摘要目的 总结隧道成型法经椎弓根椎体截骨(pedicle subtraction osteotomy,PSO)的技术要点,并探讨其临床效果及相关并发症.方法 收集2012年6月至2017年6月共41例胸腰段陈旧性椎体骨折患者资料,男19例,女22例;年龄37~67岁,平均(60.1±12.7)岁.致伤原因:外伤后非手术治疗15例,手术后失败13例,骨质疏松症13例.损伤节段:T11节段9例、T12 22例、L1 8例、L2 2例.根据随机数字法将患者分为传统PSO治疗组(传统组,21例)和改良PSO治疗组(改良组, 20例).传统组术中采用"蛋壳"技术,改良组术中采用隧道成型技术,将手术分成显露、置钉与后柱复合体的切除、椎体截骨、矫形与植骨共四个步骤.组间对比各步骤的操作时间、出血量及并发症情况.采用疼痛视觉模拟量表(visual ana?logue scale,VAS)评分及Oswestry功能障碍指数问卷(Oswestry disability index,ODI)表评价临床疗效,测量脊柱Cobb角评价后凸畸形矫正情况.结果 41例均获随访,时间12~24个月.传统组总手术时间(273.3±21.1)min,改良组(178.1 ± 12.5)min,差异有统计学意义(t=8.981,P=0.019);置钉与后柱复合体的切除、椎体截骨手术时间的组间比较,差异均有统计学意义(t置钉=4.614,P置钉=0.036;t截骨=9.089,P截骨=0.020).传统组总出血量(1540.3±38.3)ml,改良组(754.4±104.2)ml,差异有统计学意义(t=8.529,P=0.011).置钉与后柱复合体的切除、椎体截骨出血量组间分别对比差异均有统计学意义(t置钉=11.933,P置钉=0.016;t截骨=6.972,P截骨=0.013).传统组术前、术后1周及术后半年Cobb角分别为40.2°±8.9°、12.5°± 6.8°和10.4°±2.5°,改良组为39.5°±6.3°、10.4°±3.5°和9.5°±1.9°,组内对比差异有统计学意义(F改良组=189.573,P改良组=0.021;F传统组=194.699,P传统组=0.029).截骨区骨性融合时间3~6个月,平均4.8个月.传统组术后半年VAS评分和ODI分别为(2.1±0.3)分和(34.1±4.3)分,改良组为(2.2±1.1)分和(28.3±6.8)分,差异均无统计学意义(tVAS=0.218,PVAS=0.050;tODI=0.749, PODI=0.062).改良组术中出现超挖和超欠挖各1例(2/20),术中及时纠正;传统组术中出现硬膜撕裂4例(4/21),术中及时修补.结论 隧道成型技术在改良PSO治疗胸腰段陈旧性骨折中,缩短手术时间,减少术中出血,减少手术并发症,是治疗此类疾病可供选择的手术方式.

abstractsTo summarize the technical points and clinical efficacy of pedicle subtraction osteotomy (PSO) in tunneling and to explore the related complications of this technique. Methods A total of 67 cases of old vertebral fractures of the thoracolumbar region from June 2012 to June 2017 were collected. According to the inclusion and exclusion criteria, a total of 41 cases were included in the study. There were 19 males and 22 females; aged 37-67 years, mean 60.1±12.7 years; 15 cases of non-surgical treatment after trauma, 13 cases of failure after surgery and 13 cases of osteoporosis. Injury segment: 9 cases of T11, 22 cases of T12, 8 cases of L1, 2 cases of LS. Preoperative patients were diagnosed by X?ray, CT plain and 3D reconstruction com?bined with MRI. There were 23 cases of intractable back pain, 16 cases of lower extremity root pain, and 2 cases of intermittent claudication. Patients were divided into the traditional PSO treatment group (21 cases) and modified PSO treatment group (20 per?sons) according to the random number method. The traditional group were treated with the"egg shell"technique, and the im? proved group were treated with tunnel forming technology. The procedure was divided into four steps: exposure (step 1), nail place?ment and resection of the posterior column complex (step 2), vertebral osteotomy (step 3), orthopedics and bone grafting (step 4). The operation time, bleeding volume and complications of each step were compared between the two groups. The clinical efficacy was evaluated using the visual analogue scale (VAS) score and the Oswestry disability index (ODI). The X?ray spine Cobb angle was measured to evaluate the Keloid deformity correction, and the bone graft fusion was observed by CT examination. Results All patients were followed up for 12 to 24 months. The total operation time of the traditional group was 273.3±21.1 min, and the to?tal operation time of the modified group was 178.1±12.5 min, the difference between the two groups was statistically significant (t=8.981, P=0.0019). The differences between the two groups in steps 2 and 3 were statistically significant (t2=4.614, P2=0.036; t3=9.089, P3=0.020). The difference in the total bleeding volume was statistically significant (t=8.529, P=0.011). The differences in the bleeding volume between the two groups in step 2 and step 3 were statistically significant (t2=11.933, P2=0.016; t3=6.972, P3=0.013). The Cobb angles of the traditional group before surgery, 1 week after surgery and half year after surgery were 40.2°±8.9°, 12.5°±6.8°, 10.4°±2.5°, respectively. The Cobb angles of the modified group before surgery, 1 week after operation and half year after surgery were 39.5°±6.3°, 10.4°±3.5°, 9.5°±1.9°, respectively. The differences in the Cobb angle between the preoperative, postoperative 1 week and postoperative half year were statistically significant (Fmodified group=189.573, Pmodified group=0.021; Ftraditional group=194.699, Ptraditional group=0.029). The bone fusion time in the osteotomy area was 3-6 months, with an average of 4.8 months. The VAC and ODI scores of half?year post operation of the traditional group were 2.1±0.3 and 34.1±4.3, and the improved group were 2.2± 1.1 and 28.3±6.8, respectively, and the difference was not statistically significant. In the improved group, there were 1 case of over?excavation and 1 case of over?underexcavation (2/20), which were corrected in time during operation. In the traditional group, 4 cases (4/21) of dural tear occurred during the operation, and were repaired in time. Bone fusion was obtained half a year later. No clinical deaths, and no cases of surgical infection occured. Conclusion Tunnel forming technology is an alternative surgical pro?cedure for treating old fractures of the thoracolumbar region with PSO, which can shorten the operation time, reducd intraoperative bleeding and reduce surgical complications.