经皮椎体成形术和经皮椎体后凸成形术再手术原因分析
|
摘要
目的分析经皮椎体成形术(PVP)和经皮椎体后凸成形术(PKP)再手术原因,提出再手术要点及预防措施。方法收集2012年6月至2017年12月河南省洛阳正骨医院收治的465例行PVP和PKP患者资料,其中41例行再手术治疗。男8例,女33例;年龄56～89岁,平均75岁;骨质疏松性骨折37例,椎体转移瘤2例,浆细胞骨髓瘤2例。病变节段:T92例,T103例,T116例,T126例,L111例,L25例,L33例,L43例,L52例。5例脊髓损伤患者美国脊柱损伤协会(ASIA)分级为A级1例,B级1例,C级2例,D级1例;2例神经根损伤患者出现持续性神经根疼痛、麻木,肌力2～3级。34例未合并脊髓和神经根损伤患者的疼痛视觉模拟评分(VAS)平均7.8分。7例脊髓和神经根损伤患者行后路开放性手术,其余34例患者行骨水泥强化治疗(14例行PKP,20例行PVP)。所有患者再手术时间为初次手术后2 h～1年。结果 41例患者均获得随访,随访时间为6～29个月,平均18个月。再手术原因有椎体内形成假关节(3/41,7.32%)、椎管内骨水泥渗漏(7/41,17.07%)、非手术椎体再骨折(31/41,75.61%)。末次随访时,2例神经根损伤患者疼痛完全消失,残留皮肤感觉麻木症状,肌力完全恢复正常;5例脊髓损伤患者中1例ASIA分级恢复至C级,1例恢复至D级,2例恢复至E级,1例A级患者无恢复;3例形成假关节患者术后VAS评分平均2.3分;31例非手术椎体再骨折患者VAS评分平均1.8分。结论 PVP、PKP术后再手术的主要原因包括椎管内骨水泥渗漏、椎体内假关节形成、非手术椎体再骨折等,序贯的骨水泥注入、PVP与PKP合理选择、常规病理组织检查、预防跌倒教育及康复功能锻炼能降低再手术率。
Objective To analyze the risk factors of reoperation after percutaneous vertebroplasty(PVP)and kyphoplasty(PKP),and to propose surgical tips during reoperation as well as preventive measures.Methods From June 2012 to December 2017,465 patients underwent PVP and PKP in our hospital.Among them,41 cases underwent reoperation.There were 8 males and 33 females,aged from56 to89 years(average,75 years).There were 37 cases of osteoporotic fracture,2 cases of vertebral metastases,and2 cases of plasma cell myelom.The lesion segments were as follows:T9 in 2 cases,T10 in 3 cases,T11 in 6 cases,T12 in 6 cases,L1 in 11 cases,L2 in 5 cases,L3 in 3 cases,L4 in 3 cases,and L5 in 2 cases.According to the American Spinal Injury Association(ASIA)classification,5 patients with spinal cord injury were rated as follows:grade A in 1 cases,grade B in 1 cases,grade C in 2 cases,grade D in 1 cases.Two patients with nerve root injury had skin hypesthesia,and their muscle strength was gradeⅡ-Ⅲ.Thirty-four patients without spinal cord or nerve root injury had an average visual analogue scores(VAS)of 7.8 and underwent vertebral strengthening,including PKP in 14 patients and PVP in 20 patients,while the rest 7 with spinal cord and nerve root injury underwent open surgery.The patients received reoperation at 2 hours to 1 year following the first surgery.Results All 41 patients were followed up for 6 to 29 months(average,18 months).The reasons for reoperation were as follow:pseudoarthrosis in 3 cases(3/41,7.32%),bone cement leakage in the spinal canal in 7 cases(7/41,17.07%),and fracture in non-surgical vertebral segments in31 cases(31/41,75.61%).At the final follow-up,2 patients with nerve root injury only had residual numbness;among the 5 patients with spinal cord injury,1 case improved to grade C,1 case to grade D,2 cases to grade E,and1 case remained grade A according to the ASIA scales;the mean VAS score was 2.3 points in 3 patients who had pseudoarthrosis,while 31 patients with vertebral fractures of non-surgical segments had an average VAS score of 1.8.Conclusion The reasons for reoperation after PVP and PKP include intraspinal leakage of cement,pseudoarthrosis in vertebral body,and vertebral fractures of non-surgical segments.Sequential bone cement injection,critical selection of PVP and PKP cases,routine pathological examination,prevention of falls and rehabilitation exercises can reduce the risk of reoperation.
Objective To analyze the risk factors of reoperation after percutaneous vertebroplasty(PVP)and kyphoplasty(PKP),and to propose surgical tips during reoperation as well as preventive measures.Methods From June 2012 to December 2017,465 patients underwent PVP and PKP in our hospital.Among them,41 cases underwent reoperation.There were 8 males and 33 females,aged from56 to89 years(average,75 years).There were 37 cases of osteoporotic fracture,2 cases of vertebral metastases,and2 cases of plasma cell myelom.The lesion segments were as follows:T9 in 2 cases,T10 in 3 cases,T11 in 6 cases,T12 in 6 cases,L1 in 11 cases,L2 in 5 cases,L3 in 3 cases,L4 in 3 cases,and L5 in 2 cases.According to the American Spinal Injury Association(ASIA)classification,5 patients with spinal cord injury were rated as follows:grade A in 1 cases,grade B in 1 cases,grade C in 2 cases,grade D in 1 cases.Two patients with nerve root injury had skin hypesthesia,and their muscle strength was gradeⅡ-Ⅲ.Thirty-four patients without spinal cord or nerve root injury had an average visual analogue scores(VAS)of 7.8 and underwent vertebral strengthening,including PKP in 14 patients and PVP in 20 patients,while the rest 7 with spinal cord and nerve root injury underwent open surgery.The patients received reoperation at 2 hours to 1 year following the first surgery.Results All 41 patients were followed up for 6 to 29 months(average,18 months).The reasons for reoperation were as follow:pseudoarthrosis in 3 cases(3/41,7.32%),bone cement leakage in the spinal canal in 7 cases(7/41,17.07%),and fracture in non-surgical vertebral segments in31 cases(31/41,75.61%).At the final follow-up,2 patients with nerve root injury only had residual numbness;among the 5 patients with spinal cord injury,1 case improved to grade C,1 case to grade D,2 cases to grade E,and1 case remained grade A according to the ASIA scales;the mean VAS score was 2.3 points in 3 patients who had pseudoarthrosis,while 31 patients with vertebral fractures of non-surgical segments had an average VAS score of 1.8.Conclusion The reasons for reoperation after PVP and PKP include intraspinal leakage of cement,pseudoarthrosis in vertebral body,and vertebral fractures of non-surgical segments.Sequential bone cement injection,critical selection of PVP and PKP cases,routine pathological examination,prevention of falls and rehabilitation exercises can reduce the risk of reoperation.
引文
[1]Gerling MC,Eubanks JD,Patel R,et al.Cement augmentation of refractory osteoporotic vertebral compression fractures:survivorship analysis[J].Spine(Phila Pa 1976),2011,36(19):E1266-E1269.
[2]McCarthy J,Davis A.Diagnosis and management of vertebral compression fractures[J].Am Fam Physician,2016,94(1):44-50.
[3]龚遂良,陈宝,范顺武,等.椎体内裂隙样变对经皮椎体后凸成形术疗效的影响[J].中华骨科杂志,2014,34(1):6-12.
[4]王翀妍,单治,陈欢欢,等.椎基静脉孔与椎体内裂隙相通可能是后凸成形术骨水泥渗漏的危险因素[J].中华骨科杂志,2014,34(4):373-379.
[5]Corcos G,Dbjay J,Mastier C,et al.Cement leakage in percutaneous vertebroplasty for spinal metastases:a retrospective evaluation of incidence and risk factors[J].Spine(Phila Pa 1976),2014,39(5):E332-E338.
[6]Hoppe S,Wangler S,Aghayev E,et al.Reduction of cement leakage by sequential PMMA application in a vertebroplasty model[J].Eur Spine J,2016,25(11):3450-3455.
[7]Elnoamany H.Percutaneous vertebroplasty:a new serial injection technique to minimize cement leak[J].Asian Spine J,2015,9(6):855-862.
[8]Hoppe S,Elfiky T,Keel MJ,et al.Lavage prior to vertebral augmentation reduces the risk for cement leakage[J].Eur Spine J,2016,25(11):3463-3469.
[9]吴四军,刘正,姚洪春,等.应用高黏度骨水泥PVP治疗骨质疏松性椎体压缩骨折与传统PKP的临床疗效比较[J].中华骨科杂志,2017,37(2):74-79.
[10]Zhang L,Wang J,Feng X,et al.A comparison of high viscosity bone cement and low viscosity bone cement vertebroplasty for severe osteoporotic vertebral compression fractures[J].Clin Neurol Neurosurg,2015,129:10-16.
[11]Yan L,Jiang R,He B,et al.A comparison between unilateral transverse process-pedicle and bilateral puncture techniques in percutaneous kyphoplasty[J].Spine(Phila Pa1976),2014,39(26):B19-B26.
[12]Nieuwenhuijse MJ,Bollen L,van Erkel AR,et al.Optimal intravertebral cement volume in percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures[J].Spine(Phila Pa 1976),2012,37(20):1747-1755.
[13]Sun HB,Jing XS,Liu YZ,et al.The optimal volume fraction in percutaneous vertebroplasty evaluated by pain relief,cementdispersion,and cement leakage:aprospective cohort study of 130 patients with painfulosteoporotic vertebral compression fracture in the thoracolumbar vertebra[J].World Neurosurg,2018,114:e677-e688.
[14]Bokov A,Mlyavykh S,Aleynik A,et al.The potential impact of venobasillar system morphology and applied technique on epidural cement leakage with percutaneous vertebroplasty[J].Pain Physician,2016,19(6):357-362.
[15]郝定均,贺宝荣,许正伟,等.经皮椎体成形术改为开放手术的原因分析[J].中华骨科杂志,2012,32(10):951-956.
[16]Senturk S,Akyoldas G,Senturk S,et al.Minimally invasive translaminar endoscopic approach to percutaneous vertebroplasty cement leakage:technical note[J].World Neurosurg,2018,117:15-19.
[17]徐宝山,胡永成,闰广辉,等.皮椎体成形术和后凸成形术的相关问题探讨[J].中华骨科杂志,2009,29(5):430-435.
[18]Zhang J,Fan Y,He X,et al.Is percutaneous kyphoplasty the better choice for minimally invasive treatment of neurologically intact osteoporotic Kümmell’s disease?Acomparison of two minimally invasive procedures[J].Int Orthop,2018,42(6):1321-1326.
[19]Wu X,Tang X,Tan M,et al.Is Balloon kyphoplasty a better treatment than percutaneous vertebroplasty for chronic obstructive pulmonary disease(COPD)patients with osteoporotic vertebral compression fractures(OVCFs)?[J].JOrthop Sci,2018,23(1):39-44.
[20]Lin CL,Lin RM,Huang KY,et al.MRI fluid sign is reliable in correlation with osteonecrosis after vertebral fractures:a histopathologic study[J].Eur Spine J,2013,22(7):1617-1623.
[21]Zhang H,Xu C,Zhang T,et al.Does percutaneous vertebroplasty or balloon kyphoplasty for osteoporotic vertebral compression fractures increase the incidence of new vertebral fractures?A meta-analysis[J].Pain Physician,2017,20(1):E13-E28.
[22]Martikos K,Greggi T,Faldini C,et al.Osteoporotic thoracolumbar compression fractures:long-term retrospective comparison between vertebroplasty and conservative treatment[J].Eur Spine J,2018,27(Suppl 2):244-247.
[23]Cao J,Kong L,Meng F,et al.Risk factors for new vertebral compression fractures after vertebroplasty:a meta-analysis[J].ANZ J Surg,2016,86(7-8):549-554.
[24]Ma X,Xing D,Ma J,et al.Risk factors for new vertebral compression fractures after percutaneous vertebroplasty:qualitative evidence synthesized from a systematic review[J].Spine(Phila Pa 1976),2013,38(12):E713-E722.
[25]Rho YJ,Choe WJ,Chun YI.Risk factors predicting the new symptomatic vertebral compression fractures after percutaneous vertebroplasty or kyphoplasty[J].Eur Spine J,2012,21(5):905-911.
[26]Kim MH,Lee AS,Min SH,et al.Risk factors of new compression fractures in adjacent vertebrae after percutaneous vertebroplasty[J].Asian Spine J,2011,5(3):180-187.
[27]Bae JS,Park JH,Kim KJ,et al.Analysis of risk factors for secondary new vertebral compression fracture following percutaneous vertebroplasty in patients with osteoporosis[J].World Neurosurg,2017,99:387-394.
[28]李继刚,杨惠林,王根林,等.PVP与PKP术中取材活检对椎体压缩骨折病因诊断的价值[J].中国脊柱脊髓杂志,2010,20(11):945-949.
[2]McCarthy J,Davis A.Diagnosis and management of vertebral compression fractures[J].Am Fam Physician,2016,94(1):44-50.
[3]龚遂良,陈宝,范顺武,等.椎体内裂隙样变对经皮椎体后凸成形术疗效的影响[J].中华骨科杂志,2014,34(1):6-12.
[4]王翀妍,单治,陈欢欢,等.椎基静脉孔与椎体内裂隙相通可能是后凸成形术骨水泥渗漏的危险因素[J].中华骨科杂志,2014,34(4):373-379.
[5]Corcos G,Dbjay J,Mastier C,et al.Cement leakage in percutaneous vertebroplasty for spinal metastases:a retrospective evaluation of incidence and risk factors[J].Spine(Phila Pa 1976),2014,39(5):E332-E338.
[6]Hoppe S,Wangler S,Aghayev E,et al.Reduction of cement leakage by sequential PMMA application in a vertebroplasty model[J].Eur Spine J,2016,25(11):3450-3455.
[7]Elnoamany H.Percutaneous vertebroplasty:a new serial injection technique to minimize cement leak[J].Asian Spine J,2015,9(6):855-862.
[8]Hoppe S,Elfiky T,Keel MJ,et al.Lavage prior to vertebral augmentation reduces the risk for cement leakage[J].Eur Spine J,2016,25(11):3463-3469.
[9]吴四军,刘正,姚洪春,等.应用高黏度骨水泥PVP治疗骨质疏松性椎体压缩骨折与传统PKP的临床疗效比较[J].中华骨科杂志,2017,37(2):74-79.
[10]Zhang L,Wang J,Feng X,et al.A comparison of high viscosity bone cement and low viscosity bone cement vertebroplasty for severe osteoporotic vertebral compression fractures[J].Clin Neurol Neurosurg,2015,129:10-16.
[11]Yan L,Jiang R,He B,et al.A comparison between unilateral transverse process-pedicle and bilateral puncture techniques in percutaneous kyphoplasty[J].Spine(Phila Pa1976),2014,39(26):B19-B26.
[12]Nieuwenhuijse MJ,Bollen L,van Erkel AR,et al.Optimal intravertebral cement volume in percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures[J].Spine(Phila Pa 1976),2012,37(20):1747-1755.
[13]Sun HB,Jing XS,Liu YZ,et al.The optimal volume fraction in percutaneous vertebroplasty evaluated by pain relief,cementdispersion,and cement leakage:aprospective cohort study of 130 patients with painfulosteoporotic vertebral compression fracture in the thoracolumbar vertebra[J].World Neurosurg,2018,114:e677-e688.
[14]Bokov A,Mlyavykh S,Aleynik A,et al.The potential impact of venobasillar system morphology and applied technique on epidural cement leakage with percutaneous vertebroplasty[J].Pain Physician,2016,19(6):357-362.
[15]郝定均,贺宝荣,许正伟,等.经皮椎体成形术改为开放手术的原因分析[J].中华骨科杂志,2012,32(10):951-956.
[16]Senturk S,Akyoldas G,Senturk S,et al.Minimally invasive translaminar endoscopic approach to percutaneous vertebroplasty cement leakage:technical note[J].World Neurosurg,2018,117:15-19.
[17]徐宝山,胡永成,闰广辉,等.皮椎体成形术和后凸成形术的相关问题探讨[J].中华骨科杂志,2009,29(5):430-435.
[18]Zhang J,Fan Y,He X,et al.Is percutaneous kyphoplasty the better choice for minimally invasive treatment of neurologically intact osteoporotic Kümmell’s disease?Acomparison of two minimally invasive procedures[J].Int Orthop,2018,42(6):1321-1326.
[19]Wu X,Tang X,Tan M,et al.Is Balloon kyphoplasty a better treatment than percutaneous vertebroplasty for chronic obstructive pulmonary disease(COPD)patients with osteoporotic vertebral compression fractures(OVCFs)?[J].JOrthop Sci,2018,23(1):39-44.
[20]Lin CL,Lin RM,Huang KY,et al.MRI fluid sign is reliable in correlation with osteonecrosis after vertebral fractures:a histopathologic study[J].Eur Spine J,2013,22(7):1617-1623.
[21]Zhang H,Xu C,Zhang T,et al.Does percutaneous vertebroplasty or balloon kyphoplasty for osteoporotic vertebral compression fractures increase the incidence of new vertebral fractures?A meta-analysis[J].Pain Physician,2017,20(1):E13-E28.
[22]Martikos K,Greggi T,Faldini C,et al.Osteoporotic thoracolumbar compression fractures:long-term retrospective comparison between vertebroplasty and conservative treatment[J].Eur Spine J,2018,27(Suppl 2):244-247.
[23]Cao J,Kong L,Meng F,et al.Risk factors for new vertebral compression fractures after vertebroplasty:a meta-analysis[J].ANZ J Surg,2016,86(7-8):549-554.
[24]Ma X,Xing D,Ma J,et al.Risk factors for new vertebral compression fractures after percutaneous vertebroplasty:qualitative evidence synthesized from a systematic review[J].Spine(Phila Pa 1976),2013,38(12):E713-E722.
[25]Rho YJ,Choe WJ,Chun YI.Risk factors predicting the new symptomatic vertebral compression fractures after percutaneous vertebroplasty or kyphoplasty[J].Eur Spine J,2012,21(5):905-911.
[26]Kim MH,Lee AS,Min SH,et al.Risk factors of new compression fractures in adjacent vertebrae after percutaneous vertebroplasty[J].Asian Spine J,2011,5(3):180-187.
[27]Bae JS,Park JH,Kim KJ,et al.Analysis of risk factors for secondary new vertebral compression fracture following percutaneous vertebroplasty in patients with osteoporosis[J].World Neurosurg,2017,99:387-394.
[28]李继刚,杨惠林,王根林,等.PVP与PKP术中取材活检对椎体压缩骨折病因诊断的价值[J].中国脊柱脊髓杂志,2010,20(11):945-949.