Alvine Gregory F, Swain James M, Asher Marc A, Burton Douglas C
University of Kansas Medical Center, Kansas City, KS 66160-7387, USA.
J Spinal Disord Tech. 2004 Aug;17(4):251-64. doi: 10.1097/01.bsd.0000095827.98982.88.
The controversy of burst fracture surgical management is addressed in this retrospective case study and literature review.
The series consisted of 40 consecutive patients, index included, with 41 fractures treated with stiff, limited segment transpedicular bone-anchored instrumentation and arthrodesis from 1987 through 1994.
No major acute complications such as death, paralysis, or infection occurred. For the 30 fractures with pre- and postoperative computed tomography studies, spinal canal compromise was 61% and 32%, respectively. Neurologic function improved in 7 of 14 patients (50%) and did not worsen in any. The principal problem encountered was screw breakage, which occurred in 16 of the 41 (39%) instrumented fractures. As we have previously reported, transpedicular anterior bone graft augmentation significantly decreased variable screw placement (VSP) implant breakage. However, it did not prevent Isola implant breakage in two-motion segment constructs. Compared with VSP, Isola provided better sagittal plane realignment and constructs that have been found to be significantly stiffer. Unplanned reoperation was necessary in 9 of the 40 patients (23%). At 1- and 2-year follow-up, 95% and 79% of patients were available for study, and a satisfactory outcome was achieved in 84% and 79%, respectively. These satisfaction and reoperation rates are consistent with the literature of the time.
Based on these observations and the loads to which implant constructs are exposed following posterior realignment and stabilization of burst fractures, we recommend that three- or four-motion segment constructs, rather than two motion, be used. To save valuable motion segments, planned construct shortening can be used. An alternative is sequential or staged anterior corpectomy and structural grafting.
本回顾性病例研究及文献综述探讨了爆裂骨折手术治疗的争议。
该系列包括40例连续患者（含索引病例），从1987年至1994年，共41处骨折采用坚强、节段有限的经椎弓根骨锚定器械及关节融合术治疗。
未发生死亡、瘫痪或感染等重大急性并发症。对于30例术前行计算机断层扫描和术后行计算机断层扫描的骨折患者，椎管受压率分别为61%和32%。14例患者中有7例（50%）神经功能改善，无1例恶化。主要问题是螺钉断裂，41例器械固定骨折中有16例（39%）发生螺钉断裂。正如我们之前所报道的，经椎弓根前路植骨增强显著降低了可变螺钉位置（VSP）植入物断裂。然而，它并不能防止双活动节段结构中Isola植入物断裂。与VSP相比，Isola在矢状面复位方面表现更好，且已发现其结构明显更坚固。40例患者中有9例（23%）需要进行非计划再次手术。在1年和2年随访时，分别有95%和79%的患者可供研究，分别有84%和79%的患者获得了满意的结果。这些满意度和再次手术率与当时的文献一致。
基于这些观察结果以及爆裂骨折后路复位和稳定后植入物结构所承受的负荷，我们建议使用三或四个活动节段结构，而非两个活动节段结构。为了保留宝贵的活动节段，可采用计划内的结构缩短术。另一种选择是分期或分阶段进行前路椎体次全切除和结构性植骨。
