1、煩惱有何懼怕，既然躲不掉，就調好心態與它共存。心向陽光，何懼風霜。茫茫人海你我相遇就是緣分，歡迎下載！TreatmentTreatment of Thoracolumbar Fracture of Thoracolumbar Fracture 胸腰段骨折的治療胸腰段骨折的治療 Byung-Guk Kim1, Jin-Myoung Dan1, Dong-Eun Shin2 1Department of Orthopaedic Surgery, CHA Gumi Medical Center, School of Medicine, CHA University, Gumi, Korea 2Dep

2、artment of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea 22021/4/26Abstract 摘要摘要 The most common fractures of the spine are associated with the thoracolumbar junction. The goals of treatment of thoracolumbar fracture are leading to early mobilization and rehabilita

3、tion by restoring mechanical stability of fracture and inducing neurologic recovery, thereby enabling patients to return to the workplace. However, it is still debatable about the treatment methods. Neurologic injury should be identified by thorough physical examination for motor and sensory nerve s

4、ystem in order to determine the appropriate treatment. 32021/4/26Abstract 摘要摘要 The mechanical stability of fracture also should be evaluated by plain radiographs and computed tomography. In some cases, magnetic resonance imaging is required to evaluate soft tissue injury involving neurologic structu

5、re or posterior ligament complex. Based on these physical examinations and imaging studies, fracture stability is evaluated and it is determined whether to use the conservative or operative treatment. The development of instruments have led to more interests on the operative treatment which saves mo

6、bile segments without fusion and on instrumentation through minimal invasive approach in recent years. It is still controversial for the use of these treatments because there have not been verified evidences yet. However, the morbidity of patients can be decreased and good clinical and radiologic ou

7、tcomes can be achieved if the recent operative treatments are used carefully considering the fracture pattern and the injury severity. 42021/4/26Abstract 摘要摘要 脊柱最常見的骨折幾乎都發生在胸腰段。胸腰段骨折的治療就是通過恢復骨折的機械穩定和神經的恢復來達到早期活動和康復的目的，進而使患者盡早返回工作崗位。 然而在治療方式的選擇上仍然存在著爭議。通過對運動感覺神經系統的檢查確定神經損傷并決定恰當的治療方式。骨折的機械穩定通過X線平片和CT進

8、行評估。一些案例中，需要使用MRI來評估涉及神經結構或者后縱韌帶聯合的軟組織損傷。基于這些查體和影像學檢查，完成對骨折穩定性的評估并且決定是否進行保守治療或者手術治療。 近年來通過微創手段減少了手術節段而不融合，并且節省耗材。因還沒有明確的證據，所以在使用這些治療上仍然存在著爭議，如果手術在斟酌骨折類型和創傷嚴重程度之后進行，病人的手術并發癥可以降低并且可以獲得好的臨床和影像學結果。52021/4/26Introduction 引言引言Ninety percent of all spine fractures are related to the thoracolumbar region 1.

9、 Especially, the majority of thoracolumbar injuries occur at the T11 to L2 level, which is the biomechanically weak for stress 2.The causes of thoracolumbar fracture are different depending on patients age. In younger patients, fracture is more likely to occur due to a high-energy trauma,， such as m

10、otor vehicle accident, motorcycle accident, and falling injury. However, in elderly, even falls from standing position to ground can cause fractures due to osteoporosis and decreased cognition 3,4。62021/4/26Introduction 引言引言Twenty to forty percent of fractures are associated with neurologic injuries

11、 5. If the patients involve in a severe trauma, the complications, such as paralysis and deformity, may occur after that accident. Even if the patients do not experience any complications, there could be limits of daily activities or difficulty to return to work due to chronic pain 6. Therefore, the

12、 appropriate treatment for the thoracolumbar fracture is important.72021/4/26Introduction 引言引言The primary goal of treatment of the thoracolumbar fracture is keeping patients alive,protecting from the further neural damage,， obtaining the stability by reconstructing anatomical alignment of spinal col

13、umns and returning patients to workplace through early mobilization and rehabilitation. These fundamental principles have not been changed for decades. However, it has been ongoing controversy in determining treatment methods until now.82021/4/26Introduction 引言引言百分之九十的脊柱骨折發生在胸腰段。尤其， 胸腰段創傷主要發生在胸11到腰2

14、水平，這一水平是生物力學應力薄弱點。胸腰段脊柱創傷因患者的年齡不同其發生的原因也不盡相同。在年輕的患者中，胸腰段骨折更傾向發生于高能創傷中，例如汽車車禍，摩托車事故以及墜落損傷。然而，在高齡患者中，甚至從站立狀態跌倒都可能會導致骨質疏松性骨折和認知的下降。20%-40%的骨折都會伴隨著神經的損傷。如果病人涉及嚴重的創傷，可能會發生并發癥，例如可能會在事故之后出現癱瘓和畸形。 92021/4/26Introduction 引言引言即使患者沒有發生任何并發癥，仍然會存在慢性疼痛來限制日常活動并很難返回工作崗位。因此，對于胸腰段的脊柱損傷來說恰當的治療是非常重要的。確保病人存活是治療胸腰段脊柱骨折的

15、首要目標，保護神經不受遠期損傷，通過重建脊柱的解剖序列使得椎體獲得穩定并且通過早期的康復功能鍛煉讓患者返回工作崗位。近十年這些治療的基本準則都沒有發生改變。.但是，直到現在在確定治療方案的時候仍然存在著爭議。102021/4/26Discussion 討論討論Stability of thoracolumbar fracture 骨折的穩定性骨折的穩定性Fracture stability 機械穩定性機械穩定性mechanical stability神經穩定性神經穩定性neurological stabilityFracture stability is an important factor

16、 in determining the treatment of thoracolumbar fracture.在確定胸腰段骨折的治療方案中骨折斷段的穩定性是一個非常重要的因素。在確定胸腰段骨折的治療方案中骨折斷段的穩定性是一個非常重要的因素。112021/4/269、 人的價值，在招收誘惑的一瞬間被決定。22.3.2322.3.23Wednesday, March 23, 202210、低頭要有勇氣，抬頭要有低氣。21:20:4521:20:4521:203/23/2022 9:20:45 PM11、人總是珍惜為得到。22.3.2321:20:4521:20Mar-2223-Mar-2212

17、、人亂于心，不寬余請。21:20:4521:20:4521:20Wednesday, March 23, 202213、生氣是拿別人做錯的事來懲罰自己。22.3.2322.3.2321:20:4521:20:45March 23, 202214、抱最大的希望，作最大的努力。2022年3月23日星期三下午9時20分45秒21:20:4522.3.2315、一個人炫耀什么，說明他內心缺少什么。2022年3月下午9時20分22.3.2321:20March 23, 202216、業余生活要有意義，不要越軌。2022年3月23日星期三21時20分45秒21:20:4523 March 202217、一

18、個人即使已登上頂峰，也仍要自強不息。下午9時20分45秒下午9時20分21:20:4522.3.23Discussion 討論討論 Denis將不穩定性的胸腰段脊柱分為三個等級： mechanical instability機械不穩定（一級）機械不穩定（一級） neurological instability神經不穩定（二級）神經不穩定（二級） combined mechanical and neurologic instability機械合并神經不穩定（三級）機械合并神經不穩定（三級） 132021/4/26Discussion 討論討論The mechanical stability of

19、 thoracolumbar spine is evaluated by whether posterior ligament complex (PLC)評估胸腰段脊柱的機械穩定性是由后縱韌帶復合（評估胸腰段脊柱的機械穩定性是由后縱韌帶復合（PLC）是）是否受到損傷決定的否受到損傷決定的 PLC組成： SSL：Supraspinous ligament 棘上韌帶 ISL：Interspinous ligament 棘間韌帶 Capsule of the facet joint 小關節囊 ligamentum flavum 黃韌帶142021/4/26Discussion 討論討論Classif

20、ication of thoracolumbar fracturesDenis分型分型McAfee分型分型AO分型分型Thoracolumbar Injury Severity Score/Thoracolumbar Injury Classification and Severity Score (TLISS)/ (TLCIS)152021/4/26Discussion 討論討論前柱前柱:前縱韌帶、椎體前1/2和椎間盤的前部;中柱中柱:后縱韌帶、椎體后1/2及椎間盤的后部;后柱后柱:椎弓、黃韌帶、椎間小關節和棘間韌帶。162021/4/26Discussion 討論討論compression

21、 fracture壓縮骨折burst fracture爆裂骨折 flexion-distraction injury (seat-belt injury)屈曲牽張損傷（安全帶傷） fracture-dislocation骨折脫位Denis classified thoracolumbar fractures into 4 categories172021/4/26Discussion 討論討論wedge compression fracture楔形壓縮骨折stable burst fracture穩定型爆裂骨折，unstable burst fracture不穩定型爆裂骨折Chance fracture機會骨折flexion-distraction injury and translational injury屈曲分離損傷以及水平位移損傷 McAfee et al. divided thoracolumb