本文選題：骨盆后環(huán)骨折 + 腰骶叢��； 參考：《山東大學》2015年碩士論文

【摘要】：目的：1、探討骨盆后環(huán)骨折合并腰骶叢損傷的臨床特點；2、探討骨盆后環(huán)骨折合并腰骶叢損傷的診斷策略；3、總結(jié)分析我院近年來接診的骨盆后環(huán)骨折合并腰骶叢損傷的不同治療方式效果,得出最恰當治療方案。對象與方法：2005年1月至2013年1月,山東省立醫(yī)院創(chuàng)傷骨科共收治205例骨盆骨折患者,其中43例患者被診斷出骨盆后環(huán)骨折合并腰骶叢損傷。男28例,女15例；年齡16-58歲,平均36.3歲。受傷原因：車禍傷28例,重物砸傷2例,墜落傷6例,爆炸傷1例,碾壓傷6例。骨盆骨折按Tile分型：A型3例,B型15例,C型25例；按骨盆后環(huán)骨折部位分類：髂骨翼骨折3例,骶髂關(guān)節(jié)骨折9例,骶骨骨折31例；骶骨骨折按Denis分型：Denis Ⅰ型2例,Denis Ⅱ型13例,Denis Ⅲ型16例。其中閉合性骨盆骨折39例,開放性骨盆骨折4例,陳舊型骨盆骨折7例。ISS評分16-43分,平均22.2分。所有患者按照骨盆急救流程處理,待其病情穩(wěn)定后,綜合患者臨床癥狀、體格檢查、影像學檢查結(jié)果確立診斷,然后根據(jù)其會陰和下肢感覺障礙區(qū)、運動障礙進行腰骶叢神經(jīng)根損害節(jié)段定位,根據(jù)AISA脊髓損傷評分標準對患者下肢進行感覺評分和運動評分。11例患者行神經(jīng)損害保守治療,32例患者行神經(jīng)減壓松解術(shù),其中單純前路減壓10例,單純后路減壓17例,前后聯(lián)合入路減壓5例。36例行骨折復(fù)位固定,其中外固定架固定4例(2例外固定架為終極固定,2例二期行髂腰固定),后路“M”形鋼板內(nèi)固定5例,髂腰固定13例,骶髂前路重建雙鋼板固定9例,骶髂螺釘固定5例,同時前環(huán)固定15例。結(jié)果：(1)骨盆后環(huán)骨折合并腰骶叢損傷臨床特點43例腰骶叢損傷患者出現(xiàn)會陰和下肢功能障礙,或表現(xiàn)為會陰及下肢區(qū)域感覺障礙,或表現(xiàn)為下肢運動障礙及膀胱、肛周括約肌功能障礙,或二者同時存在。52側(cè)肢體出現(xiàn)感覺障礙,9例患者(神經(jīng)減壓松解組8例、神經(jīng)保守治療組1例)出現(xiàn)雙側(cè)下肢感覺障礙,減壓松解組3側(cè)和保守治療組1側(cè)下肢出現(xiàn)放射性疼痛。其中單純腓總神經(jīng)損傷感覺障礙表現(xiàn)15側(cè)(28.85%),腓總神經(jīng)合并脛神經(jīng)損傷感覺障礙表現(xiàn)30側(cè)(57.69%),股神經(jīng)損傷感覺障礙6側(cè)(11.54%),股后皮神經(jīng)損傷感覺障礙21側(cè)(40.38%)。L2-S2節(jié)段神經(jīng)感覺支受損,其中L2神經(jīng)根損傷5側(cè)(9.61%),L3節(jié)段神經(jīng)根損傷5側(cè)(9.61%),L4節(jié)段神經(jīng)根損傷6側(cè)(11.54%),L5節(jié)段神經(jīng)根損傷26側(cè)(50.00%),S1節(jié)段神經(jīng)根損傷31側(cè)(59.61%),S2神經(jīng)根損傷21側(cè)(40.38%)。48側(cè)肢體出現(xiàn)運動障礙,9例患者(神經(jīng)減壓松解組8例、神經(jīng)保守治療組1例)出現(xiàn)雙側(cè)下肢運動障礙。其中單純腓總神經(jīng)支配肌肉肌力下降11側(cè)(22.92%),腓總神經(jīng)合并脛神經(jīng)支配肌肉肌力下降30側(cè)(62.50%),股神經(jīng)支配肌肉肌力下降5側(cè)(10.42%),臀上神經(jīng)支配臀中肌、臀小肌肌力下降2側(cè)(4.17%)。L2-S1節(jié)段神經(jīng)運動支受損,其中L2節(jié)段神經(jīng)根損傷5側(cè)(10.42%),L3節(jié)段神經(jīng)根損傷5側(cè)(10.42%),L4節(jié)段神經(jīng)根損傷24側(cè)(50.00%),L5節(jié)段神經(jīng)根損傷25側(cè)(52.08%),S1神經(jīng)根損傷30側(cè)(62.50%)。18例(41.86%)患者出現(xiàn)鞍區(qū)感覺障礙、膀胱、肛周括約肌功能障礙等馬尾神經(jīng)損傷表現(xiàn),表現(xiàn)為大小便失禁、性功能障礙。(2)保守治療與神經(jīng)減壓松解腰骶叢損傷的臨床效果對比減壓松解組患者術(shù)中發(fā)現(xiàn)腰骶叢神經(jīng)均受損,其中骶管內(nèi)骨質(zhì)壓迫神經(jīng)13例,骶孔狹窄變形4例,腰骶干被骨折塊、骨痂壓迫9例,骨折縫隙卡壓腰骶干1例,骶管內(nèi)骨質(zhì)壓迫神經(jīng)合并腰骶干被骨塊壓迫5例,合并神經(jīng)受牽拉而變細8例,合并部分神經(jīng)根撕脫性損傷5例。術(shù)后患者手術(shù)刀口均獲得一期愈合,未發(fā)生皮膚壞死和感染,無醫(yī)源性神經(jīng)損傷發(fā)生。40例(減壓松解組30例、保守治療組10例)患者獲得隨訪,隨訪時間12-46個月,平均18個月。35患者骨折獲得臨床愈合,愈合時間8-15周,平均10.8周;1例外固定架終極固定患者骨盆畸形愈合,患側(cè)肢體比對側(cè)肢體出現(xiàn)短縮2cm。根據(jù)ASIA脊髓損傷評分標準,神經(jīng)保守治療組患者入院時患肢感覺評分平均為30.77分,隨訪患肢感覺評分平均為33.08分,感覺評分增量平均為2.13分；減壓松解組患者入院時患肢感覺評分平均為29.69分,隨訪患肢感覺評分平均為34.46分,感覺評分增量平均為4.77分；兩組樣本感覺評分增量均數(shù)t檢驗示有統(tǒng)計學意義。根據(jù)ASIA脊髓損傷評分標準,神經(jīng)保守治療組患者入院時患肢運動評分平均為18.80分,隨訪患肢運動評分平均為21.13分,運動評分增量平均為2.33分；減壓松解組患者入院時患肢運動評分平均為16.18分,隨訪患肢運動評分平均為22.63分,運動評分增量平均為6.45分；兩組運動評分增量樣本均數(shù)t檢驗示存在統(tǒng)計學意義,減壓組運動評分增量高于非減壓組。綜合考慮腰骶叢神經(jīng)下肢功能,根據(jù)英國醫(yī)學研究院神經(jīng)外科學會提出的MCRR標準,末次隨訪保守治療組神經(jīng)功能恢復(fù)情況：優(yōu)4側(cè),良4側(cè),可2側(cè),差1側(cè),優(yōu)良率為72.73%。減壓松解組神經(jīng)功能恢復(fù)情況：優(yōu)19側(cè),良12側(cè),可5側(cè),差2側(cè),優(yōu)良率81.58%。減壓組優(yōu)良率(82.05%)和非減壓組優(yōu)良率(70.00%)之間無明顯統(tǒng)計學差異(P=0.405)。18例鞍區(qū)感覺減退合并膀胱、肛周功能括約肌、性功能障礙患者,完全恢復(fù)9例,部分恢復(fù)5例,無恢復(fù)4例。結(jié)論：1、骨盆后環(huán)骨折合并腰骶叢損傷其損傷平面在骨盆,臨床表現(xiàn)為80%患腓總神經(jīng)損傷癥狀,約60%合并脛神經(jīng)損傷癥狀,約40%患馬尾神經(jīng)損傷表現(xiàn),偶有股神經(jīng)損傷癥狀。腰骶叢神經(jīng)根損傷主要集中于L4-S2,L4運動支損傷幾率遠遠高于L4感覺支損傷幾率。2、骨盆后環(huán)出現(xiàn)骨折時,一旦出現(xiàn)上述癥狀,應(yīng)仔細查看患者CT,確定是否存在骨質(zhì)壓迫神經(jīng)的可能,如有疑慮,進一步行MR檢查或肌電圖。結(jié)合臨床癥狀,正確診治腰骶叢是否損傷并對損傷水平定位。3、對損傷的腰骶叢進行探查減壓,其神經(jīng)恢復(fù)效果整體上未優(yōu)于保守治療。但對于腰骶叢損傷患者的感覺功能評分以及運動功能評分提升量,減壓松解組優(yōu)于保守治療組(P0.05)。
[Abstract]:Objective: 1, to explore the clinical characteristics of posterior pelvic ring fracture combined with lumbosacral plexus injury; 2, to explore the diagnostic strategy of posterior pelvic ring fracture combined with lumbosacral plexus injury; 3, to summarize and analyze the effect of different treatment methods on posterior pelvic ring fracture combined with lumbosacral plexus injury in our hospital in recent years. The object and method: 1 in 2005. From month to January 2013, 205 cases of pelvic fracture were treated in Shangdong Province-owned Hospital trauma department of orthopedics, of which 43 patients were diagnosed with posterior pelvic ring fracture combined with lumbosacral plexus injury. 28 cases were male, 15 women, 16-58 years old and 36.3 years old. The cause of injury: 28 cases of accident injury, 2 cases of heavy weight injury, 1 falling injuries, 1 cases of explosion injury, 6 cases of roller injury. Tile classification: 3 cases of type A, 15 cases of type B, 25 cases of type C; classification of fracture site of posterior pelvic ring: 3 cases of iliac wing fracture, 9 cases of sacroiliac joint fracture, 31 cases of sacral fracture, 2 cases of Denis I, 13 cases of Denis II, 16 cases of Denis type III, 9 closed pelvic fractures, 4, obsolete type of open pelvic fracture. The.ISS score of 7 cases of pelvic fracture was 16-43 points, with an average of 22.2 points. All patients were treated according to the pelvic emergency procedure. After the disease was stable, the clinical symptoms, physical examination, and imaging findings of the patients were diagnosed, and then the segmental location of the lumbosacral plexus nerve root damage was made according to the perineal and lower extremities, and the segment of the lumbosacral plexus nerve root damage was located, according to AISA The score of the spinal cord injury score and the score of the lower extremities of the patients were treated with the conservative treatment of nerve damage in.11 patients. 32 patients underwent decompression of nerve decompression, including 10 cases with simple anterior decompression, 17 cases with simple posterior decompression and 5 cases of.36 routine fracture reduction and fixation, including 4 external fixators (2 exceptions). The final fixation was the ultimate fixation, 2 cases were fixed in two stages of ilium and lumbar fixation, 5 cases of internal fixation with "M" shaped plate, 13 cases of iliac lumbar fixation, 9 cases of double plate fixation of sacroiliac anterior approach, 5 sacroiliac screw fixation and 15 cases with anterior ring fixation. Results: (1) the clinical characteristics of posterior pelvic ring fracture combined with lumbosacral plexus injury, 43 cases of lumbosacral plexus injury patients appeared perineal and lower extremities. Dysfunction, or manifested as perineal and lower extremities sensory disorders, or manifested as lower extremity dyskinesia and bladder, perianal sphincter dysfunction, or the simultaneous presence of.52 side limbs in the two cases, 9 cases (8 cases of neurodecompression and 1 cases of neuroconservative treatment group) with bilateral lower limb sensation disorder, 3 sides of decompression and release group, and 3 sides and protection. In the 1 sides of the treatment group, 1 sides of the lower extremities had radioactivity pain, of which 15 sides (28.85%) were found in the simple peroneal nerve injury sensation disorder, 30 side (57.69%), 6 side (11.54%) of the sensory barrier of the femoral nerve injury, and 21 (40.38%).L2-S2 segments of the posterior femoral cutaneous nerve injury, of which the nerve sensory branches were damaged, of which L2 Nerve root injury in 5 sides (9.61%), nerve root injury in L3 segment 5 sides (9.61%), nerve root injury in L4 segment 6 side (11.54%), nerve root injury in 26 side of L5 segment (50%), nerve root injury in 31 side (59.61%), S2 nerve root injury in 21 side (40.38%).48 side limbs, 9 cases (nerve decompression group 8 cases, conservative treatment group of nerve conservative treatment group) The muscle strength of the simple peroneal nerve was decreased by 11 sides (22.92%), the muscle strength of the peroneal nerve combined with the tibial nerve decreased by 30 sides (62.50%), the muscle strength of the femoral nerve innervated by 5 sides (10.42%), the superior gluteal superior gluteal muscle, and the muscle strength of the gluteus minimus decreased in 2 sides (4.17%).L2-S1 segment of the nerve motor branch. 5 sides (10.42%) of nerve root injury in middle L2 segment, 5 sides of nerve root injury in L3 segment, 24 side of nerve root injury in L4 segment (50%), 25 side of nerve root injury in L5 segment (52.08%), and 30 side of S1 nerve root injury (62.50%).18 cases (62.50%), patients with saddle area sensation disorder, bladder, perianal sphincter dysfunction, and so on. Clinical effects of urinary incontinence and sexual dysfunction. (2) comparison of the clinical effects of conservative treatment and decompression of the lumbosacral plexus injury, the lumbar and sacral plexus injuries were found in the decompression group, including 13 cases of sacral compression, 4 cases of sacral stenosis, 9 cases of lumbosacral fracture, 9 cases of callus compression, 1 cases of lumbosacral pressure in the fracture crevice, sacral canal. 5 cases of internal osteoponial compression combined with lumbosacral trunk were compressed by lumbosacral lump, 8 cases with nerve distraction and 5 cases of avulsion of nerve root, 5 cases were combined with partial nerve root avulsion injury. The postoperative patients were all healed, without skin necrosis and infection, no iatrogenic nerve injury occurred in.40 cases (30 cases of decompression release group and 10 cases of conservative treatment group). The follow-up time was 12-46 months, the average 18 months of.35 patients were healed, the healing time was 8-15 weeks, an average of 10.8 weeks. 1 cases with the ultimate fixator were healed, the side limb was compared with the side limb, 2cm. was based on the ASIA spinal cord injury score, and the patients in the nerve conservative treatment group were admitted to the hospital. The average of 30.77 points was 33.08, the average of sensory score was 2.13, the average of the sensory score was 29.69, the average of the patients was 34.46, the increment of sensory score was 4.77, and the increment of sensory score in two groups of samples was t test. According to the ASIA spinal cord injury score standard, the average of the limb movement score of the patients in the conservative treatment group was 18.80, the average of the follow-up limb movement score was 21.13, the average of the exercise score was 2.33. The average of the limb movement score of the patients in the decompression group was 16.18, and the average of the follow-up limb movement score was 2. 2.63 points, the average increment of the exercise score was 6.45, and the average number of incremental samples in the two groups was statistically significant. The increment of the exercise score in the decompression group was higher than that of the non decompression group. The MCRR standard of the lumbosacral plexus and the lower limb of the lumbosacral plexus was taken into consideration, according to the standard of the Department of Neurosurgery Institute of the Institute of medical research of the British Medical Institute and the last follow-up of the conservative treatment group. Functional recovery: excellent 4 sides, good 4 sides, 2 sides, 1 sides, excellent rate of 72.73%. decompression group nerve function recovery: excellent 19 side, good 12 side, 5 side, poor 2 side, excellent rate of 81.58%. decompression group (82.05%) and non decompression group (70%) without significant statistical difference (P=0.405).18 case saddle area hyposensory combined bladder, 9 cases of anal functional sphincter and sexual dysfunction were recovered completely, 5 cases recovered partially and 4 cases were not recovered. Conclusion: 1, the posterior pelvic ring fracture combined with lumbosacral plexus injury in the pelvis, the clinical manifestation is that 80% of the peroneal nerve injury symptoms, about 60% combined with the tibial nerve injury symptoms, about 40% of the cauda equina injury, and occasional shit lesion Injury symptoms. Lumbosacral plexus nerve root damage is mainly concentrated in L4-S2, L4 motor branch damage is far higher than the risk of L4 sensory injury risk.2, when the pelvic posterior ring fracture, once the symptoms of the pelvic posterior ring, should be carefully examined the patient CT, determine whether there is the possibility of bone compression of the nerve, if there is doubt, further MR examination or electromyography. Combined clinical Symptoms, correct diagnosis and treatment of lumbosacral plexus damage and location of the damage level.3, the damaged lumbosacral plexus are explored and decompressed, and the effect of nerve recovery is not better than conservative treatment on the whole. But for the sensory function score of the patients with lumbosacral plexus injury and the improvement of motor function score, the decompression and release group is better than the conservative treatment group (P0.05).

【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R687.3

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本文編號：1876053