可注射骨水泥强化椎弓根螺钉治疗骨质疏松性胸腰椎爆裂骨折的临床疗效
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摘要
背景:胸腰椎爆裂骨折的手术治疗常采用椎弓根螺钉内固定术,而老年患者由于骨质疏松易发生螺钉固定不牢靠,出现螺钉松动、退钉,造成固定失败。目的:探讨应用可注射骨水泥强化椎弓根螺钉内固定术治疗骨质疏松性胸腰椎爆裂骨折的临床疗效。方法:选取2014年1月至2015年9月西安交通大学医学院附属红会医院收治的骨质疏松性胸腰椎爆裂骨折患者56例,均采用可注射骨水泥强化椎弓根螺钉后路钉棒内固定术。记录患者术前及末次随访美国脊柱损伤协会(ASIA)神经功能分级,测量并比较患者术前、术后7 d、末次随访疼痛视觉模拟评分法(VAS)评分、Oswestry功能障碍指数(ODI)评分、伤椎椎体前后缘压缩率、后凸Cobb角。结果 :所有患者均顺利完成手术。术中无神经损伤发生,骨水泥无明显渗漏,骨折复位满意,术后神经功能较术前明显恢复。术后随访12~24个月,末次随访X线及CT检查示,椎体骨折愈合良好,内固定位置良好,未见螺钉松动、断钉。患者术后7 d、末次随访VAS评分、ODI评分、伤椎前后缘压缩率、后凸Cobb角均较术前下降(P均<0.05)。患者末次随访上述指标与术后7 d的差异均无统计学意义。结论:对于骨质疏松性胸腰椎爆裂骨折患者,骨水泥强化椎弓根螺钉内固定能提供坚实稳定性,有效恢复脊柱序列,维持椎体复位后高度,利于神经功能恢复,值得在临床中推广应用。
Background: Thoracolumbar burst fractures are often treated with pedicle screw fixation. However, pedicle screws are hard to be fixed stable in elderly patients with osteoporosis and often fail due to screw loosening and screw withdrawal. Objective: To explore the clinical effect of bone cement injectable pedicle screw in the treatment of osteoporotic thoracolumbar burst fracture. Methods: A total of 56 patients with osteoporotic thoracolumbar burst fracture, treated by bone cement-injectable cannulated pedicle screw posterior rod fixation between January 2014 to September 2015 were enrolled in this study. The compression rates of anterior and posterior edge of fractured vertebra, convex Cobb angle, visual analog pain score(VAS) and Oswestry disability index(ODI) were recorded at preoperation, 7 days after operation and last follow-up, and the nerve function grade of ASIA were recorded at preoperation and last follow-up. Results: All patients completed the surgery successfully without nerve function worsen and obvious bone cement leakage, and they all had satisfactory fracture reduction and recovered nerve function compared with that before the operation. The patients were followed up for 12 to 24 months. X-ray and CT examination showed that the fractures healed well, the pedicle screws fixed well and no screw loosening and broken observed.VAS score, ODI score, compression rates of anterior edge and posterior edge of fractured vertebra and Cobb angel were improved at 7 days after operation and last follow-up compared with that before operation(P<0.05), but there was no statistically significant difference between 7 days after operation and last follow-up(P>0.05). Conclusions: For the patients with osteoporotic thoracolumbar burst fracture, bone cement injectable cannulated pedicle screw rod fixation can provide strong stability, restore spinal sequence effectively, maintain vertebral body height reduction and be conducive to neural functional recovery,which is worth being promoted in clinical application.
Background: Thoracolumbar burst fractures are often treated with pedicle screw fixation. However, pedicle screws are hard to be fixed stable in elderly patients with osteoporosis and often fail due to screw loosening and screw withdrawal. Objective: To explore the clinical effect of bone cement injectable pedicle screw in the treatment of osteoporotic thoracolumbar burst fracture. Methods: A total of 56 patients with osteoporotic thoracolumbar burst fracture, treated by bone cement-injectable cannulated pedicle screw posterior rod fixation between January 2014 to September 2015 were enrolled in this study. The compression rates of anterior and posterior edge of fractured vertebra, convex Cobb angle, visual analog pain score(VAS) and Oswestry disability index(ODI) were recorded at preoperation, 7 days after operation and last follow-up, and the nerve function grade of ASIA were recorded at preoperation and last follow-up. Results: All patients completed the surgery successfully without nerve function worsen and obvious bone cement leakage, and they all had satisfactory fracture reduction and recovered nerve function compared with that before the operation. The patients were followed up for 12 to 24 months. X-ray and CT examination showed that the fractures healed well, the pedicle screws fixed well and no screw loosening and broken observed.VAS score, ODI score, compression rates of anterior edge and posterior edge of fractured vertebra and Cobb angel were improved at 7 days after operation and last follow-up compared with that before operation(P<0.05), but there was no statistically significant difference between 7 days after operation and last follow-up(P>0.05). Conclusions: For the patients with osteoporotic thoracolumbar burst fracture, bone cement injectable cannulated pedicle screw rod fixation can provide strong stability, restore spinal sequence effectively, maintain vertebral body height reduction and be conducive to neural functional recovery,which is worth being promoted in clinical application.
引文
[1]吴李勇,陈少坚,凌广烽,等.空心带侧孔椎弓根螺钉灌注骨水泥强化技术治疗老年性胸腰椎爆裂性骨折.颈腰痛杂志,2014,35(6):423-426.
[2] Mehta H, Santos E, Ledonio C, et al. Biomechanical analysis of pedicle screw thread differential design in an osteoporotic cadaver model. Clin Biomech(Bristol, Avon), 2012, 27(3):234-240.
[3] Hoppe S, Keel MJ. Pedicle screw augmentation in osteoporotic spine:indications, limitations and technical aspects. Eur J Trauma Emerg Surg, 2017,43(1):3-8.
[4]中华医学会骨质疏松和骨矿盐疾病分会.原发性骨质疏松症诊疗指南(2017).中华骨质疏松和骨矿盐疾病杂志,2017,10(5):413-444.
[5]袁鑫,王彦辉,陈学明,等.经皮椎体成型术治疗胸腰椎骨质疏松性爆裂骨折.北京医学,2016, 38(7):661-665.
[6]周喜宗,汪厚军,郭伦强,等.后路椎管270°环形减压伤椎置钉内固定治疗胸腰椎爆裂性骨折.中华骨与关节外科杂志,2018, 11(5):330-333.
[7] Rajasekaran S, Kanna RM, Schnake KJ, et al. Osteoporotic Thoracolumbar Fractures-How Are They Different?-Classification and Treatment Algorithm. J Orthop Trauma, 2017, 31Suppl 4:S49-S56.
[8]孙兆云,陈伯华,郭新银,等.后路间接减压治疗不同椎管侵占率的胸腰椎爆裂骨折的效果观察.中华骨与关节外科杂志,2015, 8(2):135-139.
[9] Weiser L, Huber G, Sellenschloh K, et al. Insufficient stability of pedicle screws in osteoporotic vertebrae:biomechanical correlation of bone mineral density and pedicle screw fixation strength. Eur Spine J, 2017, 26(11):2891-2897.
[10] Kiyak G, Balikci T, Heydar AM, et al. Comparison of the Pullout Strength of Different Pedicle Screw Designs and Augmentation Techniques in an Osteoporotic Bone Model. Asian Spine J, 2018,12(1):3-11.
[11] Becker S, Chavanne A, Spitaler R, Kropik K, Aigner N, et al.Assessment of different screw augmentation techniques and screw designs in osteoporotic spines. Eur Spine J.2008.17.(11):1462-1469.
[12] Kueny RA, Kolb JP, Lehmann W, et al. Influence of the screw augmentation technique and a diameter increase on pedicle screw fixation in the osteoporotic spine:pullout ver-sus fatigue testing. Eur Spine J, 2014, 23(10):2196-2202.
[13] Manon J, Hussain MM, Harris J, et al. Biomechanical Investigation of a Novel Revision Device in an Osteoporotic Model:Pullout Strength of Pedicle Screw Anchor Versus Larger Screw Diameter. Clin Spine Surg, 2017,30(6):265-271.
[14] Niu JJ, Shen MJ, Meng B, et al. Percutaneous kyphoplasty for the treatment of osteoporotic thoracolumbar fractures with neurological deficit:radicular pain can mimic disc herniation. Int J Clin Exp Med, 2014,7(8):2360-2364.
[15]刘扬,刘丹,肖运祥,等.新型可灌注骨水泥椎弓根螺钉的生物力学性能及在骨质疏松性腰椎退变中的应用.中国组织工程研究,2016,20(31):4671-4676.
[16] Choma TJ, Pfeiffer FM, Swope RW, et al. Pedicle screw design and cement augmentation in osteoporotic vertebrae:effects of fenestrations and cement viscosity on fixation and extraction.Spine(Phila Pa 1976), 2012,37(26):E1628-E1632.
[17] Shea TM, Laun J, Gonzalez-Blohm SA, et al. Designs and techniques that improve the pullout strength of pedicle screws in osteoporotic vertebrae:current status. Biomed Res Int, 2014:748393.
[18] Hong YR, Song BJ, Jung SS, et al. Predictive Factors for Upgrading Patients with Benign Breast Papillary Lesions Using a Core Needle Biopsy. J Breast Cancer, 2016, 19(4):410-416.
[19] Liu D, Sheng J, Wu HH, et al. Biomechanical study of injectable hollow pedicle screws for PMMA augmentation in severely osteoporotic lumbar vertebrae:effect of PMMA distribution and volume on screw stability. J Neurosurg Spine,2018:1-8.[Epub ahead of print].
[20] Liu Y, Xu J, Sun D, et al. Biomechanical and finite element analyses of bone cement-Injectable cannulated pedicle screw fixation in osteoporotic bone. J Biomed Mater Res B Appl Biomater, 2016,104(5):960-967.
[21] Folsch C, Goost H, Figiel J, et al. Correlation of pull-out strength of cement-augmented pedicle screws with CT-volumetric measurement of cement. Biomed Technol(Berl),2012, 57(6):473-480.
[22]刘达,谢庆云,张波,等.重度骨质疏松腰椎中椎弓根螺钉稳定性与骨水泥注射剂量的相关性.中国脊柱脊髓杂志,2015, 25(4):355-360.
[2] Mehta H, Santos E, Ledonio C, et al. Biomechanical analysis of pedicle screw thread differential design in an osteoporotic cadaver model. Clin Biomech(Bristol, Avon), 2012, 27(3):234-240.
[3] Hoppe S, Keel MJ. Pedicle screw augmentation in osteoporotic spine:indications, limitations and technical aspects. Eur J Trauma Emerg Surg, 2017,43(1):3-8.
[4]中华医学会骨质疏松和骨矿盐疾病分会.原发性骨质疏松症诊疗指南(2017).中华骨质疏松和骨矿盐疾病杂志,2017,10(5):413-444.
[5]袁鑫,王彦辉,陈学明,等.经皮椎体成型术治疗胸腰椎骨质疏松性爆裂骨折.北京医学,2016, 38(7):661-665.
[6]周喜宗,汪厚军,郭伦强,等.后路椎管270°环形减压伤椎置钉内固定治疗胸腰椎爆裂性骨折.中华骨与关节外科杂志,2018, 11(5):330-333.
[7] Rajasekaran S, Kanna RM, Schnake KJ, et al. Osteoporotic Thoracolumbar Fractures-How Are They Different?-Classification and Treatment Algorithm. J Orthop Trauma, 2017, 31Suppl 4:S49-S56.
[8]孙兆云,陈伯华,郭新银,等.后路间接减压治疗不同椎管侵占率的胸腰椎爆裂骨折的效果观察.中华骨与关节外科杂志,2015, 8(2):135-139.
[9] Weiser L, Huber G, Sellenschloh K, et al. Insufficient stability of pedicle screws in osteoporotic vertebrae:biomechanical correlation of bone mineral density and pedicle screw fixation strength. Eur Spine J, 2017, 26(11):2891-2897.
[10] Kiyak G, Balikci T, Heydar AM, et al. Comparison of the Pullout Strength of Different Pedicle Screw Designs and Augmentation Techniques in an Osteoporotic Bone Model. Asian Spine J, 2018,12(1):3-11.
[11] Becker S, Chavanne A, Spitaler R, Kropik K, Aigner N, et al.Assessment of different screw augmentation techniques and screw designs in osteoporotic spines. Eur Spine J.2008.17.(11):1462-1469.
[12] Kueny RA, Kolb JP, Lehmann W, et al. Influence of the screw augmentation technique and a diameter increase on pedicle screw fixation in the osteoporotic spine:pullout ver-sus fatigue testing. Eur Spine J, 2014, 23(10):2196-2202.
[13] Manon J, Hussain MM, Harris J, et al. Biomechanical Investigation of a Novel Revision Device in an Osteoporotic Model:Pullout Strength of Pedicle Screw Anchor Versus Larger Screw Diameter. Clin Spine Surg, 2017,30(6):265-271.
[14] Niu JJ, Shen MJ, Meng B, et al. Percutaneous kyphoplasty for the treatment of osteoporotic thoracolumbar fractures with neurological deficit:radicular pain can mimic disc herniation. Int J Clin Exp Med, 2014,7(8):2360-2364.
[15]刘扬,刘丹,肖运祥,等.新型可灌注骨水泥椎弓根螺钉的生物力学性能及在骨质疏松性腰椎退变中的应用.中国组织工程研究,2016,20(31):4671-4676.
[16] Choma TJ, Pfeiffer FM, Swope RW, et al. Pedicle screw design and cement augmentation in osteoporotic vertebrae:effects of fenestrations and cement viscosity on fixation and extraction.Spine(Phila Pa 1976), 2012,37(26):E1628-E1632.
[17] Shea TM, Laun J, Gonzalez-Blohm SA, et al. Designs and techniques that improve the pullout strength of pedicle screws in osteoporotic vertebrae:current status. Biomed Res Int, 2014:748393.
[18] Hong YR, Song BJ, Jung SS, et al. Predictive Factors for Upgrading Patients with Benign Breast Papillary Lesions Using a Core Needle Biopsy. J Breast Cancer, 2016, 19(4):410-416.
[19] Liu D, Sheng J, Wu HH, et al. Biomechanical study of injectable hollow pedicle screws for PMMA augmentation in severely osteoporotic lumbar vertebrae:effect of PMMA distribution and volume on screw stability. J Neurosurg Spine,2018:1-8.[Epub ahead of print].
[20] Liu Y, Xu J, Sun D, et al. Biomechanical and finite element analyses of bone cement-Injectable cannulated pedicle screw fixation in osteoporotic bone. J Biomed Mater Res B Appl Biomater, 2016,104(5):960-967.
[21] Folsch C, Goost H, Figiel J, et al. Correlation of pull-out strength of cement-augmented pedicle screws with CT-volumetric measurement of cement. Biomed Technol(Berl),2012, 57(6):473-480.
[22]刘达,谢庆云,张波,等.重度骨质疏松腰椎中椎弓根螺钉稳定性与骨水泥注射剂量的相关性.中国脊柱脊髓杂志,2015, 25(4):355-360.