单侧椎弓根旁外侧入路与双侧椎弓根入路经皮椎体后凸成形术治疗骨质疏松性胸椎压缩性骨折的对比研究
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摘要
目的:比较单侧椎弓根旁外侧入路与双侧椎弓根入路经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗骨质疏松性胸椎压缩性骨折的临床疗效和安全性。方法:回顾性分析47例骨质疏松性胸椎压缩性骨折患者的病例资料,其中采用单侧椎弓根旁外侧入路PKP治疗22例(单侧组),采用双侧椎弓根入路PKP治疗25例(双侧组)。男12例,女35例;年龄61~83岁,中位数68岁;骨折椎体位于T_61例、T_71例、T_84例、T_92例、T_(10)10例、T_(11)15例、T_(12)14例。比较2组患者的手术时间、骨水泥灌注量、胸腰背部疼痛视觉模拟量表(visual analogue scale,VAS)评分、椎体前缘高度及并发症发生情况。结果:(1)手术时间和骨水泥灌注量。单侧组手术时间短于双侧组[(37. 18±7. 06) min,(42. 20±8. 42) min,t=2. 196,P=0. 033],骨水泥灌注量少于双侧组[(3. 89±0. 67) m L,(4. 78±0. 84) m L,t=3. 983,P=0. 000]。(2)胸腰背部疼痛VAS评分。时间因素与分组因素不存在交互效应(F=0. 219,P=0. 804); 2组患者胸腰背部疼痛VAS评分比较,组间差异无统计学意义,即不存在分组效应(F=0. 157,P=0. 694);手术前后不同时间点之间胸腰背部疼痛VAS评分的差异有统计学意义,即存在时间效应(F=524. 723,P=0. 000); 2组患者胸腰背部疼痛VAS评分随时间均呈降低趋势,且2组的降低趋势完全一致[(6. 45±0. 91)分,(2. 18±0. 91)分,(1. 86±0. 71)分,F=192. 881,P=0. 000;(6. 44±0. 82)分,(2. 36±0. 86)分,(1. 88±0. 60)分,F=375. 230,P=0. 000]。(3)椎体前缘高度。时间因素与分组因素不存在交互效应(F=6. 416,P=0. 130); 2组患者椎体前缘高度比较,组间差异无统计学意义,即不存在分组效应(F=0. 332,P=0. 567);手术前后不同时间点之间椎体前缘高度的差异有统计学意义,即存在时间效应(F=7. 265,P=0. 008); 2组患者椎体前缘高度随时间均呈升高趋势,且2组的升高趋势完全一致[(18. 14±2. 82)分,(19. 89±2. 74)分,(19. 73±2. 75)分,F=338. 832,P=0. 000;(18. 12±2. 09)分,(20. 51±1. 99)分,(20. 31±1. 99)分,F=114. 890,P=0. 000]。(4)安全性。2组均未出现肺栓塞、低氧血症等骨水泥植入综合征以及切口感染、血肿形成。单侧组4例出现骨水泥渗漏,其中侧前方渗漏1例、椎间盘渗漏2例、静脉丛渗漏1例; 1例出现伤椎邻近椎体骨折。双侧组10例出现骨水泥渗漏,其中侧前方渗漏8例、椎间盘渗漏2例; 1例出现肋间神经损伤,2例出现伤椎邻近椎体骨折。单侧组并发症发生率低于双侧组(χ~2=4. 243,P=0. 039)。因骨水泥渗漏量少,未出现神经根症状,均未做特殊处理;邻近椎体骨折者,再次行PKP治疗后治愈。结论:单侧椎弓根旁外侧入路与双侧椎弓根入路PKP治疗骨质疏松性胸椎压缩性骨折,均能缓解胸腰背部疼痛和恢复椎体高度,但前者较后者手术时间短、骨水泥灌注量少、并发症少。
Objective: To compare the clinical curative effect and safety of percutaneous kyphoplasty( PKP) through unilateral extrapedicular approach versus bilateral transpedicular approach for treatment of thoracic osteoporotic vertebral compression fracture( OVCF).Methods: The medical records of 47 patients with thoracic OVCFs were analyzed retrospectively. Twenty-two patients were treated with PKP through unilateral extrapedicular approach( unilateral group),while the others were treated with PKP through bilateral transpedicular approach( bilateral group). The patients consisted of 12 males and 35 females,and ranged in age from 61 to 83 years( Median = 68 yrs).The fractures located at T_6( 1),T_7( 1),T_8( 4),T_9( 2),T_(10)( 10),T_(11)( 15) and T_(12)( 14). Operative time,consumption of bone cements,thoracolumbar pain visual analogue scale( VAS) scores,vertebrae anterior border height and postoperative complications were compared between the 2 groups respectively. Results: The operative time was shorter and the consumption of bone cements was less in unilateral group compared to bilateral group( 37. 18 +/-7. 06 vs 42. 20 +/-8. 42 min,t = 2. 196,P = 0. 033; 3. 89 +/-0. 67 vs 4. 78 +/-0. 84 m L,t =3. 983,P = 0. 000). There was no interaction between time factor and group factor in thoracolumbar pain VAS scores( F = 0. 219,P =0. 804). There was no statistical difference in the thoracolumbar pain VAS scores between the 2 groups,in other words,there was no group effect( F = 0. 157,P = 0. 694). There was statistical difference in the thoracolumbar pain VAS scores between different timepoints before and after the surgery,in other words,there was time effect( F = 524. 723,P = 0. 000). The thoracolumbar pain VAS scores presented a timedependent decreasing trend in both of the 2 groups,and the 2 groups were consistent with each other in the decreasing trend of thoracolumbar pain VAS scores( 6. 45 +/-0. 91,2. 18 +/-0. 91,1. 86 +/-0. 71 points,F = 192. 881,P = 0. 000; 6. 44 +/-0. 82,2. 36 +/-0. 86,1. 88 +/-0. 60 points,F = 375. 230,P = 0. 000). There was no interaction between time factor and group factor in vertebrae anterior border height( F = 6. 416,P = 0. 130). There was no statistical difference in vertebrae anterior border height between the 2 groups,in other words,there was no group effect( F = 0. 332,P = 0. 567). There was statistical difference in vertebrae anterior border height between different timepoints before and after the surgery,in other words,there was time effect( F = 7. 265,P = 0. 008). The vertebrae anterior border height presented a time-dependent increasing trend in both of the 2 groups,and the 2 groups were consistent with each other in the increasing trend of vertebrae anterior border height( 18. 14 +/-2. 82,19. 89 +/-2. 74,19. 73 +/-2. 75 points,F = 338. 832,P = 0. 000; 18. 12 +/-2. 09,20. 51 +/-1. 99,20. 31 +/-1. 99 points,F = 114. 890,P = 0. 000). Bone cement implantation syndromes such as pulmonary embolism and hypoxemia,incision infection and hematoma were not found in the 2 groups. The bone cement leakage were found in 14 patients. Anterolateral leakage( 1),leakage into intervertebral disc( 2) and venous plexus( 1) were found in unilateral group,while anterolateral leakage( 8) and leakage into intervertebral disc( 2) were found in bilateral group. The adjacent vertebral fracture( 1) was found in unilateral group. The intercostals nerve injury( 1) and the adjacent vertebral fractures( 2) were found in bilateral group. The incidence rate of postoperative complication was lower in unilateral group compared to bilateral group( χ~2= 4. 243,P = 0. 039). No nerve root symptoms appeared due to small amount of bone cement leakage,so the patients were not given any special treatment. The patients with adjacent vertebral fractures were cured with another PKP. Conclusion: Both PKP through unilateral extrapedicular approach and PKP through bilateral transpedicular approach can alleviate thoracolumbar pain and restore vertebral height in the treatment of thoracic OVCF,however,the former has such advantages as shorter operative time,less consumption of bone cements and postoperative complications.
Objective: To compare the clinical curative effect and safety of percutaneous kyphoplasty( PKP) through unilateral extrapedicular approach versus bilateral transpedicular approach for treatment of thoracic osteoporotic vertebral compression fracture( OVCF).Methods: The medical records of 47 patients with thoracic OVCFs were analyzed retrospectively. Twenty-two patients were treated with PKP through unilateral extrapedicular approach( unilateral group),while the others were treated with PKP through bilateral transpedicular approach( bilateral group). The patients consisted of 12 males and 35 females,and ranged in age from 61 to 83 years( Median = 68 yrs).The fractures located at T_6( 1),T_7( 1),T_8( 4),T_9( 2),T_(10)( 10),T_(11)( 15) and T_(12)( 14). Operative time,consumption of bone cements,thoracolumbar pain visual analogue scale( VAS) scores,vertebrae anterior border height and postoperative complications were compared between the 2 groups respectively. Results: The operative time was shorter and the consumption of bone cements was less in unilateral group compared to bilateral group( 37. 18 +/-7. 06 vs 42. 20 +/-8. 42 min,t = 2. 196,P = 0. 033; 3. 89 +/-0. 67 vs 4. 78 +/-0. 84 m L,t =3. 983,P = 0. 000). There was no interaction between time factor and group factor in thoracolumbar pain VAS scores( F = 0. 219,P =0. 804). There was no statistical difference in the thoracolumbar pain VAS scores between the 2 groups,in other words,there was no group effect( F = 0. 157,P = 0. 694). There was statistical difference in the thoracolumbar pain VAS scores between different timepoints before and after the surgery,in other words,there was time effect( F = 524. 723,P = 0. 000). The thoracolumbar pain VAS scores presented a timedependent decreasing trend in both of the 2 groups,and the 2 groups were consistent with each other in the decreasing trend of thoracolumbar pain VAS scores( 6. 45 +/-0. 91,2. 18 +/-0. 91,1. 86 +/-0. 71 points,F = 192. 881,P = 0. 000; 6. 44 +/-0. 82,2. 36 +/-0. 86,1. 88 +/-0. 60 points,F = 375. 230,P = 0. 000). There was no interaction between time factor and group factor in vertebrae anterior border height( F = 6. 416,P = 0. 130). There was no statistical difference in vertebrae anterior border height between the 2 groups,in other words,there was no group effect( F = 0. 332,P = 0. 567). There was statistical difference in vertebrae anterior border height between different timepoints before and after the surgery,in other words,there was time effect( F = 7. 265,P = 0. 008). The vertebrae anterior border height presented a time-dependent increasing trend in both of the 2 groups,and the 2 groups were consistent with each other in the increasing trend of vertebrae anterior border height( 18. 14 +/-2. 82,19. 89 +/-2. 74,19. 73 +/-2. 75 points,F = 338. 832,P = 0. 000; 18. 12 +/-2. 09,20. 51 +/-1. 99,20. 31 +/-1. 99 points,F = 114. 890,P = 0. 000). Bone cement implantation syndromes such as pulmonary embolism and hypoxemia,incision infection and hematoma were not found in the 2 groups. The bone cement leakage were found in 14 patients. Anterolateral leakage( 1),leakage into intervertebral disc( 2) and venous plexus( 1) were found in unilateral group,while anterolateral leakage( 8) and leakage into intervertebral disc( 2) were found in bilateral group. The adjacent vertebral fracture( 1) was found in unilateral group. The intercostals nerve injury( 1) and the adjacent vertebral fractures( 2) were found in bilateral group. The incidence rate of postoperative complication was lower in unilateral group compared to bilateral group( χ~2= 4. 243,P = 0. 039). No nerve root symptoms appeared due to small amount of bone cement leakage,so the patients were not given any special treatment. The patients with adjacent vertebral fractures were cured with another PKP. Conclusion: Both PKP through unilateral extrapedicular approach and PKP through bilateral transpedicular approach can alleviate thoracolumbar pain and restore vertebral height in the treatment of thoracic OVCF,however,the former has such advantages as shorter operative time,less consumption of bone cements and postoperative complications.
引文
[1] BOONEN S,WAHL DA,NAUROY L,et al. Balloon kyphoplasty and vertebroplasty in the management of vertebral compression fractures[J]. Osteoporos Int,2011,22(12):2915-2934.
[2]杨惠林,YUAN HA,陈亮,等.椎体后凸成形术治疗老年骨质疏松脊柱压缩骨折[J].中华骨科杂志,2004,23(5):262-265.
[3]黄胜,许靖,项禹诚,等.单侧与双侧入路经皮椎体成形术治疗骨质疏松压缩性骨折的比较研究[J].中国矫形外科杂志,2013,21(2):115-118.
[4]杨建平,谢国华,薛峰,等.单球囊单、双侧扩张经皮椎体后凸成形术治疗骨质疏松性椎体压缩骨折的比较[J].中医正骨,2014,26(3):21-24.
[5]申勇,刘法敬,张英泽,等.单、双侧经皮椎体后凸成形术治疗骨质疏松性椎体压缩骨折的疗效[J].中国脊柱脊髓杂志,2011,21(3):202-206.
[6]蒋协远,王大伟.骨科临床疗效评价标准[M].北京:人民卫生出版社,2005:123.
[7]中国老年学学会骨质疏松委员会,骨质疏松症诊断标准学科组.中国人骨质疏松症诊断标准专家共识(第三稿·2014版)[J].中国骨质疏松杂志,2014,20(9):1007-1010.
[8]王璐,赵琳,刘伯锋,等.胸椎椎弓根应用解剖对椎弓根钉置入方法的影响[J].中国老年学杂志,2013,33(18):4387-4390.
[9] BOUZA C,LPEZ-CUADRADO T,ALMENDRO N,et al.Safety of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures in Europe:a meta-analysis of randomized controlled trials[J]. Eur Spine J,2015,24(4):715-723.
[10]谭中宝,狄镇海,张建,等. CT图像模拟穿刺路径在经皮椎体成形术中的应用价值[J].放射学实践,2012,27(9):998-1000.
[11] CHEN LH,HSIEH MK,LIAO JC,et al. Repeated percutaneous vertebroplasty for refracture of cemented vertebrae[J].Arch Orthop Trauma Surg,2011,131(7):927-933.
[12]王想福,范有福,石瑞芳,等.单侧穿刺椎体后凸成形术骨水泥分布与穿刺角度的关系[J].中国骨伤,2015,28(8):704-707.
[13] ZHONG BY,WU CG,HE SC,et al. ANVCFV score system:assessment for probability of new vertebral compression fractures after percutaneous vertebroplasty in patients with vertebral compression fractures[J]. Pain Physician,2015,18(6):1047-1057.
[14] PHILLIPS FM,TODD WETZEL F,LIEBERMAN I,et al.An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty[J]. Spine(Phila Pa 1976),2002,27(19):2173-2178.
[15]鲁常胜,蒋涛,鲁婷玮,等.经皮椎体后凸成形术椎管内骨水泥渗漏的诊断及预防[J].临床骨科杂志,2017,20(1):30-33.
[16]耿家金,赵平,牛和明,等.分次灌注骨水泥技术治疗骨质疏松性椎体压缩骨折疗效观察[J].中国骨与关节损伤杂志,2013,28(3):225-227.
[17]王远政,田晓滨,李波,等.高粘度骨水泥与低粘度骨水泥经皮椎体成形术治疗严重骨质疏松性椎体压缩性骨折的前瞻性比较研究[J].中华创伤骨科杂志,2017,19(1):54-60.
[18]郑毓嵩,张勇,林金丁,等.椎体成形术骨水泥渗漏的相关危险因素分析[J].中华创伤杂志,2015,31(4):312-316.
[19]TAYLOR RS,TAYLOR RJ,FRITZELL P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures—A comparative systematic review of efficacy and safety[J].Spine(Phila Pa 1976),2006,31(23):2747-2755.
[20]陈建德,樊晓琦,夏炳江,凌义龙.球囊扩张部位对椎体后凸成形术治疗骨质疏松性椎体压缩骨折疗效及安全性的影响[J].中医正骨,2017,29(2):11-16.
[2]杨惠林,YUAN HA,陈亮,等.椎体后凸成形术治疗老年骨质疏松脊柱压缩骨折[J].中华骨科杂志,2004,23(5):262-265.
[3]黄胜,许靖,项禹诚,等.单侧与双侧入路经皮椎体成形术治疗骨质疏松压缩性骨折的比较研究[J].中国矫形外科杂志,2013,21(2):115-118.
[4]杨建平,谢国华,薛峰,等.单球囊单、双侧扩张经皮椎体后凸成形术治疗骨质疏松性椎体压缩骨折的比较[J].中医正骨,2014,26(3):21-24.
[5]申勇,刘法敬,张英泽,等.单、双侧经皮椎体后凸成形术治疗骨质疏松性椎体压缩骨折的疗效[J].中国脊柱脊髓杂志,2011,21(3):202-206.
[6]蒋协远,王大伟.骨科临床疗效评价标准[M].北京:人民卫生出版社,2005:123.
[7]中国老年学学会骨质疏松委员会,骨质疏松症诊断标准学科组.中国人骨质疏松症诊断标准专家共识(第三稿·2014版)[J].中国骨质疏松杂志,2014,20(9):1007-1010.
[8]王璐,赵琳,刘伯锋,等.胸椎椎弓根应用解剖对椎弓根钉置入方法的影响[J].中国老年学杂志,2013,33(18):4387-4390.
[9] BOUZA C,LPEZ-CUADRADO T,ALMENDRO N,et al.Safety of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures in Europe:a meta-analysis of randomized controlled trials[J]. Eur Spine J,2015,24(4):715-723.
[10]谭中宝,狄镇海,张建,等. CT图像模拟穿刺路径在经皮椎体成形术中的应用价值[J].放射学实践,2012,27(9):998-1000.
[11] CHEN LH,HSIEH MK,LIAO JC,et al. Repeated percutaneous vertebroplasty for refracture of cemented vertebrae[J].Arch Orthop Trauma Surg,2011,131(7):927-933.
[12]王想福,范有福,石瑞芳,等.单侧穿刺椎体后凸成形术骨水泥分布与穿刺角度的关系[J].中国骨伤,2015,28(8):704-707.
[13] ZHONG BY,WU CG,HE SC,et al. ANVCFV score system:assessment for probability of new vertebral compression fractures after percutaneous vertebroplasty in patients with vertebral compression fractures[J]. Pain Physician,2015,18(6):1047-1057.
[14] PHILLIPS FM,TODD WETZEL F,LIEBERMAN I,et al.An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty[J]. Spine(Phila Pa 1976),2002,27(19):2173-2178.
[15]鲁常胜,蒋涛,鲁婷玮,等.经皮椎体后凸成形术椎管内骨水泥渗漏的诊断及预防[J].临床骨科杂志,2017,20(1):30-33.
[16]耿家金,赵平,牛和明,等.分次灌注骨水泥技术治疗骨质疏松性椎体压缩骨折疗效观察[J].中国骨与关节损伤杂志,2013,28(3):225-227.
[17]王远政,田晓滨,李波,等.高粘度骨水泥与低粘度骨水泥经皮椎体成形术治疗严重骨质疏松性椎体压缩性骨折的前瞻性比较研究[J].中华创伤骨科杂志,2017,19(1):54-60.
[18]郑毓嵩,张勇,林金丁,等.椎体成形术骨水泥渗漏的相关危险因素分析[J].中华创伤杂志,2015,31(4):312-316.
[19]TAYLOR RS,TAYLOR RJ,FRITZELL P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures—A comparative systematic review of efficacy and safety[J].Spine(Phila Pa 1976),2006,31(23):2747-2755.
[20]陈建德,樊晓琦,夏炳江,凌义龙.球囊扩张部位对椎体后凸成形术治疗骨质疏松性椎体压缩骨折疗效及安全性的影响[J].中医正骨,2017,29(2):11-16.