Jaiswal Nitin K, Kumar Vishal, Puvanesarajah Varun, Dagar Ashish, Prakash Mahesh, Dhillon Mandeep, Dhatt Sarvdeep S
Department of Orthopaedic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
World Neurosurg. 2020 Oct;142:e413-e419. doi: 10.1016/j.wneu.2020.07.069. Epub 2020 Jul 18.
Surgical management of burst fractures is controversial, with many different operative options. From a posterior approach, decompression of the spinal cord can be performed through both indirect and direct methods, the former relying on ligamentotaxis. It is unclear whether indirect decompression with ligamentotaxis is as effective as direct decompression.
Prospective, randomized controlled data were retrospectively analyzed to include only burst fractures of the thoracolumbar junction. Patients were treated with either direct decompression, involving wide posterior decompression in addition to operative stabilization, or indirect decompression, where decompression was performed solely through ligamentotaxis. Patients were followed up at 6 months with clinical assessment and imaging. Additional clinical assessment was performed at 1 year. For all analyses, P < 0.05 was significant.
The study included 46 patients, with 18 patients in the direct decompression subgroup and 28 patients in the indirect decompression subgroup. The average age of the full cohort was 35.1 ± 13.1 years (range, 16-60 years). Most patients had L1 fractures (21/46; 46%), with an AOSpine classification type A4 fracture morphology (17/46; 37%), and were American Spinal Injury Association grade B (18/46; 39%). Both treatments resulted in similar increases in canal diameter and decreases in dural sac compromise (P > 0.5) at 6-month follow-up. Both treatments resulted in similar grades of neurological improvement (P = 0.575) at 1 year.
There were no significant differences in clinical and imaging outcomes when comparing direct decompression with ligamentotaxis. Ligamentotaxis alone may be effective in carefully selected cases.
爆裂骨折的手术治疗存在争议，有多种不同的手术选择。从后路入路，可通过间接和直接方法进行脊髓减压，前者依靠韧带整复。目前尚不清楚韧带整复间接减压是否与直接减压同样有效。
对前瞻性随机对照数据进行回顾性分析，仅纳入胸腰段交界处的爆裂骨折患者。患者接受直接减压治疗（除手术稳定外还包括广泛后路减压）或间接减压治疗（仅通过韧带整复进行减压）。在6个月时对患者进行临床评估和影像学随访。1年时进行额外的临床评估。所有分析中，P<0.05具有统计学意义。
该研究纳入46例患者，直接减压亚组18例，间接减压亚组28例。整个队列的平均年龄为35.1±13.1岁（范围16 - 60岁）。大多数患者为L1骨折（21/46；46%），AOSpine分类为A4型骨折形态（17/46；37%），美国脊髓损伤协会分级为B级（18/46；39%）。在6个月随访时，两种治疗方法在椎管直径增加和硬脊膜囊受压减轻方面效果相似（P>0.5）。1年时，两种治疗方法在神经功能改善程度上相似（P = 0.575）。
比较直接减压与韧带整复时，临床和影像学结果无显著差异。在精心挑选的病例中，单纯韧带整复可能有效。
