胸腰椎压缩骨折后路内固定术后复位丢失的临床研究
摘要
目的观察经皮角度椎弓根螺钉修复急性胸腰椎压缩骨折术后复位丢失最大发生的时间段,并分析对临床效果影响的相关因素。方法回顾分析2013年7月至2016年1月通过经皮角度椎弓根螺钉修复急性胸腰椎压缩骨折患者共78例,男57例,女21例;年龄21～65岁,平均(48±12)岁。所有患者于术后8～10个月间取出内固定物,于术后3个月、6个月、取内固定时、取出内固定后3个月、1年、2年、末期进行随访。测量不同时间点X线片上病椎前缘高度百分比(anterior vertebral height,AVH)、后缘高度百分比(posterior vertebral height,PVH)、后凸角(Cobb角)。使用视觉模拟评分(visual analogue scale,VAS)及Oswestry功能障碍指数(Oswestry disability index,ODI)评价腰背部疼痛及功能状况。结果患者随访时间2.8～4.9年,平均随访时间3.6年。术后即刻及末次随访时病椎前后缘高度百分比、后凸角较术前明显改善,差异有统计学意义(P<0.01)。病椎前后缘高度、后凸角丢失随时间推移一直存在,其丢失最大发生在术后3个月及内固定取出后3个月内(组间ANOVA对比P<0.05,差异有统计学意义),内固定取出1年后复位丢失不大。末次随访患者腰背部平均ODI评分为(7.84±2.05)%,影响因素为术前AVH(回归系数B=-0.062,P=0.048)和末次随访AVH(B=-0.034,P=0.046),PVH、Cobb角度以及内固定取出前后各指标丢失值与ODI评分无相关性。末次随访平均VAS评分(2.25±0.58)分,与上述指标均无明显相关性。结论经皮角度椎弓根螺钉系统对于急性胸腰椎压缩骨折具有良好的畸形矫正能力和临床疗效,但在术后3个月及内固定取出后3个月内复位丢失最大,需要有效的预防。椎体前缘高度可以预测远期的手术效果,而不同时间段椎体少量的丢失并不影响这种治疗的效果。
引文
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[13]赵刚,周英杰,王许可.RTS和SEXTANT经皮微创椎弓根螺钉置入修复不稳定胸腰椎骨折:椎体复位高度比较[J].中国组织工程研究,2016,20(22):3255-3262.
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[23]Klezl Z,Majeed H,Bommireddy R,et al.Early results after vertebral body stenting for fractures of the anterior column of the thoracolumbar spine[J].Injury,2011,42(10):1038-1042.
[24]Hoppe S,Aghayev E,Ahmad S,et al.Short posterior stabilization in combination with cement augmentation for the treatment of thoracolumbar fractures and the effects of implant removal[J].Global Spine Journal,2017,7(4):317-324.
[25]Chen JX,Xu DL,Sheng SR,et al.Risk factors of kyphosis recurrence after implant removal in thoracolumbar burst fractures following posterior shortsegment fixation[J].Int Orthop,2016,40(6):1253-1260.
[26]王晨光,肖湘生,沈天真,等.椎体骨折及愈合的磁共振成像[J].中华骨科杂志,1997,17(4):255-257.
[27]王根林,杨惠林.骨质疏松性椎体骨折骨不愈合的研究进展[J].中华创伤骨科杂志,2009,11(6):581-583.
[28]Shih TT,Tsuang YH,Huang KM,et al.Magnetic resonance imaging of vertebral compression fractures[J].J Formos Med Assoc,1996,95(4):313-319.
[2]Alander DH,Cui S.Percutaneous pedicle screw stabilization:surgical technique,fracture reduction,and review of current spine trauma applications[J].J Am Acad Orthop Surg,2018,26(7):231-240.
[3]Than KD,Mummaneni PV,Bridges KJ,et al.Complication rates associated with open versus percutaneous pedicle screw instrumentation among patients undergoing minimally invasive interbody fusion for adult spinal deformity[J].Neurosurgical Focus,2017,43(6):E7.
[4]Ajiboye RM,Zoller SD,D'Oro A,et al.The utility of intraoperative neuromonitoring for lumbar pedicle screw placement is questionable:A review of 9957cases[J].Spine,2017,42(13):1006-1010.
[5]贺新宁,欧晔灵,杜志勇,等.经皮椎弓根钉内固定治疗胸腰椎骨折[J].实用骨科杂志,2014,20(6):484-487.
[6]Chin KR,Fjr P,Coombs AV,et al.Clinical outcomes with midline cortical bone trajectory pedicle screws versus traditional pedicle screws in moving lumbar fusions from hospitals to outpatient surgery centers[J].Clin Spine Surg,2017,30(6):E791-E797.
[7]Aly TA.Short segment versus long segment pedicle screws fixation in management of thoracolumbar burst fractures:meta-analysis[J].Asian Spine Journal,2017,11(1):150-160.
[8]Foley KT,Gupta SK.Percutaneous pedicle screw fixation of the lumbar spine:preliminary clinicalresults[J].J Neurosurg,2002,97(1Suppl):7-12.
[9]Wang HW,Li CQ,Zhou Y,et al.Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using sextant system:an analysis of 38cases[J].China J Traumatol,2010,13(3):137-145.
[10]Raley DA,Mobbs RJ.Retrospective computed tomography scan analysis of percutaneously inserted pedicle screws for posterior transpedicular stabilization of the thoracic and lumbar spine:accuracy and complication rates[J].Spine(Phila Pa 1976),2012,37(12):1092-1100.
[11]Wiesner L,Kothe R,Schulitz KP,et al Clinical evaluation and computed tomography scan analysis of screw tracts after percutaneous insertion of pedicle screws in the lumbar spine[J].Spine(Phila Pa1976),2000,25(5):615-621.
[12]Yang M,Zhao Q,Hao D,et al.Comparison of clinical results between novel percutaneous pedicle screw and traditional open pedicle screw fixation for thoracolumbar fractures without neurological deficit[J].Int Orthop,2019,43(7):1749-1754.
[13]赵刚,周英杰,王许可.RTS和SEXTANT经皮微创椎弓根螺钉置入修复不稳定胸腰椎骨折:椎体复位高度比较[J].中国组织工程研究,2016,20(22):3255-3262.
[14]Schnee CL,Ansell LV.Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit[J].JNeurosurg,1997,86(1):48-55.
[15]Leferink V,Zimmerman K,Veldhuis E,et al.Thoracolumbar spinal fractures:radiological results of transpedicular fixation combined with transpedicular cancellous bone graft and posterior fusion in 183patients[J].European Spine Journal,2001,10(6):517-523.
[16]Shi J,Mei X,Liu J,et al.The influence of correction loss in thoracolumbar fractures treated by posterior instrumentation:a minimum 7-year follow-up[J].JClin Neurosci,2011,18(4):500-503.
[17]Verlaan JJ,Diekerhof CH,Buskens E,et al.Surgical treatment of traumatic fractures of the thoracic and lumbar spine:a systematic review of the literature on techniques,complications,and outcome[J].Spine,2004,29(7):803-814.
[18]Farcy J.Sagittal index in management of thoracolumbar burst fracture[J].Spine,1990,15(9):958-965.
[19]邱勇,朱泽章,王斌,等.钉钩联合使用预防胸腰椎骨折术后纠正丢失的远期临床效果[J].中华创伤杂志,2003,19(12):742-745.
[20]柴旭斌,周英杰,黄勇.经皮自旋转撑开椎弓根螺钉内固定系统与开放椎弓根螺钉内固定治疗胸腰椎骨折的对比研究[J].中华骨与关节外科杂志,2017,10(2):109-112.
[21]StulikJ,Krbec M,Vyskocil T.Use of bioceramics in the treatment of fractures of the thoraco-lumbar spine[J].Acta Chir Orthop Traumatol Cech,2002,69(5):288-294.
[22]Xu G,Fu X,Du C,et al.Biomechanical comparison of mono-segment transpedicular fixation with shortsegment fixation for treatment of thoracolumbar fractures:a finite element analysis[J].Proc Inst Mech Eng H,2014,228(10):1005-1013.
[23]Klezl Z,Majeed H,Bommireddy R,et al.Early results after vertebral body stenting for fractures of the anterior column of the thoracolumbar spine[J].Injury,2011,42(10):1038-1042.
[24]Hoppe S,Aghayev E,Ahmad S,et al.Short posterior stabilization in combination with cement augmentation for the treatment of thoracolumbar fractures and the effects of implant removal[J].Global Spine Journal,2017,7(4):317-324.
[25]Chen JX,Xu DL,Sheng SR,et al.Risk factors of kyphosis recurrence after implant removal in thoracolumbar burst fractures following posterior shortsegment fixation[J].Int Orthop,2016,40(6):1253-1260.
[26]王晨光,肖湘生,沈天真,等.椎体骨折及愈合的磁共振成像[J].中华骨科杂志,1997,17(4):255-257.
[27]王根林,杨惠林.骨质疏松性椎体骨折骨不愈合的研究进展[J].中华创伤骨科杂志,2009,11(6):581-583.
[28]Shih TT,Tsuang YH,Huang KM,et al.Magnetic resonance imaging of vertebral compression fractures[J].J Formos Med Assoc,1996,95(4):313-319.