Mohamad Nasrul Hanif, Salim Azizul Akram, Yusof Mohd Imran, Khoh Phaik Shan, Lim Han Sim, Bahrin Zairul, Sadagatullah Abdul Nawfar
Department of Orthopaedics, Universiti Sains Malaysia School of Medical Sciences, Kubang Kerian, MYS.
Department of Orthopaedics, Hospital Universiti Sains Malaysia, Kota Bharu, MYS.
Cureus. 2024 Jul 11;16(7):e64351. doi: 10.7759/cureus.64351. eCollection 2024 Jul.
Introduction Spine fracture in association with traumatic dural tear is a serious injury. A traumatic dural tear is difficult to determine based on initial clinical presentation and radiological imaging even with magnetic resonance imaging (MRI). However, during decompression surgery, cerebrospinal fluid leaks surrounding the injured segments are usually confirmed by directly visualizing them. For preoperative planning and intraoperatively limiting further damage to the dural and neurological structures, early detection of traumatic dural tears before surgery is important. This study aims to determine the prevalence, implication, risk factors, and complications of traumatic dural tears in patients who have undergone surgical treatment for thoracic and lumbar fractures. We believe our retrospective study would identify more accurate risk factors for traumatic dural tears and aid us with preoperative planning and operative precaution. Methods This study retrospectively included all patients who had thoracic and lumbar fractures and had posterior instrumentation and decompression surgery at three hospitals in the Northern region of Malaysia from January 2018 to December 2020. Fractures associated with pathological spine including metastatic, severe osteoporosis, ankylosing spondylitis, metabolic bone disease, those with missing data, and iatrogenic dural tears were excluded from this study. Preoperative and postoperative neurological assessments based on the American Spinal Injury Association (ASIA) impairment scale, blood loss volume, duration of the surgery, and post-surgery complications were gathered from medical records. Interpedicular distance, ratio of central canal diameter, laminar fracture gap, and pedicle fractures were identified and measured. The obtained data was analyzed using Pearson's chi-square and Fisher's exact test for categorical variables, and independent t-test/Mann-Whitney test for numerical variables. Result This study comprised a total of 93 patients who had fractures in their thoracic and lumbar regions. The mean age of the patients was 38 years. The number of patients with traumatic dural tears was 20 (21.5%). There was an association between the presence of dural tears and preoperative neurological deficits (P<0.001). Wider mean interpedicular distance (P=0.004), increased central canal diameter ratio (P<0.001), and displaced laminar fracture (P<0.001) were significantly higher in patients with traumatic dural tears. Multiple logistic regression analysis showed both incomplete (P=0.002) and complete (P=0.037) preoperative neurological deficit, increase of central diameter ratio of encroachment (P=0.011), and presence of >2mm laminar fracture gap (P=0.015) had a significant association with a traumatic dural tear. This study found that patients with traumatic dural tears had longer surgical times and statistically larger mean blood loss volumes when compared to patients without dural tears (P<0.001). There is no significant association between the complications following the surgery and the presence of a dural tear (P>0.05). Conclusion This study shows that the presence of preoperative neurological deficits, wider interpedicular distance, severe canal encroachment, and wide separation of laminar fracture may indicate the likelihood of traumatic dural tear in spine fracture. These factors will enable surgeons to enhance their operational planning and make early preparations for the management of dural tears.
引言 伴有外伤性硬脊膜撕裂的脊柱骨折是一种严重损伤。即使借助磁共振成像(MRI),外伤性硬脊膜撕裂也很难根据初始临床表现和影像学检查来确定。然而,在减压手术过程中,通常可通过直接观察来确认损伤节段周围的脑脊液漏。对于术前规划以及术中限制对硬脊膜和神经结构的进一步损伤而言,术前早期发现外伤性硬脊膜撕裂很重要。本研究旨在确定接受胸腰椎骨折手术治疗患者中外伤性硬脊膜撕裂的发生率、影响、危险因素及并发症。我们相信,我们的回顾性研究将能找出更准确的外伤性硬脊膜撕裂危险因素,并有助于我们进行术前规划和采取手术预防措施。
方法 本研究回顾性纳入了2018年1月至2020年12月在马来西亚北部地区三家医院接受胸腰椎骨折手术且进行后路内固定和减压手术的所有患者。本研究排除了与病理性脊柱相关的骨折,包括转移性、重度骨质疏松、强直性脊柱炎、代谢性骨病、数据缺失者以及医源性硬脊膜撕裂。从病历中收集基于美国脊髓损伤协会(ASIA)损伤量表的术前和术后神经功能评估、失血量、手术时长及术后并发症情况。确定并测量椎弓根间距、中央管直径比、椎板骨折间隙及椎弓根骨折情况。对获得的数据进行分析,分类变量采用Pearson卡方检验和Fisher精确检验,数值变量采用独立t检验/曼-惠特尼检验。
结果 本研究共纳入93例胸腰椎骨折患者。患者的平均年龄为38岁。外伤性硬脊膜撕裂患者有20例(21.5%)。硬脊膜撕裂的存在与术前神经功能缺损之间存在关联(P<0.001)。外伤性硬脊膜撕裂患者的平均椎弓根间距更宽(P=0.004)、中央管直径比增加(P<0.001)以及椎板骨折移位(P<0.001)情况显著更高。多因素logistic回归分析显示,术前不完全(P=0.002)和完全(P=0.037)神经功能缺损、中央侵占直径比增加(P=0.011)以及存在大于两毫米的椎板骨折间隙(P=0.015)均与外伤性硬脊膜撕裂存在显著关联。本研究发现,与无硬脊膜撕裂的患者相比,外伤性硬脊膜撕裂患者的手术时间更长,平均失血量在统计学上更大(P<0.001)。术后并发症与硬脊膜撕裂的存在之间无显著关联(P>0.05)。
结论 本研究表明,术前神经功能缺损、椎弓根间距更宽、严重椎管侵占及椎板骨折分离较宽可能提示脊柱骨折中外伤性硬脊膜撕裂的可能性。这些因素将使外科医生能够改进手术规划,并为硬脊膜撕裂的处理尽早做好准备。