NGOAI KHOA SO DAC BIET 1,2,3/2012
DANH GIA KET QUA DIEU TRj CQ NANG OAY NHIEU MANH COT SONG LUNG-THAT LUNG
Vu Tam Trirc*, Nguyin The Luyen*, D6 Phu-ffc Hung*
TOM TAT
Bat van de: Gay nhieu manh (GNM) cot song lUng-that lu'ng (CS L-TL)la loai gay thudng gap nhat cua toan bd viing cot sdng. Bay ludn la de tai thdi sU xet ve khia canh \\Sa chpn phUPng phap dieu tn phau thuat hay bao tdn. Do dd, mot nghien cull tien ciiu ve dieu tri cd nang(DTCN) loai gay nay lai Viet Nam la mdt nhu cau thiet thu'c.
Odi t&dng va ph&dng phap nghien c&u:
Thiet ke nghien ciiu: tien ciiu md ta cat doc.
Nghien ciiu du'dc tien hanh tren cac benh nhan (BN) GNM CSL-TL thudc loai gay vu'ng, khdng cd bien chiTng than kinh, trong do tuoi lao dong dutfc dieu trj tai khoa cot song B tit thang 6 nam 2009 den thang 6 nam 2010. BN du'dc dieu trj bao ton theo phu'dng phap cd nang, bao gom giai doan nam nghi tuyet ddi tai giUdng t i f 6 den 8 tuan ket hdp tap vat ly trj lieu tap manh cd than minh.
Ket qua: Cd 41 BN dUdc nghien ciru vdi thdi gian theo doi trung binh 18 thang, t i le nam/nii': 2 / 1 , dp tuoi trung binh la 40.95± .68 tuoi. Ve giai phau, gdc gii trung binh tang ten 2.6°, til- 15.6° tang Ien 18.2°. Ve chii'c nang cot song, CO 9 5 % BN dat chirc nang rat tot va tdt.
Khong ghi nhan tru'dng hpp nao cd ton thu'Png than kinh t h i i phat nao, cd 1 tru'dng hdp khdng lanh xu'dng.
Kei/uan: Dieu trj cd nang GNM CS-LTL cho thay cd hieu qua tot it nhat trong thdi gian dau sau chan thu'dng. Viec tap luyen cd nang giup cai thien chirc nang cot song sau chan thu'dng.
Ttt'Aftiw.'dieu tn a i nang, gay nhieu manh, cot song luhg-that lutig, manh lui, du'dng kinh ong song, phan loai dy^ tren phan bo liTc Ien ddt sdng gay.
* Bo mon Chan Th&dng Chinh Hinh - Dai Hgc Y D&dc TP HCM S U M M A R Y
EVALUATION OF FUNCTIONAL TREATMENT OF THORACOLUMBAR BURST FRACTURE
Introduction: Thoracolumbar burst fracture keeps the highest percentage of the entire human spine fractures. The Indication of conservative and operative treatment of this kind of injury Is always a debatable topic. Hence, a prospective study focusing on the functional treatment of this fracture in the conditions of Vietnam is a critical need.
Material and method: Design of study: case series; type of study: prospective.
The patients are selected at the Spinal Department B of the Hospital of traumatology- orthopaedy from June 2009 to june 2010. Only those who meet the criteria on inclusion (stable burst fracture without neurologic complication) will follow a functional treatment including a period from 6 to 8 weeks of strict recumbency and a program of physical therapy.
Results: Forty-one patients with a mean age of 40 years and a sex ratio (men/women) of 2/1 are evaluated by a mean of 18 months.
Anatomically, there is an increase of local kyphotic angle of 2.6°, from 15.5" on admission to 18.2° at final follow up. Clinically, there are 95% of cases qualifed excellent and good. There is no cases of late neurologic'deterioration. I n one case, there are clinical and imaging evidences of non union.
Conclusion: Functional treatment of thoracolumbar burst fractures provides a good short-term prognosis. The physical therapy with
373
DAI HQI HOI NGOAI KHOA VN L A N THCT Xll VA HOI NGH[ KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
trunc muscles enhancing excercises does improve the final outcome.
Key words: functional treatment, thoracolumbar burst fractures, Load sharing classification.
I. OATVXNOE
Do nhimg dac diem giai phlu, sinh ly rat dac tnmg ma cac chan thircmg gay, gay trat- dac biet la GNM ciia viing chuyen tiep L-TL (tir Tl 1 den L2) ludn chiem ti le cao nhat trong cac nghien cihi ciia cac tac gia trong [1], [2], [3] va ngoai nude [4], [5], [6], [8], [10],[12]J13],[14].
Viec didu tri loai GNM CSL-TL ludn la mpt van de thdi sir thu hiit sir tranh luan cua cac tac gia ve chpn lira giira dieu tri bao tdn hay phau thuat ddi vdi cac trudng hpp khdng cd bien chiing than kinh. Viec nghien cdu sau ve sinh ca hpc ciia CS L-TL khien cho dieu tri bao tdn ngay cang dat duac nhiing tien bd dang ke. Nhung cdng trinh nghien ciiu cua cac tac gia Mumford [13], Chow [5], Moller [12], Shen va Shen [14] ... dlu cho thiy dieu tri bao tdn an toan va cho ket qua tdt.
Tai Viet Nam, cac tac gia Hoang Tidn Bao, Nguyin Quang Long. TrSn Thanh My... ket luEin dieu tri co nang GNM cho k^t qua chap nhan duoc. Tuy nhien phin ldn cac nghien cim nay deu la md ta cSt ngang hoac hdi ctm va deu duac thuc hien tu thap nien 80 trd ve trudc. Do dd viec nghien ciiu tidn cuu nham danh gia phuang phap dieu tri nay cd cdn phii hap vdi BN Viet Nam hien nay hay khong va nham de xuat nhimg thay ddi, cai tien trong dieu tri la mpt nhu cau thilt thirc
il. odi TUpNG VA PHUONG PHAP NGHIEN COU
Cac BN dugc chin doan xac dinh GNM CS L-TL khdng cd bien chiing than kinh
thuang chinh hinh tir 01/06/2009 d^n 30/06/2010
Tieu chuin chpn benh: BN thudc d6 tu6i lao ddng: nam tir 16 tudi den 60 tudi, nii ti 16 tuoi den 55 tudi, dupe chan doan xac dinh GNM CS L-TL thudc loai gay virng, khong bien chiing than kinh.
Tieu chuan loai trir: gay xucmg benh ly, gay CS kem theo chin thuong co quan khac, cd van de ve tam than khdng cd kha nang thuc hi8n cac chi dan ciia bac sT, BN khong hop tac.
Thiet ke nghien ciru: tiin cdn md ta cSt dpc.
Cdng cu nghien cuurLap hd so benh an theo ddi tir liic nhap vien ddn luc kit thiic nghien ciru, thdi gian theo ddi mdi truong hop tdi thieu la mudi hai thang tinh hi khi chin thucmg.Sd lieu duac phan tich va xir I^
bing chuong trinh STATA 11, Excel 2007.
1. Phu-ffng phap dieu tri cff nang Nhdm nghien ciiu ap dung phuang phdp DTCN ciia Magnus-Bohler, nghia la khong nan chinh va bat ddng d gay ma chi cho BN nam nghi tuyet ddi tai giudng tir 6 den 8 tuan. Trong thdi gian nay, BN khdng dupe ngdi day hay dl dung nhung cd the xoay trd va duac huong dEn tgp cac dpng tac t$p manh co than minh (hinh 1-4). Kit thiic giai doan nghi ngai tai giudng, BN bit dau roi khdi giudng va tap lay lai tim van ddng CS va cac cdng viec ciing nhu sinh hoat hang ngay.
2. Phu'ong phap theo doi va danh gia BN BN dugc theo doi dinh ky mdi 3 thang cho den thdi diem danh gia sau cimg. Tai mdi thdi diem, BN dugc danh gia toan dien ve lam sang (miic dp dau lung, tim van dong cdt sdng, cac bien chiing thin kinh neu c6...) va hinh anh hpc (gdc gii vimg, gdc biin dang than sdng, dp lun cua than ddt, bl day dia dem...). Phim CT scan dugc chup tai thdi
NGOAI KHOA SO DAC BIET 1,2,3/2012
difim nhap vien va sau chin thuong 1 nam, 2 danh gia chuc nang ciia cdt sdng. De danh nam de danh gia dp nat cua than sdng va dien gia dp nat cua than sdng tren CT scan, nhdm tien lanh xucmg cua than song. Nghien cihi nghien cim ap dung bang phan loai dua tren ap dirng bang danh gia Owestry Disability phan bd luc Ien ddt gay (Load sharing Index (ODI) va bang danh gia ciia Denis de classification).
Hinh I. Ddng tac day gdi tap cobung Hinh 2. Ddng tac bac cau tap co limg
Hinh 3. Ddng tac tap ca lung tang tien Hinh 4. Ddng tac tap ca bung tang tien
Bieu do 1. Mdi tuong quan giua goc gu viing va gdc dTa dem.
Biiu dd 2. Mdi tuong quan giua do tang gdc gii vimg va chi sd Load sharing classification.
375
DAI HOI HOI NGOAI KHOA VN LAN THU Xll VA HQI NGHI KHOA HpC NGOAI KHOA TOAN QUOC LAN XIV
i"'
I^A*. .
•ir-
< • ) • . . . . ' ' > •
Hinh 5. Dudng kinh dng sdng: a), tai thdi diem sau chan thuong la 1.1cm (60% dudng kinh ly thuylt) tang Ien 1.4 cm (86% dudng kinh ly thuyet) tai thdi diem 2 nam sau chin thuong b).
III. KET QUA
Cd 41 BN thda tieu chuan chpn benh dugc dilu tri va theo doi tai khoa CSB vdi thdi gian theo ddi trung binh la 18 thang (12- 24 thang). Ty le nam/ nii : 2/1. Dp tudi trung binh la 40.95± .68 tudi. Co che chan thuang thudng gap nhat la te cao (70%) va tai nan giao thdng (20%). Loai gay chiem ti le nhieu nhat la loai IIB (Denis), ddt sdng bi tdn thuang nhilu nhat la dot Ll va L2. Danh gia ket qua dieu tri ve giai phau hpc, sau that gian nghien ciiu trung binh la 18 thang, gdc gii trung binh tang Ien 2.6'', tir 15.6" tang Ien 18.2". Sir gia tang cua gdc gii viing nhu ket qua tren la d miic chap nhan dugc. Dp tang gdc gii viing cd tucmg quan chat che vdi dp nat ciia than ddt danh gia qua chi sd Load sharing classification.Viec tap luyen cac bai tap vat ly tri lieu khdng lam thay ddi dien tien gia tang ciia gdc gii, it nhat la trong thdi gian hai nam dau sau chan thuong.
Ve chiic nang cdt sdng, cd 95% sd BN cd chirc nang CS tir rat tdt den tdt, 5% trung binh. 83% sd BN trd lai cdng viec ban dau, 15% vin lam viec dugc nhung phai ddi cdng viec. 3% phai nghi viec. Chirc nang sau cimg CLia CS lien quan den gidi tinh (chirc nang
chiic nang CS cang kem).Viec tap luyen cac bai tap vat ly tri lieu giiip cai thien chirc nang sau cung ciia CS (sire co lung cang manh (bieu hien bang thdi gian gong co cang lau) thi chiic nang CS cang tdt (bieu hien qua chi sd ODI cang nhd)) . Ket qua nghien ciiu cung cho thay su tu tieu ciia manh liii theo thai gian: dudng kinh dng sdng khi nhap vien la 76.1±15% (so vdi dudng kinh ly thuyet), tai thdi dilm sau cimg la 85.5±11.2% (so vdi dudng kinh ly thuylt) (hinh 5).Ve biin chimg, ngoai hai bien chiing dau lung va gu, trong sd 41 BN nghien cuu cd 1 trudng hpp cd bang chung ve lam sang va hinh anh hpc ciia bien chiing khdng lanh xuong. Khdng co trudng hgp tdn thuang than kinh thii phat nao dugc ghi nhan trong sudt qua trinh nghien cuu.
IV. BAN LUAN
Theo hiiu biet ciia nhdm nghien ciru, day la nghien cuu tien ciiu dau tien tai Viet Nam ve dieu tri co nang GNM CS L-TL.
Viec thilt ke nghien cim tien cuu cho phep theo ddi dien tien theo thdi gian ciia gdc gu va riit ra nhiing kit luan nhu sau: 1). gdc ^ viing giam sau thdi gian nam nghi tuyet doi
NGOAI KHOA SO DAC BIET 1,2,3/2012
dau rai khoi giuong, goc gii tang trong 6 dSn 9 thang diu sau chin thuong, sau do 6n dinh dan; 2). su thay doi cua goc gii viing chu y6u la do su thay doi ciia goc dTa dem "he mo"
them hay "khep lai" (bilu d6 1); 3). su gia ttag cua goc gu viing tuong quan mat thilt vdi do nat cua than song bieu hien thong qua chi s6 Load sharing classification (bilu d6 2);
4).viec tap luyen cac bai tap co nang khong giup ngan ngira diln tien gii, it nhit la trong thoi gian dau sau chan thuang. Nhihig nhan dinh tren phu hop vai nhirng nghien ciru nirdc ngoai va cho thdy gia tri cua bang phan loai Load sharing classification trong viec lira chpn phuong phap dieu tri va tien lucmg dien tiln goc gii theo thai gian.
Ve chuc nang cot song, qua viec so sanh voi cac nghien ciiu nuoc ngoai, kit qua nghien cuu cho thay viec dieu tri ca nang
GNM CS L-TL tai benh vien Chin Thuong Chinh Hinh TPHCM dat kit qua dang khich le, tuong duong vai cac nghien cim nguoc ngoai, it nhat la trong thai gian diu.
Duong kinh 5ng s6ng trong GNM CS L- TL ciing la mpt moi quan tam hang diu vi day dupe xem la mot m6i de dpa cua biin chiing thin kinh. Tuy nhien, cOng nhu cac nghien cuu gin day, kit qua ciia nhom nghien ciiai cho thiy co mpt su tu chinh cua duang kinh ong s6ng bi chen ep bai manh liii theo thai gian dl dan liy lai kich thuoc ban dau (hinh 5), va khi manh lui cang Ion thi sir tu chinh nay dien ra cang nhanh. Sir tu tieu CLia manh liii dien ra dpc lap vai diln tiln cua goc gu. Do do, kich thuac cua manh liii khong nen xem la mpt chi dinh dpc lap ciia dieu tri phau thuat. Dilu nay ciing dupe ghi nhan boi cac tac gia nuoc ngoai [7],[9],[11].
Bang 4.4, Ket qua dieu tri ve mat chiic nang CS cua mdt sd nghien ciiu Tac gia
Mumford [13]
Chow [5]
Shen [14]
Ly Dai [6]
Nhdm NC
Nam
1993
1996
1999
2008
2011
So lifoing BN
41
26
38
127
41
Thiet ke NC
Hoi cu'u
Hoi ciru
Hoi CLTU
Hoi cu'u
Tien cii'u Phu'ong
phap Nep, bpt
than
Nep
CO nang
Nan, bdt, nep
Cd nang
Thdi gian NC
20 nam
34 thang
4 nam
7.2 nam
18 thang
Oau lu'ng 8 8 % khdng dau hoac it dau 7 9 % khdng dau hoac it dau 8 4 % khdng dau hoac it dau 7 1 % khdng dau hoac ft dau 9 5 % khdng dau hoac it dau
Cong viec 90% hi Ijng vdi kha nang lao ddnq 75% quay trd ve cdng viec cu 7 6 % quay t r d ve cdng viec cu 6 1 % quay t r d ve cdng viec cu 8 3 % quay trd ve cdng viec cu
377
DAI HOI HOI NGOAI KHOA VN LAN T H Q Xll VA HOI NGHI KHOA HOC NGOAI KHOA TOAN Q u 6 c LAN XIV
Ve bien chiing, khdng cd trudng hgp nao cd tdn thuang than kinh thii phat sau qua trinh theo doi. Cd 1 trudng hgp cd bang chiing khdng lanh xuong tren lam sang va hinh anh hpc.
V. KET LUAN
Qua nghien ciru ve dieu tri ca nang GNM CS L-TL, cd thi budc dku kit luan rang day la mdt phuang phap dieu tri hieu qua va an toan, it nhat la trong thdi gian dau sau chan thuang. Viec tap luyen co nang he thdng CO than minh giiip cai thien chirc nang CS sau chan thucmg.
Bang phan loai Load sharing classification phan loai gay GNM CS L-TL theo miic dp nat ciia than sdng, do dd giiip chpn lira phuang phap dieu tri bao tdn hay phau thuat, va cd gia tn trong viec tien luong gdc gii.
Dien tien ty nhien cua manh liii la ty tieu bien theo thdi gian, do dd khdng nen xem kich thudc cua manh liii la mpt chi dinh ddc lap cua dieu tri phSu thuat.
TAI UEU THAM KHAO
1. Bill Huy Phung, "Nhan xet vl 382 tnrcmg hop gay kin cot song d ngudi ldn trong vjng 10 nam tai benh vien Binh Dan", Tai lieu khoa hoc benh vien Binh Ddn. 1981.
2. Nguyen Trong Tin, 'Tinh hinh chan thirong opt sdng nguc-thSt lung tai benh vien Chan Thuong chinh Hinh", Hoi nghi thudng nin kit hap : Idn thir XV Hoi Chdn Thuang Chinh Hinh v ldn thu XVI Hoi chinh hinh Nhi. (2008), p. 7.
3. Vo Van Thanh, "Djch te hpc chan thuong cot sdng va tdn thuong cot song Iung-th5t lung", Tdi heu sinh hoat khoa hoc ky ihugl chan thuang chinh hinh so /,(1994).
4. Cantor, J.B., et al., "Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing". Spine (Phila Pa 1976). 18(8), (1993), p. 971-6.
i, Chow, G.H., et al., "Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization". Spine (Phila Pa 1976).
21(18), (1996), p, 2170-5.
