【摘要】［目的］ 總結 骶骨骨摺合並骶神經損傷的診斷與 治療 方法 。［方法］1999～2004年收治骶骨骨摺合並神經損傷患者12例，男9例，女3例。所有患者經詳細體格檢查及X線片、CT、MRI掃描等獲得確診。依據影像學資料進行Denis分型：Ⅰ型2例，Ⅱ型6例，Ⅲ型4例。不同分型採取相應的治療方法：Ⅰ、Ⅱ型骨折先行骨盆牽引等保守治療，觀察4～6周，若症狀改善不顯著則轉為手術治療；Ⅲ型骨折儘早行後路骶椎管減壓神經根探查松解手術；陳舊性Ⅱ、Ⅲ型骨折只要存在神經損傷表現，仍主張手術。共保守治療7例，手術治療5例。［結果］12例患者經6個月～3年隨訪，2例Ⅰ型骨折，6例Ⅱ型骨折患者完全恢復。4例Ⅲ型骨折患者中，1例完全恢復，2例顯著改善，1例略有恢復。［結論］骶骨位置隱蔽，骨折所造成的神經損傷症狀不明顯，臨床容易漏診，需詳細體檢並結合影像學檢查以提高確診率。不同分型骨折可採用不同的治療方法，手術方式以後路骶管減壓骶神經松解為宜，陳舊性骨折只要存在神經損傷症狀就有手術探查必要。
【關鍵詞】骶骨骨折；神經損傷；診斷； 治療
Diagnosis and surgical treatment of sacral fracture accompanied by neurological damage
Abstract：［Objective］To study the diagnosis and treatment of sacral fracture accompanied by neurological damage.［Method］Twelve patients with sacral fracture accompanied by nerve injuries were treated and analyzed during 1999 to 2004,including 9 males and 3 females. Final diagnosis was given according to the evaluation of physical examination,X-ray,CT and MRI examinations. Dennis classification found 2 cases of I type,6 cases of Ⅱ type and 4 cases of Ⅲ types. The surgical approach of these patients were selected according to the Dennis classification,Type Ⅰ and type Ⅱ were treated with conservative methods,and operations were taken if little symptom was no or a little improved. Posterior approach enlargement for sacral nerve canal,exploration and endoneurolysis on sacral nerve were performed on type Ⅲ as early as possible.Old fracture of type Ⅱ and type Ⅲ with neurologic signs had to be operated early.Conservative and operative treatments were taken 7 and 5 respectively.［Result］After six months to three years following up,two cases of Denis type Ⅰ,six cases of Denis type Ⅱ and one in four Denis type Ⅲ cases were recovered completely.Two cases of Denis Ⅲ were improved significantly while one case was improved a little.［Conclusion］The anatomical position of sacrum is not conspicuous and the symptom caused by neurological damage is too tiny to detect.Carefully physical examination combined with image analysis is necessary to elevate the rate of final diagnosis.Different surgical treatments were used to different type of sacral fracture. Posterior approach enlargement for sacral nerve canal and exploration and endoneurolysis on sacral nerve may be an ideal choice to treat sacral fracture accompanied by neurological damage.Nerves injuries is an critical operation indication for delayed sacral fracture.
Key words：sacral fracture; neurological damage;diagnosis; treatment
骶骨骨折在骨盆骨折中約占20％～30％，其中20％～50％合併有神經損傷，由於骶骨解剖位置隱蔽，骨折同時多伴有其他部位的嚴重骨折和器官損傷，且所造成的神經功能缺失也不十分明確，因此容易漏診。本院1999～2004年診治骶骨骨摺合並神經損傷患者12例，現將診治情況報告如下：
1 臨床資料
1．1 一般資料
本組男9例，女3例，年齡19～67歲，平均37歲，致傷原因：高空墜落傷6例，車禍傷5例，重物撞擊傷1例。
合併脾破裂2例，膀胱破裂1例，胸腰椎壓縮骨折2例，骨盆其他部位骨折5例。所有病例均經X線片，CT／MRI檢查證實為骶骨骨折。按Denis分型［1］，Ⅰ型2例，Ⅱ型6例，Ⅲ型4例。4例Ⅲ型骨折中2例為橫形骨折，2例為縱行骨折。12例患者均有程度不等的骶神經根損傷表現：一側或兩側臀部、大腿後側、小腿後外側疼痛麻木，肌力下降，相關部位淺感覺減退或消失。2例存在鞍區麻木，大小便功能障礙。傷後第一時間獲得確診4例，其餘病例均於傷後4～8周才獲確診。
1.2 診治方法
7例保守治療，治療方法包括：骨盆牽引、高壓氧等；5例手術治療(其中Ⅱ型1例，Ⅲ型4例)，手術均經後路骶椎板切開減壓、神經根探查松解，2例患者同時進行了內固定。
2 結 果
12例患者經6個月～3年隨訪，2例Ⅰ型骨折、6例Ⅱ型骨折骶神經損傷症狀均完全恢復，4例Ⅲ型骨折患者中，1例完全恢復，2例症狀顯著改善，但殘留小腿後外側麻木，踝關節跖屈受限，輕度跛行。1例患者術前鞍區麻木，大小便功能障礙，術後1年隨訪，患者鞍區麻木感減輕，大小便功能未恢復，但大便通過肛門口時有感覺。典型病例（圖1、2）。
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