胸腰椎骨质疏松性骨折伴后凸畸形的手术方式比较
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摘要
[目的]比较椎体成形术/后凸成形术(PVP/PKP)、后路Ponte截骨椎板间融合术和后路短缩椎弓根截骨术(PSO)治疗胸腰椎骨质疏松性骨折伴有后凸畸形的临床效果。[方法]回顾分析2009年8月～2017年7月行手术治疗的胸腰交界区脊柱骨质疏松性骨折伴后凸畸形患者40例,男8例,女32例,年龄52-86岁。其中,行PVP/PKP 16例,Ponte截骨17例, PSO截骨7例,比较三种手术的临床效果。[结果] PVP/PKP组的手术时间、术中出血量、住院时间及纠正角度最少,PSO组的手术时间、术中出血量最多, PSO组Cobb角纠正角度最好,Ponte组其次。三组患者末次随访时神经功能Frankel分级均较术前改善,三组患者术后VAS评分均较术前减少,但PVP/PKP组有5例(5/16)术后出现疼痛再发甚至加重或出现神经功能症状,影像检查发现后凸畸形进展,给予翻修手术,行前方或后方减压截骨矫形融合内固定术,术后症状缓解。[结论]对于胸腰交界区脊柱骨质疏松性骨折伴后凸畸形的患者,PVP/PKP手术创伤小但翻修率高,Ponte截骨手术总体效果更好,PSO截骨手术能达到更好的矫形效果但创伤更大,应该综合考虑各种因素决定手术方式。
[Objective] To compare the clinical outcomes of percutaneous vertebroplasty or kyphoplasty(PVP/PKP), posterior Ponte osteotomy with interlaminar fusion, and posterior pedicle shortening osteotomy(PSO) for thoracolumbar osteoporotic fractures accompanied with kyphosis deformities. [Methods] A retrospective study was conducted on 40 patients who underwent surgical treatments for thoracolumbar osteoporotic fractures accompanied with kyphosis deformities from July 2009 to August 2017, including 8 males and 32 females, aged 52-86 years. Of them, 16 patients received PVP/PKP, 17 patents underwent Ponte osteotomy and 7 patients were treated with PSO. The clinical consequences were compared among the 3 groups. [Results]Compared among the 3 groups, the PVP/PKP group had the shortest operation time, the least intraoperative blood loss, the shortest hospital stay, and the lowest deformity correction(P<0.05), whereas the PSO group proved the most time consuming and the most bleeding during operation(P<0.05), with a slight better deformity correction than the Ponte group(P<0.05). After operation, the neurological function in term of Frankel index considerably improved in all the 3 groups, additionally the VAS score significantly decreased in the 3 group compared with those before operation. During follow-up, 5 patients(5/16) in the PVP/PKP group presented deteriorating pain, even accompanied with declining neurological function and progress of kyphosis in images, which subsided after revision surgeries of anterior or posterior decompression, corrective osteotomy and instrumented fusion. [Conclusion] The PVP/PKP is of minimizing iatrogenic trauma but a high revision chance, the Ponte osteotomy achieves relatively better overall consequences, while the PSO osteotomy provides better corrective effect but a greater trauma. Various factors should be considered as selecting surgical procedure for thoracolumbar osteoporotic fractures accompanied with kyphosis.
[Objective] To compare the clinical outcomes of percutaneous vertebroplasty or kyphoplasty(PVP/PKP), posterior Ponte osteotomy with interlaminar fusion, and posterior pedicle shortening osteotomy(PSO) for thoracolumbar osteoporotic fractures accompanied with kyphosis deformities. [Methods] A retrospective study was conducted on 40 patients who underwent surgical treatments for thoracolumbar osteoporotic fractures accompanied with kyphosis deformities from July 2009 to August 2017, including 8 males and 32 females, aged 52-86 years. Of them, 16 patients received PVP/PKP, 17 patents underwent Ponte osteotomy and 7 patients were treated with PSO. The clinical consequences were compared among the 3 groups. [Results]Compared among the 3 groups, the PVP/PKP group had the shortest operation time, the least intraoperative blood loss, the shortest hospital stay, and the lowest deformity correction(P<0.05), whereas the PSO group proved the most time consuming and the most bleeding during operation(P<0.05), with a slight better deformity correction than the Ponte group(P<0.05). After operation, the neurological function in term of Frankel index considerably improved in all the 3 groups, additionally the VAS score significantly decreased in the 3 group compared with those before operation. During follow-up, 5 patients(5/16) in the PVP/PKP group presented deteriorating pain, even accompanied with declining neurological function and progress of kyphosis in images, which subsided after revision surgeries of anterior or posterior decompression, corrective osteotomy and instrumented fusion. [Conclusion] The PVP/PKP is of minimizing iatrogenic trauma but a high revision chance, the Ponte osteotomy achieves relatively better overall consequences, while the PSO osteotomy provides better corrective effect but a greater trauma. Various factors should be considered as selecting surgical procedure for thoracolumbar osteoporotic fractures accompanied with kyphosis.
引文
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[3]Sabo A,Hatgis J,Granville M,et al.Multilevel Contiguous Osteoporotic Lumbar Compression Fractures:The Relationship of Scoliosis to the Development of Cascading Fractures[J].Cureus,2017,9(12):e1962.
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[10]Shikata J,Yamamuro T,Iida H,et al.Surgical treatment for paraplegia resulting from vertebral fractures in senile osteoporosis[J].Spine,1990,15(5):485-489.
[11]Uchida K,Kobayashi S,Nakajima H,et al.Anterior expandable strut cage replacement for osteoporotic thoracolumbar vertebral collapse[J].J Neurosurg Spine,2006,4:454-462.
[12]Suk SI,Kim JH,Lee SM,et al.Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture[J].Spine(Phila Pa1976),2003,28:2170-2175.
[13]Kashii M,Yamazaki R,Yamashita T,et al.Surgical treatment for osteoporotic vertebral collapse with neurological deficits:retrospective comparative study of three procedures-anterior surgery versus posterior spinal shorting osteotomy versus posterior spinal fusion using vertebroplasty[J].Eur Spine J,2013,22(7):1633-1642.
[14]Takahasht T,Hanakita J,Kawaoka T,et.al.Indication for partial vertebral osteotomy and realignment in posterior spinal fixation for osteoporotic thoracolumbar vertebral collapse with neurological deficits[J].Neurol Med Chir,2016,56(8):485-492.
[15]Du JP,Fan Y,Liu JJ,et al.The analysis of MSTMOVCF(Multisegment thoracolumbar mild osteoporotic fractures surgery or conservative treatment)based on ASTLOF(the assessment system of thoracolumbar osteoporotic fracture)[J].Sci Rep,2018,8:8185.
[2]Kado DM,Miller-Martinez D,Lui L-Y,et al.Hyperkyphosis,kyphosis progression,and risk of non-spine fractures in older community dwelling women:the study of osteoporotic fractures(SOF)[J].J Bone Miner Res.2014,29(10):2210-2216.
[3]Sabo A,Hatgis J,Granville M,et al.Multilevel Contiguous Osteoporotic Lumbar Compression Fractures:The Relationship of Scoliosis to the Development of Cascading Fractures[J].Cureus,2017,9(12):e1962.
[4]Shota T,Yoshihiro M,Noboru H,et al.Major surgical treatment of osteoporotic vertebral fractures in the elderly:a comparison of anterior spinal fusion,anterior-posterior combined surgery and posterior closing wedge osteotomy[J].Asian Spine J,2014,8(3):322-330.
[5]Huang M-H,Barrett-Connor E,Greendale GA,et al.Hyperkyphotic posture and risk of future osteoporotic fractures:the rancho bernardo study[J].J Bone Miner Res,2006,21(3):419-423.
[6]Munting E.Surgical treatment of post-traumatic kyphosis in the thoracolumbar spine:indications and technical aspects[J].Eur Spine J,2010,19(Suppl 1):69-73.
[7]Kaneda K,Asano S,Hashimoto T,et al.The treatment of osteoporotic posttraumatic vertebral collapse using the Kaneda device and bioactive ceramic vertebral prosthesis[J].Spine,1992,17(Suppl):295-303.
[8]詹世强,周良安,王义生,等.前路手术治疗胸腰段脊柱骨折[J].中国矫形外科杂志,2004,12(10):751-752.
[9]徐冠华,崔志明,李卫东,等.后路截骨矫形手术治疗老年骨质疏松性陈旧胸腰椎骨折伴后凸畸形[J].中国脊柱脊髓杂志,2013,23(2):129-134.
[10]Shikata J,Yamamuro T,Iida H,et al.Surgical treatment for paraplegia resulting from vertebral fractures in senile osteoporosis[J].Spine,1990,15(5):485-489.
[11]Uchida K,Kobayashi S,Nakajima H,et al.Anterior expandable strut cage replacement for osteoporotic thoracolumbar vertebral collapse[J].J Neurosurg Spine,2006,4:454-462.
[12]Suk SI,Kim JH,Lee SM,et al.Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture[J].Spine(Phila Pa1976),2003,28:2170-2175.
[13]Kashii M,Yamazaki R,Yamashita T,et al.Surgical treatment for osteoporotic vertebral collapse with neurological deficits:retrospective comparative study of three procedures-anterior surgery versus posterior spinal shorting osteotomy versus posterior spinal fusion using vertebroplasty[J].Eur Spine J,2013,22(7):1633-1642.
[14]Takahasht T,Hanakita J,Kawaoka T,et.al.Indication for partial vertebral osteotomy and realignment in posterior spinal fixation for osteoporotic thoracolumbar vertebral collapse with neurological deficits[J].Neurol Med Chir,2016,56(8):485-492.
[15]Du JP,Fan Y,Liu JJ,et al.The analysis of MSTMOVCF(Multisegment thoracolumbar mild osteoporotic fractures surgery or conservative treatment)based on ASTLOF(the assessment system of thoracolumbar osteoporotic fracture)[J].Sci Rep,2018,8:8185.