经皮球囊扩张椎体后凸成形后椎体再骨折的危险:回顾性多因素分析
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摘要
背景:已有一些研究分析了经皮球囊扩张椎体后凸成形后再骨折的高危因素,但对经皮球囊扩张椎体后凸成形后椎体再骨折的高危风险因素及干预措施尚存有争议。目的:分析经皮球囊扩张椎体后凸成形后椎体再骨折的风险因素,探讨针对性的风险因素干预在预防经皮球囊扩张椎体后凸成形后再骨折中的应用价值。方法:纳入骨质疏松性椎体压缩性骨折患者,2009年4月至2011年4月接受经皮球囊扩张椎体后凸成形治疗的60例作为A组,采用Logistic多因素分析经皮球囊扩张椎体后凸成形后再次椎体骨折的高危因素,并针对高危因素制定相应的干预措施;2013年5至2015年5月60例接受经皮球囊扩张椎体后凸成形治疗的患者,作为B组,接受针对性干预处理(对患椎邻近存在椎体真空裂隙征的椎体,予以预防性注入骨水泥;服用抗骨质疏松药物,并进行健康用药指导等),术后随访记录并比较两组椎体再骨折发生率等情况。结果与结论:(1)A组术后平均随访18个月,21例再次发生骨折,38例未发生骨折;B组10例患者再次出现椎体骨折,B组2年无事件生存时间显著长于A组(P=0.015);(2)Logistic多因素模型分析结果显示,术前骨密度T值、抗骨质疏松治疗依从性、糖皮质激素用药史、术中骨水泥渗漏及椎体裂隙征是影响经皮球囊扩张椎体后凸成形后再次骨折的独立因素(P <0.05);(3)经ROC分析显示,术前骨密度T值和抗骨质疏松依从性评分预测患者经皮球囊扩张椎体后凸成形后再次骨折的AUC分别为0.772和0.693(β=0.064,0.067,95%CI=0.646-0.898,0.562-0.823,P=0.001,0.014),最佳截断值分别为-3.74和4.53分,敏感度分别为0.795和0.81,特异度分别为0.762和0.59;(4)结果说明,经皮球囊扩张椎体后凸成形后重视术前骨密度、术后抗骨质疏松治疗依从性、糖皮质激素用药史等高危风险因素警示作用,给予针对性干预有助于降低术后再骨折发生率,改善预后。
BACKGROUND: Risk factors for vertebral re-fracture after percutaneous kyphoplasty(PKP) have been studied, but have not been confirmed, and the treatment measurements remain controversial.OBJECTIVE: To analyze the risk factors for vertebral re-fracture after PKP and to explore the application value of targeted risk factor intervention in the prevention of re-fracture after PKP. METHODS: Totally 60 patients with osteoporotic vertebral compression fractures from April 2009 to April 2011 treated with PKP were used as group A. The risk factors for vertebral re-fracture after PKP were evaluated by Logistic multivariate analysis, and the targeted risk factor intervention was designed. Sixty patients with osteoporotic vertebral compression fractures from May 2013 to May 2015 undergoing PKP served as group B, and treated with targeted intervention(injecting bone cement into the nearby vertebrae with intravertebral vacuum cleft; administrating antiosteoporosis drug, and receiving medication guidance). The postoperative incidence of re-fracture was recorded and compared between two groups. RESULTS AND CONCLUSION:(1) After followed up for 18 months postoperatively, in the group A, there were 21 cases of re-fracture and 38 cases of none-fracture. In the group B, there were 10 patients with re-fracture. The survival time in 2 years without adverse event in the group B was significantly longer than that in the group A(P=0.015).(2) The results of Logistic multivariate model analysis showed that the T score of bone mineral density at baseline, compliance of anti-osteoporosis treatment, history of glucocorticoid, postoperative bone cement leakage and intravertebral vacuum cleft were independent factors for re-fracture after PKP(P < 0.05).(3) The ROC analysis showed that the preoperative T score of bone mineral density and compliance of anti-osteoporosis treatment predicted that the AUC of re-fracture after PKP were 0.772 and 0.693 respectively(β=0.064, 0.067; 95%CI=0.646-0.898, 0.562-0.823; P=0.001, 0.014). The best cut-off values were-3.74 and 4.53 scores respectively, the sensitivities were 0.795 and 0.81, respectively, and the specificities were 0.762 and 0.59 respectively.(4) These results indicate that we should pay more attentions for prediction role of high risk factors(including preoperative bone mineral density, compliance of postoperative anti-osteoporosis treatment, and history of glucocorticoid), and giving targeted interventions will reduce the incidence of postoperative fracture and improve the prognosis.
BACKGROUND: Risk factors for vertebral re-fracture after percutaneous kyphoplasty(PKP) have been studied, but have not been confirmed, and the treatment measurements remain controversial.OBJECTIVE: To analyze the risk factors for vertebral re-fracture after PKP and to explore the application value of targeted risk factor intervention in the prevention of re-fracture after PKP. METHODS: Totally 60 patients with osteoporotic vertebral compression fractures from April 2009 to April 2011 treated with PKP were used as group A. The risk factors for vertebral re-fracture after PKP were evaluated by Logistic multivariate analysis, and the targeted risk factor intervention was designed. Sixty patients with osteoporotic vertebral compression fractures from May 2013 to May 2015 undergoing PKP served as group B, and treated with targeted intervention(injecting bone cement into the nearby vertebrae with intravertebral vacuum cleft; administrating antiosteoporosis drug, and receiving medication guidance). The postoperative incidence of re-fracture was recorded and compared between two groups. RESULTS AND CONCLUSION:(1) After followed up for 18 months postoperatively, in the group A, there were 21 cases of re-fracture and 38 cases of none-fracture. In the group B, there were 10 patients with re-fracture. The survival time in 2 years without adverse event in the group B was significantly longer than that in the group A(P=0.015).(2) The results of Logistic multivariate model analysis showed that the T score of bone mineral density at baseline, compliance of anti-osteoporosis treatment, history of glucocorticoid, postoperative bone cement leakage and intravertebral vacuum cleft were independent factors for re-fracture after PKP(P < 0.05).(3) The ROC analysis showed that the preoperative T score of bone mineral density and compliance of anti-osteoporosis treatment predicted that the AUC of re-fracture after PKP were 0.772 and 0.693 respectively(β=0.064, 0.067; 95%CI=0.646-0.898, 0.562-0.823; P=0.001, 0.014). The best cut-off values were-3.74 and 4.53 scores respectively, the sensitivities were 0.795 and 0.81, respectively, and the specificities were 0.762 and 0.59 respectively.(4) These results indicate that we should pay more attentions for prediction role of high risk factors(including preoperative bone mineral density, compliance of postoperative anti-osteoporosis treatment, and history of glucocorticoid), and giving targeted interventions will reduce the incidence of postoperative fracture and improve the prognosis.
引文
[1]Lin X,Xiong D,Peng YQ,et al.Epidemiology and management of osteoporosis in the People's Republic of China:current perspectives.Clin Interv Aging.2015;10(1):1017-1033.
[2]唐汉武,林一峰,孙丽,等.骨质疏松性椎体压缩性骨折的临床特点分析[J].广州中医药大学学报,2014,31(1):7-10.
[3]Wang S,Wang Q,Kang J,et al.An imaging anatomical study on percutaneous kyphoplasty for lumbar via a unilateral transverse process-pedicle approach.Spine. 2014;39(9):701-706.
[4]Gan M,Zou J,Song D,et al.Is balloon kyphoplasty better than percutaneous vertebroplasty for osteoporotic vertebral biconcave-shaped fractures.Acta Radiologica. 2014;55(8):985-991.
[5]叶向阳,汤立新,程省,等.骨密度对骨质疏松性椎体压缩性骨折PKP术后骨折再发风险的评估价值[J].中国骨质疏松杂志,2017,23(2):154-158.
[6]胡乐,王永祥.PVP/PKP术后继发邻近椎体骨折危险因素的研究进展[J].中国脊柱脊髓杂志,2017,27(4):377-380.
[7]印平,马远征,马迅,等.骨质疏松性椎体压缩性骨折的治疗指南[J].中国骨质疏松杂志,2015,21(6):643-648.
[8]Alsous M, Alhalaiqa F, Abu F R, et al. Reliability and validity of Arabic translation of Medication Adherence Report Scale(MARS)and Beliefs about Medication Questionnaire(BMQ)-specific for use in children and their parents. Plos One.2017;12(2):1-14.
[9]杨朝林,刘日新,袁国奇,等.骨质疏松压缩骨折经皮椎体成形术伤椎高度变化的MSCT与临床疗效的评价[J].中国CT和MRI杂志,2015,13(4):107-110.
[10]刘军,邢更彦.骨质疏松与骨关节炎的相关性研究进展[J].中国矫形外科杂志,2014, 22(15):1389-1392.
[11]赵毅,柳根哲,彭亚,等.单纯PKP与PKP结合过伸复位法治疗新鲜骨质疏松椎体压缩性骨折的对比研究[J].世界中西医结合杂志,2016,11(8):1156-1158.
[12]曹勇,蒋栋,洪晔,等.经皮球囊扩张椎体后凸成形术治疗骨质疏松性椎体压缩性骨折68例分析[J].江苏医药, 2016,42(21):2398-2400.
[13]李铠湘,李文锐.骨质疏松性椎体骨折PVP/PKP术后新发骨折的相关因素[J].中国矫形外科杂志,2017,25(10):907-911.
[14]郭刚,赵海燕.青春后期女性骨密度及血清钙离子和甲状旁腺激素水平[J].中国学校卫生,2013,34(8):1000-1003.
[15]吴骞,陈建庭,钟招明,等.中老年人正位腰椎及髋部骨密度扫描对骨质疏松诊断敏感性的比较[J].中国骨质疏松杂志,2010,16(12):940-941.
[16]解凡,张云.绝经期后女性双髋部和腰椎部骨密度值在骨质疏松诊断中敏感性的比较[J].辽宁医学杂志,2013,27(5).220-222.
[17]Zhang C,Zhu K,Zhou J,et al.Influence on adjacent lumbar bone density after strengthening of T12, L1 segment vertebral osteoporotic compression fracture by percutaneous vertebroplasty and percutaneous kyphoplasty. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2013;27(7):819-823.
[18]彭冉东,邓强,李中锋,等.骨质疏松性椎体压缩骨折PKP术后近期手术椎体再骨折原因探讨[J].实用骨科杂志, 2017,23(9):781-785.
[19]王涛,范恒俊,张福利,等.PKP后骨折椎体及邻近椎体应力变化有限元分析[J].山东医药,2014,54(22):8-10.
[20]Katzman WB,Vittinghoff E,Kado DM, et al.Thoracic kyphosis and rate of incident vertebral fractures:the Fracture Intervention Trial. Osteoporos Int. 2016;27(3):899-903.
[21]郑勇,王剑,刘先齐,等.骨密度与经皮椎体后凸成形术疗效的相关性研究[J].检验医学与临床, 2017, 14(14):2094-2096.
[22]Liu T,Zhe L,Su Q,et al.Cement leakage in osteoporotic vertebral compression fractures with cortical defect using high-viscosity bone cement during unilateral percutaneous kyphoplasty surgery. Medicine.2017;96(25):1-5.
[23]易志坚,曹家树,王茂林,等.经皮椎体成形术后椎体再发骨折的危险因素分析[J].颈腰痛杂志,2013,34(6):474-476.
[24]吴爱悯,倪文飞,池永龙.椎体内裂隙征的形成机理、影像学特征及手术治疗[J].脊柱外科杂志,2012,10(1):56-59.
[25]王庆武,强晓军,王振江.预防性注入骨水泥防止骨质疏松继发性脊椎骨折疗效分析[J].中国医学创新,2011,8(13):129-130.
[26]Yao W,Dai W,Jiang L,et al.Sclerostin-antibody treatment of glucocorticoid-induced osteoporosis maintained bone mass and strength.Osteoporosis Int.2016;27(1):283-294.
[27]张学武,姚海红,梅轶芳,等.全国多中心使用糖皮质激素风湿病患者骨质疏松调查[J].中华临床免疫和变态反应杂志, 2017,11(3):277-284.
[28]赵志刚,勘武生,李鹏,等.经皮椎体成形术治疗新鲜骨质疏松性椎体压缩性骨折[J].中华创伤骨科杂志,2014,16(3):218-221.
[29]张义龙,任磊,孙志杰,等.椎体成形术后新发椎体骨折与脊柱矢状位参数的相关性分析[J].重庆医学,2017,46(4):483-485.
[30]张义龙,任磊,孙志杰,等.椎体成形后新发椎体压缩骨折:与骨质疏松及脊柱矢状位序列失衡有关[J].中国组织工程研究, 2016,20(35):5263-5269.
[31]Zhao G,Liu X,Li F.Balloon kyphoplasty versus percutaneous vertebroplasty for treatment of osteoporotic vertebral compression fractures(OVCFs).Osteoporosis Int. 2016;27(9):1-12.
[32]葛云林,陶利江,卢一生.经皮球囊扩张椎体后凸成形术术后再发椎体骨折的危险因素和防治策略[J].颈腰痛杂志, 2016,37(5):404-407.
[2]唐汉武,林一峰,孙丽,等.骨质疏松性椎体压缩性骨折的临床特点分析[J].广州中医药大学学报,2014,31(1):7-10.
[3]Wang S,Wang Q,Kang J,et al.An imaging anatomical study on percutaneous kyphoplasty for lumbar via a unilateral transverse process-pedicle approach.Spine. 2014;39(9):701-706.
[4]Gan M,Zou J,Song D,et al.Is balloon kyphoplasty better than percutaneous vertebroplasty for osteoporotic vertebral biconcave-shaped fractures.Acta Radiologica. 2014;55(8):985-991.
[5]叶向阳,汤立新,程省,等.骨密度对骨质疏松性椎体压缩性骨折PKP术后骨折再发风险的评估价值[J].中国骨质疏松杂志,2017,23(2):154-158.
[6]胡乐,王永祥.PVP/PKP术后继发邻近椎体骨折危险因素的研究进展[J].中国脊柱脊髓杂志,2017,27(4):377-380.
[7]印平,马远征,马迅,等.骨质疏松性椎体压缩性骨折的治疗指南[J].中国骨质疏松杂志,2015,21(6):643-648.
[8]Alsous M, Alhalaiqa F, Abu F R, et al. Reliability and validity of Arabic translation of Medication Adherence Report Scale(MARS)and Beliefs about Medication Questionnaire(BMQ)-specific for use in children and their parents. Plos One.2017;12(2):1-14.
[9]杨朝林,刘日新,袁国奇,等.骨质疏松压缩骨折经皮椎体成形术伤椎高度变化的MSCT与临床疗效的评价[J].中国CT和MRI杂志,2015,13(4):107-110.
[10]刘军,邢更彦.骨质疏松与骨关节炎的相关性研究进展[J].中国矫形外科杂志,2014, 22(15):1389-1392.
[11]赵毅,柳根哲,彭亚,等.单纯PKP与PKP结合过伸复位法治疗新鲜骨质疏松椎体压缩性骨折的对比研究[J].世界中西医结合杂志,2016,11(8):1156-1158.
[12]曹勇,蒋栋,洪晔,等.经皮球囊扩张椎体后凸成形术治疗骨质疏松性椎体压缩性骨折68例分析[J].江苏医药, 2016,42(21):2398-2400.
[13]李铠湘,李文锐.骨质疏松性椎体骨折PVP/PKP术后新发骨折的相关因素[J].中国矫形外科杂志,2017,25(10):907-911.
[14]郭刚,赵海燕.青春后期女性骨密度及血清钙离子和甲状旁腺激素水平[J].中国学校卫生,2013,34(8):1000-1003.
[15]吴骞,陈建庭,钟招明,等.中老年人正位腰椎及髋部骨密度扫描对骨质疏松诊断敏感性的比较[J].中国骨质疏松杂志,2010,16(12):940-941.
[16]解凡,张云.绝经期后女性双髋部和腰椎部骨密度值在骨质疏松诊断中敏感性的比较[J].辽宁医学杂志,2013,27(5).220-222.
[17]Zhang C,Zhu K,Zhou J,et al.Influence on adjacent lumbar bone density after strengthening of T12, L1 segment vertebral osteoporotic compression fracture by percutaneous vertebroplasty and percutaneous kyphoplasty. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2013;27(7):819-823.
[18]彭冉东,邓强,李中锋,等.骨质疏松性椎体压缩骨折PKP术后近期手术椎体再骨折原因探讨[J].实用骨科杂志, 2017,23(9):781-785.
[19]王涛,范恒俊,张福利,等.PKP后骨折椎体及邻近椎体应力变化有限元分析[J].山东医药,2014,54(22):8-10.
[20]Katzman WB,Vittinghoff E,Kado DM, et al.Thoracic kyphosis and rate of incident vertebral fractures:the Fracture Intervention Trial. Osteoporos Int. 2016;27(3):899-903.
[21]郑勇,王剑,刘先齐,等.骨密度与经皮椎体后凸成形术疗效的相关性研究[J].检验医学与临床, 2017, 14(14):2094-2096.
[22]Liu T,Zhe L,Su Q,et al.Cement leakage in osteoporotic vertebral compression fractures with cortical defect using high-viscosity bone cement during unilateral percutaneous kyphoplasty surgery. Medicine.2017;96(25):1-5.
[23]易志坚,曹家树,王茂林,等.经皮椎体成形术后椎体再发骨折的危险因素分析[J].颈腰痛杂志,2013,34(6):474-476.
[24]吴爱悯,倪文飞,池永龙.椎体内裂隙征的形成机理、影像学特征及手术治疗[J].脊柱外科杂志,2012,10(1):56-59.
[25]王庆武,强晓军,王振江.预防性注入骨水泥防止骨质疏松继发性脊椎骨折疗效分析[J].中国医学创新,2011,8(13):129-130.
[26]Yao W,Dai W,Jiang L,et al.Sclerostin-antibody treatment of glucocorticoid-induced osteoporosis maintained bone mass and strength.Osteoporosis Int.2016;27(1):283-294.
[27]张学武,姚海红,梅轶芳,等.全国多中心使用糖皮质激素风湿病患者骨质疏松调查[J].中华临床免疫和变态反应杂志, 2017,11(3):277-284.
[28]赵志刚,勘武生,李鹏,等.经皮椎体成形术治疗新鲜骨质疏松性椎体压缩性骨折[J].中华创伤骨科杂志,2014,16(3):218-221.
[29]张义龙,任磊,孙志杰,等.椎体成形术后新发椎体骨折与脊柱矢状位参数的相关性分析[J].重庆医学,2017,46(4):483-485.
[30]张义龙,任磊,孙志杰,等.椎体成形后新发椎体压缩骨折:与骨质疏松及脊柱矢状位序列失衡有关[J].中国组织工程研究, 2016,20(35):5263-5269.
[31]Zhao G,Liu X,Li F.Balloon kyphoplasty versus percutaneous vertebroplasty for treatment of osteoporotic vertebral compression fractures(OVCFs).Osteoporosis Int. 2016;27(9):1-12.
[32]葛云林,陶利江,卢一生.经皮球囊扩张椎体后凸成形术术后再发椎体骨折的危险因素和防治策略[J].颈腰痛杂志, 2016,37(5):404-407.