Greenberg Jacob K, Burks Stephen Shelby, Dibble Christopher F, Javeed Saad, Gupta Vivek P, Yahanda Alexander T, Perez-Roman Roberto J, Govindarajan Vaidya, Dailey Andrew T, Dhall Sanjay, Hoh Daniel J, Gelb Daniel E, Kanter Adam S, Klineberg Eric O, Lee Michael J, Mummaneni Praveen V, Park Paul, Sansur Charles A, Than Khoi D, Yoon Jon J W, Wang Michael Y, Ray Wilson Z
1Department of Neurological Surgery, Washington University in St. Louis, St. Louis, Missouri.
2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.
J Neurosurg Spine. 2021 Oct 29;36(4):558-567. doi: 10.3171/2021.7.SPINE21790. Print 2022 Apr 1.
Minimally invasive surgery (MIS) techniques can effectively stabilize and decompress many thoracolumbar injuries with decreased morbidity and tissue destruction compared with open approaches. Nonetheless, there is limited direction regarding the breadth and limitations of MIS techniques for thoracolumbar injuries. Consequently, the objectives of this study were to 1) identify the range of current practice patterns for thoracolumbar trauma and 2) integrate expert opinion and literature review to develop an updated treatment algorithm.
A survey describing 10 clinical cases with a range of thoracolumbar injuries was sent to 12 surgeons with expertise in spine trauma. The survey results were summarized using descriptive statistics, along with the Fleiss kappa statistic of interrater agreement. To develop an updated treatment algorithm, the authors used a modified Delphi technique that incorporated a literature review, the survey results, and iterative feedback from a group of 14 spine trauma experts. The final algorithm represented the consensus opinion of that expert group.
Eleven of 12 surgeons contacted completed the case survey, including 8 (73%) neurosurgeons and 3 (27%) orthopedic surgeons. For the 4 cases involving patients with neurological deficits, nearly all respondents recommended decompression and fusion, and the proportion recommending open surgery ranged from 55% to 100% by case. Recommendations for the remaining cases were heterogeneous. Among the neurologically intact patients, MIS techniques were typically recommended more often than open techniques. The overall interrater agreement in recommendations was 0.23, indicating fair agreement. Considering both literature review and expert opinion, the updated algorithm indicated that MIS techniques could be used to treat most thoracolumbar injuries. Among neurologically intact patients, percutaneous instrumentation without arthrodesis was recommended for those with AO Spine Thoracolumbar Classification System subtype A3/A4 (Thoracolumbar Injury Classification and Severity Score [TLICS] 4) injuries, but MIS posterior arthrodesis was recommended for most patients with AO Spine subtype B2/B3 (TLICS > 4) injuries. Depending on vertebral body integrity, anterolateral corpectomy or mini-open decompression could be used for patients with neurological deficits.
Spine trauma experts endorsed a range of strategies for treating thoracolumbar injuries but felt that MIS techniques were an option for most patients. The updated treatment algorithm may provide a foundation for surgeons interested in safe approaches for using MIS techniques to treat thoracolumbar trauma.
与开放手术相比，微创手术（MIS）技术能有效稳定和减压许多胸腰椎损伤，且发病率和组织破坏程度更低。尽管如此，关于MIS技术在胸腰椎损伤治疗中的广度和局限性，指导意见有限。因此，本研究的目的是：1）确定当前胸腰椎创伤的治疗模式范围；2）整合专家意见和文献综述，制定最新的治疗算法。
向12位脊柱创伤领域的外科医生发送了一份描述10例不同胸腰椎损伤临床病例的调查问卷。使用描述性统计方法总结调查结果，并计算评分者间一致性的Fleiss κ统计量。为制定最新的治疗算法，作者采用了改良的德尔菲技术，该技术纳入了文献综述结果、调查结果以及来自14位脊柱创伤专家组成员的迭代反馈。最终的算法代表了该专家组的共识意见。
12位被联系的外科医生中有11位完成了病例调查，其中包括8位（73%）神经外科医生和3位（27%）骨科医生。对于4例涉及神经功能缺损患者的病例，几乎所有受访者都推荐减压和融合手术，推荐开放手术的比例因病例而异，从55%到100%不等。其余病例的建议则各不相同。在神经功能正常的患者中，通常推荐MIS技术的频率高于开放技术。建议的总体评分者间一致性为0.23，表明一致性一般。综合文献综述和专家意见，最新算法表明MIS技术可用于治疗大多数胸腰椎损伤。在神经功能正常的患者中，对于AO脊柱胸腰椎分类系统亚型A3/A4（胸腰椎损伤分类和严重程度评分[TLICS]为4）损伤的患者，建议采用非融合的经皮器械固定，但对于大多数AO脊柱亚型B2/B3（TLICS>4）损伤的患者，建议采用MIS后路融合术。根据椎体完整性，对于有神经功能缺损的患者可采用前外侧椎体切除或微创开放减压术。
脊柱创伤专家认可多种治疗胸腰椎损伤策略，但认为MIS技术对大多数患者是一种选择。最新的治疗算法可能为有兴趣采用MIS技术安全治疗胸腰椎创伤的外科医生提供基础。
