Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Autovía A-7 Km 187, 29603 Marbella, Malaga, Spain.
Injury. 2011 Sep;42 Suppl 2:S64-71. doi: 10.1016/j.injury.2011.06.200. Epub 2011 Aug 15.
Surgical treatment of spinal fractures consists of postural reduction and segmental arthrodesis, together with an eventual performance of spinal canal decompression. Spinal arthrodesis consists of the combination of a hardware system for mechanical stabilisation together with a biological substance for enhancement of bone formation. To date, autologous graft is the only biological substance demonstrated to possess osteogenic properties. Cancellous bone graft has greater cellular activity than cortical graft, whereas cortical graft is stronger. Consequently, according to biological and biomechanical properties of autograft, spinal posterior arthrodesis is better enhanced by cancellous autograft, whereas anterior interbody tricortical bone is more suitable for anterior fusion. Allograft does not cause harvesting complications as autograft does, and also its amount is theoretically unlimited; nevertheless the rate of bone fusion facilitated by allograft is far from that enhanced by autograft given that allograft has no osteoprogenitor cells. There is little evidence on the efficacy of demineralised bone matrix for spinal fusion. Bone morphogenetic proteins (BMPs) are in use in spinal surgery, but their exact role with respect to type, dose, and carrier, together with their cost-effectiveness, need further clinical delineation. Calcium phosphate compounds appear to be good as carriers; however, they have no osteoinductive or osteogenic properties. Current clinical literature seem to indicate their usefulness for bony fusion in spinal surgery, when combined with bone marrow aspirate or used as an extender for autologous bone graft. Age, length of fusion, location, and concurrent diseases should be definitive for fusion outcome; papers on spinal arthrodesis should neatly stratify these variables. Unfortunately, since that is not the rule, conclusions drawn from current literature are very unreliable. Autograft remains the gold standard, and cancellous bone is advisable in posterolateral approaches, whereas tricortical iliac crest autograft appears appropriate for interbody support. In longer segments, its expansion with BMPs looks safe at least. Basic knowledge has been achieved from animal experiments, and clinical application of the findings to humans should be done very cautiously; in any case, both anterior and posterior arthrodesis must be protected with instrumentation used according to appropriate biomechanical principles. A combination of failure of the correct graft together with proper instrumentation will result in poorer outcome, even if the right graft is used.
脊柱骨折的手术治疗包括体位复位和节段性关节融合，以及最终进行椎管减压。脊柱关节融合术包括用于机械稳定的硬件系统与用于增强骨形成的生物物质的组合。迄今为止，自体移植物是唯一被证明具有成骨特性的生物物质。松质骨移植物比皮质骨移植物具有更高的细胞活性，而皮质骨移植物更强。因此，根据自体移植物的生物和生物力学特性，脊柱后路关节融合术最好用松质骨自体移植物增强，而前路椎间三皮质骨更适合前路融合。同种异体移植物不会像自体移植物那样引起采集并发症，而且其数量在理论上是无限的；然而，同种异体移植物促进骨融合的速度远低于自体移植物，因为同种异体移植物没有成骨前体细胞。关于脱钙骨基质在脊柱融合中的疗效的证据很少。骨形态发生蛋白 (BMPs) 已用于脊柱手术，但关于其类型、剂量和载体以及成本效益的确切作用仍需要进一步的临床描述。磷酸钙化合物似乎作为载体很好；然而，它们没有成骨或成骨特性。目前的临床文献似乎表明，当与骨髓抽吸液结合使用或用作自体骨移植物的扩展剂时，它们在脊柱手术中的骨融合有用。年龄、融合长度、位置和并存疾病应明确为融合结果；关于脊柱关节融合术的论文应明确分层这些变量。不幸的是，由于并非如此，因此从当前文献中得出的结论非常不可靠。自体移植物仍然是金标准，松质骨适用于后路外侧入路，而三皮质髂嵴自体移植物适用于椎间支撑。在较长的节段中，至少使用 BMP 进行扩展看起来是安全的。从动物实验中已经获得了基础知识，并且应该非常谨慎地将这些发现应用于人类临床；在任何情况下，都必须根据适当的生物力学原则使用器械来保护前后关节融合。如果正确的移植物与适当的器械一起失效，即使使用了正确的移植物，也会导致结果更差。
