广泛应用，并为其在临床实践中的应用提供了有价值的见解。本研究强调了先进MIS技术在胸腰椎骨折治疗中提高患者预后和减少并发症的重要性。FDA器械/药物状态本摘要不讨论或包括任何适用的器械或药物。

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P38. Efficacy of minimal invasive posterior fixation and biportal endoscopic decompression in patients with thoracolumbar fractures with incomplete neurological deficit: a prospective observational study

BACKGROUND CONTEXT

Thoracolumbar fractures, particularly those accompanied by incomplete neurological deficits, present significant challenges in spine surgery. These fractures, predominantly located at the thoracolumbar junction (T10-L2), are prone to instability due to the biomechanical transition from a rigid thoracic to a mobile lumbar spine. Approximately 25%-32% of such fractures result in neurological deficits, necessitating surgical intervention. Traditionally, open approaches for fixation and decompression have been standard, but they are associated with higher morbidity. Minimally invasive surgery (MIS), including posterior fixation and biportal endoscopic decompression, offers a promising alternative with reduced tissue disruption, improved visualization, and faster recovery. However, the optimal approach for managing thoracolumbar fractures with incomplete neurological deficits remains inconclusive. This study aims to evaluate the efficacy of MIS posterior fixation combined with biportal endoscopic decompression in addressing mechanical stabilization and neural decompression in such cases.

PURPOSE

To assess the clinical and radiological outcomes of minimally invasive posterior fixation and biportal endoscopic decompression in thoracolumbar fractures with incomplete neurological deficits. Primary objective: Evaluate the adequacy of decompression using postoperative MRI, defined by a clear subarachnoid space around neural structures. Secondary objectives: Assess neurological recovery using ASIA motor and sensory scores. Analyze radiological outcomes, including correction and maintenance of sagittal Cobb’s angle. Investigate the incidence of complications such as iatrogenic dural injury and surgical site infections. Measure postoperative pain (VAS scores) and compare them at each follow-up interval. Assess hospital stay duration and clinical outcomes compared to patients undergoing open surgery.

STUDY DESIGN/SETTING

This is a prospective observational study conducted at the Department of Orthopedics and Trauma, All India Institute of Medical Sciences (AIIMS), Rishikesh. The study spans 18 months, with patient enrollment over 12 months and follow-ups extending to 6 months. The research adheres to Level III evidence and involves comprehensive clinical and radiological evaluations.

PATIENT SAMPLE

Inclusion criteria: thoracolumbar fractures (T11-L5, AO type A/B) with incomplete neurological deficits (ASIA Grades B, C, D). Less than 50% canal compromise. Bony injury to the posterior ligamentous complex (PLC). McCormack score < 4 and patients presenting within 3 weeks of injury. Exclusion criteria: AO type C injuries, comminuted fractures, pathological fractures, or ligamentous injuries to the PLC. Patients unfit for surgery or unwilling to provide consent. The final sample size includes all eligible patients admitted to the trauma and orthopedics department undergoing MIS and biportal endoscopic decompression.

OUTCOME MEASURES

Primary outcomes: adequacy of decompression (clear CSF rim on postoperative MRI). Secondary outcomes: ASIA motor and sensory scores. Sagittal Cobb’s angle correction and maintenance. Incidence of complications. VAS scores at different intervals. Length of hospital stay.

METHODS

Preoperative assessment: Clinical evaluation: ASIA Grade, motor, and sensory scores. • VAS pain scores. Radiological analysis: X-rays, CT (canal compromise, facet injuries), and MRI (site and degree of compression). Intraoperative parameters: visible dural pulsation as a sign of decompression. Conversion rates from MIS to open surgery. Postoperative Assessment: X-rays to evaluate sagittal Cobb’s angle correction at 2 weeks, 1, 3, and 6 months. MRI to verify neural decompression. • Clinical evaluation of ASIA scores and VAS pain relief. Statistical Analysis: • Descriptive data analyzed using mean ± SD. • ?² test for categorical variables and paired t-tests for continuous variables. • Data processing through SPSS or EPI-Info 7.0.

RESULTS

Preliminary data analysis indicates that MIS posterior fixation and biportal decompression: 1. Achieved satisfactory neural decompression, evidenced by clear CSF space on postoperative MRI. 2. Resulted in significant neurological improvement, as reflected in ASIA motor and sensory scores. 3. Demonstrated effective sagittal Cobb’s angle correction with minimal loss of alignment at 6 months. 4. Reduced postoperative pain (VAS scores) compared to preoperative levels. 5. Shortened hospital stays and lowered complication rates compared to open surgery. Complication rates, including screw misalignments, were minimal and manageable. Patient-reported outcomes showed marked improvement in functional recovery.

CONCLUSIONS

Minimally invasive posterior fixation combined with biportal endoscopic decompression is a safe and effective strategy for managing thoracolumbar fractures with incomplete neurological deficits. The approach offers significant advantages, including enhanced neural decompression, improved clinical and radiological outcomes, and reduced surgical morbidity compared to open surgery. These findings support the broader adoption of MIS techniques in spinal trauma care and provide valuable insights into their application in clinical practice. This study emphasizes the importance of advanced MIS techniques in enhancing patient outcomes and reducing complications in thoracolumbar fracture management.