Varma Raghuprasad
L H Hiranandani Hospital, Powai, Mumbai, India.
Fortis Group of Hospitals In Mumbai and Navi Mumbai, Mumbai, India.
Eur Spine J. 2016 Apr;25(4):1117-22. doi: 10.1007/s00586-014-3575-5. Epub 2014 Sep 13.
To evaluate the effect of integrity of dural sac in determining motor neurological recovery in patients with cauda equinal and epiconal injuries in vertebral fractures at thoracolumbar junction.
Thirty-one patients with single-level vertebra fracture over T12-L2 with cauda equinal or epiconal injuries that underwent posterior spinal decompression and stabilization were evaluated in the period between 2006 and 2012. All patients included had motor incomplete ASIA C in neurology and were either Type B or C (AO/Magerl classification) of fracture morphology. Radiologist opinion to confirm the level of conus in MRI was done preoperatively. Intraoperative findings with respect to intactness of dura was noted. All MRI images were postoperatively evaluated by an independent, blinded radiologist for evidence of dural breach caused by the trauma. All participants provided basic demographic data, ambulatory status, and current neurology and received neurologic examination at intervals. The differences in neurologic injury sites and functional walkers in patients with different levels of vertebral injury were analyzed. Receiver operating characteristic curve analysis was used to define the cut-off value of lower extremities motor score (LEMS) in functional walkers and non-walkers. All patients were seen at a postoperative follow-up of minimum 18 months.
Data of the 31 patients were analyzed. Seventeen patients (55%) had epiconus and lumbar roots lesions and 14 (45%) had cauda equina lesions. The injury was at the T12 vertebra in 9 patients (29%), L1 in 12 (39%) and in L2 in 10 patients (32%). Mean LEMS for patients with T12, L1, and L2 fractures were calculated. Fourteen patients had intraoperative findings of intact dura as against 17 patients with dural breach. MRI images when revisited by an independent radiologist by keeping him blind about the intraoperative surgeons findings showed statistically very good interobserver agreement (κ = 0.618) with regard to integrity of the dural sac. Postoperative neurological assessment at minimum 18 months follow-up showed that four out of the 14 patients with intact dura were walkers (28%) whereas of the 17 patients with dural breach, 13 were walkers (82%).
Neurological recovery in cauda equinal and epiconal injuries in thoracolumbar fractures is significantly less likely in an intact dural sac, probably because the dural breach prevents the roots to take as much impact as compared to an intact dural sac.
评估硬脊膜囊完整性对胸腰段椎体骨折马尾神经和圆锥损伤患者运动神经功能恢复的影响。
对2006年至2012年间31例T12 - L2单节段椎体骨折合并马尾神经或圆锥损伤并接受后路脊柱减压及内固定的患者进行评估。纳入的所有患者神经功能均为运动不完全性ASIA C级，骨折形态为B型或C型（AO/Magerl分类）。术前由放射科医生通过MRI确定圆锥水平。记录术中硬脊膜完整性的情况。术后由一名独立的、不知情的放射科医生对所有MRI图像进行评估，以确定创伤导致硬脊膜破裂的证据。所有参与者提供基本人口统计学数据、行走状态和当前神经功能状况，并定期接受神经学检查。分析不同椎体损伤水平患者神经损伤部位和功能性步行者的差异。采用受试者工作特征曲线分析确定功能性步行者和非步行者下肢运动评分（LEMS）的临界值。所有患者术后随访至少18个月。
对31例患者的数据进行分析。17例患者（55%）有圆锥和腰神经根损伤，14例（45%）有马尾神经损伤。损伤位于T12椎体的有9例（29%），L1椎体的有12例（39%），L2椎体的有10例（32%）。计算了T12、L1和L2骨折患者的平均LEMS。14例患者术中发现硬脊膜完整，17例患者存在硬脊膜破裂。一名独立放射科医生在不知道手术医生术中发现的情况下复查MRI图像，结果显示在硬脊膜囊完整性方面观察者间一致性在统计学上非常好（κ = 0.618）。术后至少18个月的神经学评估显示，14例硬脊膜完整的患者中有4例（28%）能够行走，而17例硬脊膜破裂的患者中有13例（82%）能够行走。
胸腰段骨折马尾神经和圆锥损伤中，硬脊膜囊完整时神经功能恢复的可能性显著降低，可能是因为硬脊膜破裂与完整硬脊膜囊相比，使神经根受到的冲击更小。
