老年骨质疏松性胸腰椎压缩骨折的微创治疗对策
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摘要
背景
骨质疏松症是常见的老年疾病,在绝经后妇女尤其多发,而骨质疏松性椎体压缩骨折是骨质疏松症的最常见并发症之一,随着社会人口的老龄化的趋势越来越明显,骨质疏松症患者逐渐增多,由此导致的胸腰椎压缩骨折也逐年增多。对于老年骨质疏松性椎体压缩骨折的治疗,在以往多以保守治疗为主,但老年人一般体质较差,合并症较多,保守治疗发生并发症的几率较高,而手术治疗创伤较大,风险也较高。老年病人手术及麻醉耐受性多较差,多数病人不能耐受或不能接受传统的开放手术治疗。因而,如何采取微创有效的治疗方式成为治疗胸腰椎压缩骨折研究较多的课题。
法国的神经放射学医师首先采用经皮椎体成形术治疗颈椎血管瘤并获得成功。以后,PVP被逐渐应用于骨质疏松性椎体骨折和脊柱肿瘤的治疗,后来又在PVP的基础上加以改进,设计了球囊扩张椎体后凸成形术及Sky膨胀式椎体成形器,国内也有一些学者结合中医正脊复位等方式衍生出正脊复位加PVP的技术方式,也取得了很好的治疗效果。但在采取哪种椎体成形方式、采取单侧穿刺还是双侧穿刺、骨水泥注入量多少、骨水泥弥散方式对治疗效果的影响等多方面问题仍有较多争论,分析我院近几年各种治疗方式的数据并进行了系统研究,我们提出了自己的观点和选择方式。
目的
1、观察不同椎体成形手术方式对骨质疏松性压缩骨折治疗效果和放射暴露剂量的影响。
2、观察不同骨水泥弥散方式对骨质疏松性压缩骨折治疗效果和骨水泥渗漏率的影响。
3、观察单侧穿刺和双侧穿刺注入骨水泥对骨质疏松性压缩骨折治疗效果和放射暴露、手术耐受的影响。
4、观察不同骨水泥注入量对骨质疏松性压缩骨折治疗效果和骨水泥渗漏率的影响。
5、通过各种术式的多指标观察,综合评价并指导不同情况下椎体成形手术方式的选择。
方法
1、PVP与PKP及手法复位PVP临床应用比较
回顾研究2010年9月至2012年9月我院收治的骨质疏松性腰1单椎体压缩骨折行双侧穿刺PVP和PKP以及手法复位PVP治疗的病例,观察VAS评分、后凸畸形角(Cobb角)的测量、JOA评分、骨水泥弥散方式、骨水泥渗漏发生率、手术中放射暴露剂量、手术时间、手术中患者耐受情况等并进行统计学分析。
2、不同骨水泥弥散方式对治疗效果的影响
分析骨质疏松性胸腰椎压缩骨折行单侧穿刺经皮椎体成形术病例,术后摄正侧位DR片,以Auto CAD2007图形处理软件计算骨水泥团块区面积和弥散区面积,然后计算正侧位平均弥散区与平均团块区面积的比值K,定义K<50%为团块型,50%≦K≦100%为混合型,K>100%为弥散型。按骨水泥弥散类型分3组,观察各治疗组的VAS评分、椎体高度压缩率、JOA评分、骨水泥渗漏率等并进行统计学分析。
3、PVP双侧穿刺与单侧穿刺注入骨水泥的临床应用比较
分析骨质疏松性胸12及腰1椎体双椎体压缩骨折病例,行单侧或双侧PVP治疗,观察VAS评分、椎体高度压缩率、JOA评分、手术中放射暴露剂量、手术时间、手术中患者耐受情况等,进行统计学分析。
4双侧穿刺注入不同骨水泥量的临床应用比较
分析骨质疏松性腰1椎体压缩骨折病例,分为双侧少量骨水泥PVP治疗组和双侧多量骨水泥PVP治疗组,少量组每侧均注入1.5ml,总量3m],双侧多量骨水泥PVP组每侧尽可能注入约2.5-3ml骨水泥,总量约5-6ml,或至出现骨水泥少量外渗时停止,总量>4ml。观察VAS评分、椎体高度压缩率、JOA评分、骨水泥渗漏率、手术中血压下降情况等并进行统计学分析。
结果
1、PVP与PKP及手法复位PVP临床应用比较
VAS评分：三组在术前和术后组内比较均有显著性差异(t1=2.712,P<0.05；t2=2.608,P<0.05；t3=2.679,P<0.05)。术前组间比较及术后组间比较均三组无显著性差异(F1=2.326,P>0.05；F2=2.075,P>0.05)。
后凸畸形角(Cobb角)的测量：各组在术前和术后组内比较均有显著性差异(t1=2.698,P<0.05；t2=2.953,P<0.05；t3=3.107,P<0.05)。术前组间比较三组均无显著性差异(F1=2.373,P>0.05),而术后后凸畸形矫正率比较三组有显著性差异(F2=2.865,P<0.05),通过两两比较可发现PVP组与PKP组及手法复位PVP组均有显著差异,而PKP组与手法复位PVP组无显著差异。
JOA评分：各组在术前和术后组内比较均有显著性差异(t1=3.118,P<0.05；t2=2.976,P<0.05；t3=2.853,P<0.05)。术前组间比较及术后组间比较均三组无显著性差异(F1=2.413,P>0.05；F2=2.652,P>0.05)。三组的术后优良率比较经ridit分析也无显著差异(X2=1.853,P>0.05)。
骨水泥弥散方式：X2检验分析三组的弥散类型构成不同(X2=17.631,P<0.05),PVP组弥散型和混合型为主,PKP组、手法复位PVP组以团块型和混合型为主。
骨水泥渗漏发生率：各组在骨水泥渗漏率方面无显著性差异(X2=2.633,P>0.05)。
术中放射暴露情况：三组的放射暴露时间比较有显著性差异(F1=12.751,P<0.05),通过两两比较可发现每两组间均有显著差异；三组的剂量-面积乘积比较也有显著性差异(F2=11.854,P<0.05),通过两两比较可发现每两组均有显著差异,从三组的平均时间来看,PVP组剂量-面积乘积最小,手法复位PVP组放射量略多,PKP组放射暴露最大。
手术时间：各组的手术时间比较有显著性差异(F=11.652,P<0.05),两两比较均有显著差异。PVP组手术时间最短,PKP组手术时间最长。
手术中患者耐受情况：三组的手术耐受率比较有显著性差异(X2=7.623,P<0.05),PVP组有最好的手术耐受率。
2、不同骨水泥弥散方式对治疗效果的影响
VAS评分：团块型组与混合型及弥散型组在术前和术后组内比较均有显著性差异(t1=2.724,P<0.05；t2=3.159,P<0.05；t3=3.263,P<0.05)。术前组间比较及术后组间比较均三组无显著性差异(F1=2.357,P>0.05；F2=2.289,P>0.05)。
椎体高度压缩率：三组在术前和术后组内比较均有显著性差异(t11=2.963,P<0.05；t2=3.027,P<0.05；t3=2.726,P<0.05)。术前组间比较三组均无显著性差异(F,=2.238,P>O.05),而术后组间三组有显著性差异(F2=6.351,P<0.05),通过两两比较可发现团块型组、混合型组与弥散型组均有显著差异,而团块型组与混合型组无显著差异。团块型与混合型的弥散方式可能更多地恢复压缩椎体高度。
JOA评分：各组在术前和术后组内比较均有显著性差异(t1=2.983,P<0.05；t2=3.125,P<0.05；t3=3.257,P<0.05)。术前组间比较及术后组间比较均无显著性差异(F,=1.867,P>0.05；F2=2.113,P>0.05)。三组的术后优良率比较经ridit分析也无显著差异(X2=0.846,P>0.05)。
骨水泥渗漏发生率：三组在骨水泥渗漏率方面无显著性差异(X2=1.536,P>0.05)。
3、PVP双侧穿刺与单侧穿刺注入骨水泥的临床应用比较
VAS评分：单侧穿刺PVP组与双侧穿刺PVP组在术前和术后组内比较均有显著性差异(t1=3.231,P<0.05；t2=3.352,P<0.05)。术前组间比较及术后组间比较均两组无显著性差异(t1=1.215,P>0.05；t2=1.078,P>0.05)。
椎体高度压缩率：单侧穿刺PVP组与双侧穿刺PVP组在术前和术后组内比较均有显著性差异(t13.389,P<0.05；t2=3.265,P<0.05)。术前、术后组间比较两组均无显著性差异(t1=1.574,P>0.05；t2=1.692,P>0.05)。
JOA评分：两组在术前和术后组内比较均有显著性差异(t1=3.236,P<0.05；t2=3.186,P<0.05)。术前组间比较及术后组间比较两组均无显著性差异(t1=1.358,P>0.05；t2=1.524,P>0.05)。两组的术后优良率比较经ridit分析也无显著差异(u=1.156,P>0.05)。
手术中放射暴露情况：单侧穿刺PVP组和双侧穿刺PVP组透视时间和剂量-面积乘积比较有显著性差异(t1=3.164,P<0.05；t2=3.235,P<0.05),单侧穿刺组透视时间和剂量-面积乘积较少。
手术时间：两组手术时间比较有显著性差异(t=4.635,P<0.05),单侧穿刺PVP组手术时间较短。
手术中患者耐受情况：两组的手术耐受率比较有显著性差异(X2=4.157,P<0.05),单侧穿刺PVP组有较好的手术耐受率。
4、双侧穿刺注入不同骨水泥量的临床应用比较
VAS评分：双侧少量骨水泥PVP组与双侧多量骨水泥PVP组在术前和术后组内比较均有显著性差异(t1=3.168,P<0.05；t1=3.563,P<0.05)。术前组间比较及术后组间比较均无显著性差异(t1=1.231,P<0.05；t2=1.352,P<0.05)。
椎体高度压缩率：两组在术前和术后组内比较均有显著性差异(t1=2.653,P<0.05；t2=3.117,P<0.05)。术前和术后两组间比较均无显著性差异(t1=1.365,P>0.05；t2=1.286,P>0.05)。
JOA评分：两组在术前和术后组内比较均有显著性差异(t1=3.974,P<0.05；t2=3.821,P<0.05)。术前及术后组间比较均无显著性差异(t1=1.532,P>0.05；t2=1.163,P>0.05)。两组的术后优良率比较经ridit分析也无显著差异(u=0.956,P>0.05)。
骨水泥渗漏率：两组在骨水泥渗漏率方面有显著性差异(X2=4.936,P<0.05)。双侧均采取多量注入可以明显增加骨水泥的渗漏率。
手术中血压下降情况：个别病例发生血压小范围波动,所有病例未发生骨水泥注射过程中血压突然下降至休克的情况。
结论
1、PVP与PKP及手法复位PVP临床治疗效果相似,PKP对后凸畸形矫正较好,PVP有较好的手术耐受性,手术时间和放射暴露较少。
2、不同骨水泥弥散方式对早期治疗效果影响无明显差别。
3、PVP双侧穿刺与单侧穿刺注入骨水泥临床治疗效果相当,单侧穿刺有较好的手术耐受性,手术时间和放射暴露较少。
4、双侧穿刺注入不同骨水泥量的临床治疗效果相似,多量注入骨水泥渗漏率相对较高。
5、简易PVP治疗骨质疏松性椎体压缩骨折可取得满意疗效并可提高手术耐受性,减少放射暴露,对老年人尤其适用。
6、在椎体成形术中可根据具体情况具体选择术式,只要掌握好手术指征、熟练操作技术、术中严密监视,均可以获得满意的治疗效果及最少的并发症发生率。
Background
Osteoporosis is the frequent disease of old ages, expecially occurs in the post-menopause old females, and the vertebral compression fracture is the most common complication of osteoporosis. Along with the aging frequency of the social populacation, the amount of osteoporosis patient increased gradually, and the thoracic and lumbar compression fracture increased accordingly. With regard to the old age osteoporosis compression fracture, the conservative treatment was the common method formerly. But the body constitution of the old ages are not good commonly, they often have many complications, the rate of complications is high. However, the surgery method has more trauma and more risk. The tolerance of the surgery and anesthesia of the old ages is not good, many patient can not tolerant or accept the traditionary open surgery method. So, how to take a more minimal injury and more effective treatment become an important topic of the therapy of thoracic and lumbar compression fracture.
The French neuroradiologist adopted the percutaneous vertebroplasty to treat the cervical vertebral angeioma first and achieved big success. Afterward, the percutaneous vertebroplasty was adopted to treat the vertebral compression fracture and vertebral tumor gradually. Later, with the basis of the percutaneous vertebroplasyty, the percutaneous kyphoplasty and Sky kyphoplasty were designed and applicated. Also, some scholar adopted the manipulative reduction unioned percutaneous verteoplasty to treat the vertebral fracture and accepted good effect too.
But, many question involved the percutaneous vertebroplasty was not certain. For example, the questions of which vertebroplasty style is better, one side and two side approach which is better, more or less bone cement infusing in is better, the therapeutic efficacy of the bone cement dispersing style remains many controversy. Through analyzing and studying the recent year therapeutic data of our hospital, we proposed our opinion and the choice rules about the percutaneous vertebroplasty.
Objective
1To observe the therapeutic efficacity and the radiological exposure of different percutaneous vertebroplasty style.
2To observe the therapeutic efficacity and bone cement leak rate of different bone cement disperse style.
3To observe the therapeutic efficacity of single or doule side vertebral approach style.
4To observe the therapeutic efficacity and bone cement leak rate of different bone cement infusing quantity.
5Through the observation of all sorts of indicatrix, evaluate and guide the choice of different vertevroplasty style.
Method
1The clinical application comparison of PVP, PKP and manipulative reduction PVP
Review the case of osteoporosis first lumbar vertebral fracture between Sep.2010to Sep.2012accepted double-side approach PVP, PKP and manipulative reduction PVP in our orthopaedics department, observe the VAS score, the Cobb's angle improvement rate,the JOA score,the bone cement disperse style,the bone cement leak rate, the radiological exposure, the operation time and the tolerant competence of the patient, then analyse the data statistically.
2The effect of different bone cement disperse style to therapeutic efficacity
Review the osteoporosis thoracic and lumbar vertebral compression fracture cases which accepted the single-side approach PVP and taken the anteroposterior position and lateral position DR picture. Calculate the area of the disperse district and the bolus district with the Auto CAD2007graphic processing soft and calculate the ratios of the two district and classify the cases to3type according to the ratios. Observe the VAS Score, the vertebral height compression rate, the JOA score and the cement leak rate, then analyse the data statistically.
3The clinical application comparison of double-side and single-side vertevral approach PVP
Review the cases of twelfth thoracic vertevral and first lumbar vertebral compression fracture which accepted the double-side or single-side approach PVP, Observe the VAS score, vertebral height compression rate, JOA score, the radiological exposure, the operation time and tolerant competence of the patient, analyse the data statistically.
4The clinical application comparison of different bone cement quantity
Review the cases of first lumbar vertebral compression fracture which accepted the double-side approach PVP with small bone cement quantity or large quantity, Observe the VAS score, vertebral height compression rate, JOA score,the bone cement leak rate and the blood pressure descending,analyse the data statistically.
Result
1The clinical application comparison of PVP, PKP and manipulative reduction PVP
The VAS score shows the significant different inside any group compared with the preoperative and postoperative score (=2.712, P<0.05; t2=2.608, P<0.05; t3=2.679, P<0.05). But there is no significant different among3groups preoperatively and postoperatively (F,=2.326, P>0.05; F2=2.075,P>0.05)
the Cobb's angle measurement shows the significant different inside any group compared with the preoperative and postoperative value (t1=2.698,P<0.05;t2=2.953, P<0.05; t3=3.107, P<0.05). And there is no significant different among3groups preoperatively (F,=2.373, P>0.05), But there is significant different of the Cobb's angle improvement rate among3groups postoperatively (F2=2.865, P<0.05) Compared with each other, there is significant different between PVP and manipulative PVP group or PVP and PKP group, no significant different between PKP and manipulative groups.
The JOA score shows the significant different inside any group compared with the preoperative and postoperative score (t1=3.118, P<0.05; t2=2.976, P<0.05; t3=2.853,P<0.05). But there is no significant different among3groups preoperatively and postoperatively (F,=2.413, P>0.05; F2=2.652, P>0.05)。The fineness rate among3groups has no significant different (X2=1.853, P>0.05)
The bone cement disperse style composition among3groups is significant different (X2=17.631, P<0.05). the bone cement leak rate shows no significant different among3groups (X2=2.633, P>0.05) The radiological exposure shows significant different among3groups (F,=12.751, P<0.05). Compared with each other, there is significant different between each2groups, the PVP group shows the least exposure, the PKP group shows the most exposure.
the operation time shows significant different among3groups (F=11.652, P<0.05). Compared with each other, there is significant different between each2groups, the PVP group shows the least operation time, the PKP group shows the most operation time. The tolerant competence of the patient shows significant different among3groups (X2=7.623, P<0.05), the PVP group shows the best tolerance.
2The effect of different bone cement disperse style to therapeutic efficacity
The VAS score shows the significant different inside any group compared with the preoperative and postoperative score (t1=2.724, P<0.05; t2=3.159, P<0.05;t3=3.263,p<0.05). But there is no significant different among3groups preoperatively and postoperatively (F,=2.357, P>0.05; F2=2.289, P>0.05)
the vertebral compression rate shows the significant different inside any group compared with the preoperative and postoperative value (t,=2.963, p<0.05; t2=3.027, p<0.05; t3=2.726, p<0.05). And there is no significant different among3groups preoperatively (F1=2.238, P>0.05), there is significant different among3groups postoperatively (F2=6.351, p<0.05).Compared with each other, there is significant different between PVP and manipulative PVP group or PVP and PKP group, no significant different between PKP and manipulative groups.
The JOA score shows the significant different inside any group compared with the preoperative and postoperative score (t1=2.983, p<0.05; t2=3.125, P<0.05; t3=3.257, P<0.05). But there is no significant different among3groups preoperatively and postoperatively (F1=1.867, P>0.05; F2=2.113, P>0.05). The fineness rate among3groups has no significant different (X2=0.846, P>0.05)
The bone cement leak rate shows no significant different among3groups (X2=1.536, P>0.05)
3The clinical application comparison of double-side and single-side vertevral approach PVP
The VAS score shows the significant different inside any group compared with the preoperative and postoperative score (t1=3.231, P<0.05; t2=3.352, P<0.05). But there is no significant different between2groups preoperatively and postoperatively(t1=3.231, P<0.05; t2=3.352, P<0.05)
The vertebral compression rate shows the significant different inside any group compared with the preoperative and postoperative value (t1=3.389,P<0.05;t2=3.265, P<0.05).And there is no significant different between2groups preoperatively and preoperatively (t1=1.574, P>0.05; t2=1.692, P>0.05)
The JOA score shows the significant different inside any group compared with the preoperative and postoperative score (t1=3.236, P<0.05; t2=3.186, P<0.05). But there is no significant different between2groups preoperatively and postoperatively(t1=1.358, P>0.05; t2=1.524, P>0.05). The fineness rate between2groups has no significant different (u=1.156, P>0.05)
The radiological exposure time and dose area product show significant different between2groups (t1=3.164, P<0.05; t2=3.235, P<0.05), the single-side approach PVP group shows the less radiological exposure. The operation time shows significant different between2groups (t=4.635, P<0.05), the single-side approach PVP group shows the less operation time. The tolerant competence of the patient shows significant different between2groups (X2=4.157, P<0.05),the PVP group shows the better tolerance.
4The clinical application comparison of different bone cement quantity
The VAS score shows the significant different inside any group compared with the preoperative and postoperative score(t1=3.168, P<0.05;t2=3.563, P<0.05). But there is no significant different between2groups preoperatively and postoperatively(t1=1.231,P<0.05; t2=1.352,P<0.05)
The vertebral compression rate shows the significant different inside any group compared with the preoperative and postoperative value (t1=2.653,P<0.05; t2=3.117,P<0.05).And there is no significant different between2groups preoperatively and preoperatively (t1=1.365, P>0.05; t2=1.286, P>0.05)
The JOA score shows the significant different inside any group compared with the preoperative and postoperative score (t1=3.974, P<0.05; t2=3.821,P<0.05). But there is no significant different between2groups preoperatively and postoperatively(t1=1.532, P>0.05; t2=1.163, P>0.05).The fineness rate between2groups has no significant different (u=0.956, P>0.05)
The bone cement leak rate shows significant different between2groups (X2=4.936, P<0.05), infusing more bone cement quantity can increase the leak rate.
The blood pressure of some patients descended slightly during the operation, but no serious blood pressure descending to shock in any case.
Conclusion
1The clinical therapeutic efficacity is similar among the PVP, PKP and manipulative PVP, but the PVP method shows better operation tolerance, less operation time and radiological exposure. The PKP method is some better in kyphosis correcting.
2The bone cement disperse style makes no different effect to therapeutic efficacity in early term.
3The single-side approach shows the equivalent efficacity as the double-side approach, but the single-side approach shows the better operation tolerance and less operation time, less radiological exposure.
4More or less bone cement infusion quantity during the operation may creat the similar therapeutic effect, but the more quantity makes higher bone cement leak rate.
5The simple PVP can be used in treating the osteoporosis vertebral compression fracture and get satisfied therapeutic efficacity. It can increase the operationg tolerance and decrease the radiological exposure, much applicable to old ages.
6The choice of operation style depends on the specific patient and specific circumstance. If the operation index is approciated, the technique is skilled, the operation procedure is monitored well, the therapeutic outcome will be good.
骨质疏松症是常见的老年疾病,在绝经后妇女尤其多发,而骨质疏松性椎体压缩骨折是骨质疏松症的最常见并发症之一,随着社会人口的老龄化的趋势越来越明显,骨质疏松症患者逐渐增多,由此导致的胸腰椎压缩骨折也逐年增多。对于老年骨质疏松性椎体压缩骨折的治疗,在以往多以保守治疗为主,但老年人一般体质较差,合并症较多,保守治疗发生并发症的几率较高,而手术治疗创伤较大,风险也较高。老年病人手术及麻醉耐受性多较差,多数病人不能耐受或不能接受传统的开放手术治疗。因而,如何采取微创有效的治疗方式成为治疗胸腰椎压缩骨折研究较多的课题。
法国的神经放射学医师首先采用经皮椎体成形术治疗颈椎血管瘤并获得成功。以后,PVP被逐渐应用于骨质疏松性椎体骨折和脊柱肿瘤的治疗,后来又在PVP的基础上加以改进,设计了球囊扩张椎体后凸成形术及Sky膨胀式椎体成形器,国内也有一些学者结合中医正脊复位等方式衍生出正脊复位加PVP的技术方式,也取得了很好的治疗效果。但在采取哪种椎体成形方式、采取单侧穿刺还是双侧穿刺、骨水泥注入量多少、骨水泥弥散方式对治疗效果的影响等多方面问题仍有较多争论,分析我院近几年各种治疗方式的数据并进行了系统研究,我们提出了自己的观点和选择方式。
目的
1、观察不同椎体成形手术方式对骨质疏松性压缩骨折治疗效果和放射暴露剂量的影响。
2、观察不同骨水泥弥散方式对骨质疏松性压缩骨折治疗效果和骨水泥渗漏率的影响。
3、观察单侧穿刺和双侧穿刺注入骨水泥对骨质疏松性压缩骨折治疗效果和放射暴露、手术耐受的影响。
4、观察不同骨水泥注入量对骨质疏松性压缩骨折治疗效果和骨水泥渗漏率的影响。
5、通过各种术式的多指标观察,综合评价并指导不同情况下椎体成形手术方式的选择。
方法
1、PVP与PKP及手法复位PVP临床应用比较
回顾研究2010年9月至2012年9月我院收治的骨质疏松性腰1单椎体压缩骨折行双侧穿刺PVP和PKP以及手法复位PVP治疗的病例,观察VAS评分、后凸畸形角(Cobb角)的测量、JOA评分、骨水泥弥散方式、骨水泥渗漏发生率、手术中放射暴露剂量、手术时间、手术中患者耐受情况等并进行统计学分析。
2、不同骨水泥弥散方式对治疗效果的影响
分析骨质疏松性胸腰椎压缩骨折行单侧穿刺经皮椎体成形术病例,术后摄正侧位DR片,以Auto CAD2007图形处理软件计算骨水泥团块区面积和弥散区面积,然后计算正侧位平均弥散区与平均团块区面积的比值K,定义K<50%为团块型,50%≦K≦100%为混合型,K>100%为弥散型。按骨水泥弥散类型分3组,观察各治疗组的VAS评分、椎体高度压缩率、JOA评分、骨水泥渗漏率等并进行统计学分析。
3、PVP双侧穿刺与单侧穿刺注入骨水泥的临床应用比较
分析骨质疏松性胸12及腰1椎体双椎体压缩骨折病例,行单侧或双侧PVP治疗,观察VAS评分、椎体高度压缩率、JOA评分、手术中放射暴露剂量、手术时间、手术中患者耐受情况等,进行统计学分析。
4双侧穿刺注入不同骨水泥量的临床应用比较
分析骨质疏松性腰1椎体压缩骨折病例,分为双侧少量骨水泥PVP治疗组和双侧多量骨水泥PVP治疗组,少量组每侧均注入1.5ml,总量3m],双侧多量骨水泥PVP组每侧尽可能注入约2.5-3ml骨水泥,总量约5-6ml,或至出现骨水泥少量外渗时停止,总量>4ml。观察VAS评分、椎体高度压缩率、JOA评分、骨水泥渗漏率、手术中血压下降情况等并进行统计学分析。
结果
1、PVP与PKP及手法复位PVP临床应用比较
VAS评分：三组在术前和术后组内比较均有显著性差异(t1=2.712,P<0.05；t2=2.608,P<0.05；t3=2.679,P<0.05)。术前组间比较及术后组间比较均三组无显著性差异(F1=2.326,P>0.05；F2=2.075,P>0.05)。
后凸畸形角(Cobb角)的测量：各组在术前和术后组内比较均有显著性差异(t1=2.698,P<0.05；t2=2.953,P<0.05；t3=3.107,P<0.05)。术前组间比较三组均无显著性差异(F1=2.373,P>0.05),而术后后凸畸形矫正率比较三组有显著性差异(F2=2.865,P<0.05),通过两两比较可发现PVP组与PKP组及手法复位PVP组均有显著差异,而PKP组与手法复位PVP组无显著差异。
JOA评分：各组在术前和术后组内比较均有显著性差异(t1=3.118,P<0.05；t2=2.976,P<0.05；t3=2.853,P<0.05)。术前组间比较及术后组间比较均三组无显著性差异(F1=2.413,P>0.05；F2=2.652,P>0.05)。三组的术后优良率比较经ridit分析也无显著差异(X2=1.853,P>0.05)。
骨水泥弥散方式：X2检验分析三组的弥散类型构成不同(X2=17.631,P<0.05),PVP组弥散型和混合型为主,PKP组、手法复位PVP组以团块型和混合型为主。
骨水泥渗漏发生率：各组在骨水泥渗漏率方面无显著性差异(X2=2.633,P>0.05)。
术中放射暴露情况：三组的放射暴露时间比较有显著性差异(F1=12.751,P<0.05),通过两两比较可发现每两组间均有显著差异；三组的剂量-面积乘积比较也有显著性差异(F2=11.854,P<0.05),通过两两比较可发现每两组均有显著差异,从三组的平均时间来看,PVP组剂量-面积乘积最小,手法复位PVP组放射量略多,PKP组放射暴露最大。
手术时间：各组的手术时间比较有显著性差异(F=11.652,P<0.05),两两比较均有显著差异。PVP组手术时间最短,PKP组手术时间最长。
手术中患者耐受情况：三组的手术耐受率比较有显著性差异(X2=7.623,P<0.05),PVP组有最好的手术耐受率。
2、不同骨水泥弥散方式对治疗效果的影响
VAS评分：团块型组与混合型及弥散型组在术前和术后组内比较均有显著性差异(t1=2.724,P<0.05；t2=3.159,P<0.05；t3=3.263,P<0.05)。术前组间比较及术后组间比较均三组无显著性差异(F1=2.357,P>0.05；F2=2.289,P>0.05)。
椎体高度压缩率：三组在术前和术后组内比较均有显著性差异(t11=2.963,P<0.05；t2=3.027,P<0.05；t3=2.726,P<0.05)。术前组间比较三组均无显著性差异(F,=2.238,P>O.05),而术后组间三组有显著性差异(F2=6.351,P<0.05),通过两两比较可发现团块型组、混合型组与弥散型组均有显著差异,而团块型组与混合型组无显著差异。团块型与混合型的弥散方式可能更多地恢复压缩椎体高度。
JOA评分：各组在术前和术后组内比较均有显著性差异(t1=2.983,P<0.05；t2=3.125,P<0.05；t3=3.257,P<0.05)。术前组间比较及术后组间比较均无显著性差异(F,=1.867,P>0.05；F2=2.113,P>0.05)。三组的术后优良率比较经ridit分析也无显著差异(X2=0.846,P>0.05)。
骨水泥渗漏发生率：三组在骨水泥渗漏率方面无显著性差异(X2=1.536,P>0.05)。
3、PVP双侧穿刺与单侧穿刺注入骨水泥的临床应用比较
VAS评分：单侧穿刺PVP组与双侧穿刺PVP组在术前和术后组内比较均有显著性差异(t1=3.231,P<0.05；t2=3.352,P<0.05)。术前组间比较及术后组间比较均两组无显著性差异(t1=1.215,P>0.05；t2=1.078,P>0.05)。
椎体高度压缩率：单侧穿刺PVP组与双侧穿刺PVP组在术前和术后组内比较均有显著性差异(t13.389,P<0.05；t2=3.265,P<0.05)。术前、术后组间比较两组均无显著性差异(t1=1.574,P>0.05；t2=1.692,P>0.05)。
JOA评分：两组在术前和术后组内比较均有显著性差异(t1=3.236,P<0.05；t2=3.186,P<0.05)。术前组间比较及术后组间比较两组均无显著性差异(t1=1.358,P>0.05；t2=1.524,P>0.05)。两组的术后优良率比较经ridit分析也无显著差异(u=1.156,P>0.05)。
手术中放射暴露情况：单侧穿刺PVP组和双侧穿刺PVP组透视时间和剂量-面积乘积比较有显著性差异(t1=3.164,P<0.05；t2=3.235,P<0.05),单侧穿刺组透视时间和剂量-面积乘积较少。
手术时间：两组手术时间比较有显著性差异(t=4.635,P<0.05),单侧穿刺PVP组手术时间较短。
手术中患者耐受情况：两组的手术耐受率比较有显著性差异(X2=4.157,P<0.05),单侧穿刺PVP组有较好的手术耐受率。
4、双侧穿刺注入不同骨水泥量的临床应用比较
VAS评分：双侧少量骨水泥PVP组与双侧多量骨水泥PVP组在术前和术后组内比较均有显著性差异(t1=3.168,P<0.05；t1=3.563,P<0.05)。术前组间比较及术后组间比较均无显著性差异(t1=1.231,P<0.05；t2=1.352,P<0.05)。
椎体高度压缩率：两组在术前和术后组内比较均有显著性差异(t1=2.653,P<0.05；t2=3.117,P<0.05)。术前和术后两组间比较均无显著性差异(t1=1.365,P>0.05；t2=1.286,P>0.05)。
JOA评分：两组在术前和术后组内比较均有显著性差异(t1=3.974,P<0.05；t2=3.821,P<0.05)。术前及术后组间比较均无显著性差异(t1=1.532,P>0.05；t2=1.163,P>0.05)。两组的术后优良率比较经ridit分析也无显著差异(u=0.956,P>0.05)。
骨水泥渗漏率：两组在骨水泥渗漏率方面有显著性差异(X2=4.936,P<0.05)。双侧均采取多量注入可以明显增加骨水泥的渗漏率。
手术中血压下降情况：个别病例发生血压小范围波动,所有病例未发生骨水泥注射过程中血压突然下降至休克的情况。
结论
1、PVP与PKP及手法复位PVP临床治疗效果相似,PKP对后凸畸形矫正较好,PVP有较好的手术耐受性,手术时间和放射暴露较少。
2、不同骨水泥弥散方式对早期治疗效果影响无明显差别。
3、PVP双侧穿刺与单侧穿刺注入骨水泥临床治疗效果相当,单侧穿刺有较好的手术耐受性,手术时间和放射暴露较少。
4、双侧穿刺注入不同骨水泥量的临床治疗效果相似,多量注入骨水泥渗漏率相对较高。
5、简易PVP治疗骨质疏松性椎体压缩骨折可取得满意疗效并可提高手术耐受性,减少放射暴露,对老年人尤其适用。
6、在椎体成形术中可根据具体情况具体选择术式,只要掌握好手术指征、熟练操作技术、术中严密监视,均可以获得满意的治疗效果及最少的并发症发生率。
Background
Osteoporosis is the frequent disease of old ages, expecially occurs in the post-menopause old females, and the vertebral compression fracture is the most common complication of osteoporosis. Along with the aging frequency of the social populacation, the amount of osteoporosis patient increased gradually, and the thoracic and lumbar compression fracture increased accordingly. With regard to the old age osteoporosis compression fracture, the conservative treatment was the common method formerly. But the body constitution of the old ages are not good commonly, they often have many complications, the rate of complications is high. However, the surgery method has more trauma and more risk. The tolerance of the surgery and anesthesia of the old ages is not good, many patient can not tolerant or accept the traditionary open surgery method. So, how to take a more minimal injury and more effective treatment become an important topic of the therapy of thoracic and lumbar compression fracture.
The French neuroradiologist adopted the percutaneous vertebroplasty to treat the cervical vertebral angeioma first and achieved big success. Afterward, the percutaneous vertebroplasty was adopted to treat the vertebral compression fracture and vertebral tumor gradually. Later, with the basis of the percutaneous vertebroplasyty, the percutaneous kyphoplasty and Sky kyphoplasty were designed and applicated. Also, some scholar adopted the manipulative reduction unioned percutaneous verteoplasty to treat the vertebral fracture and accepted good effect too.
But, many question involved the percutaneous vertebroplasty was not certain. For example, the questions of which vertebroplasty style is better, one side and two side approach which is better, more or less bone cement infusing in is better, the therapeutic efficacy of the bone cement dispersing style remains many controversy. Through analyzing and studying the recent year therapeutic data of our hospital, we proposed our opinion and the choice rules about the percutaneous vertebroplasty.
Objective
1To observe the therapeutic efficacity and the radiological exposure of different percutaneous vertebroplasty style.
2To observe the therapeutic efficacity and bone cement leak rate of different bone cement disperse style.
3To observe the therapeutic efficacity of single or doule side vertebral approach style.
4To observe the therapeutic efficacity and bone cement leak rate of different bone cement infusing quantity.
5Through the observation of all sorts of indicatrix, evaluate and guide the choice of different vertevroplasty style.
Method
1The clinical application comparison of PVP, PKP and manipulative reduction PVP
Review the case of osteoporosis first lumbar vertebral fracture between Sep.2010to Sep.2012accepted double-side approach PVP, PKP and manipulative reduction PVP in our orthopaedics department, observe the VAS score, the Cobb's angle improvement rate,the JOA score,the bone cement disperse style,the bone cement leak rate, the radiological exposure, the operation time and the tolerant competence of the patient, then analyse the data statistically.
2The effect of different bone cement disperse style to therapeutic efficacity
Review the osteoporosis thoracic and lumbar vertebral compression fracture cases which accepted the single-side approach PVP and taken the anteroposterior position and lateral position DR picture. Calculate the area of the disperse district and the bolus district with the Auto CAD2007graphic processing soft and calculate the ratios of the two district and classify the cases to3type according to the ratios. Observe the VAS Score, the vertebral height compression rate, the JOA score and the cement leak rate, then analyse the data statistically.
3The clinical application comparison of double-side and single-side vertevral approach PVP
Review the cases of twelfth thoracic vertevral and first lumbar vertebral compression fracture which accepted the double-side or single-side approach PVP, Observe the VAS score, vertebral height compression rate, JOA score, the radiological exposure, the operation time and tolerant competence of the patient, analyse the data statistically.
4The clinical application comparison of different bone cement quantity
Review the cases of first lumbar vertebral compression fracture which accepted the double-side approach PVP with small bone cement quantity or large quantity, Observe the VAS score, vertebral height compression rate, JOA score,the bone cement leak rate and the blood pressure descending,analyse the data statistically.
Result
1The clinical application comparison of PVP, PKP and manipulative reduction PVP
The VAS score shows the significant different inside any group compared with the preoperative and postoperative score (=2.712, P<0.05; t2=2.608, P<0.05; t3=2.679, P<0.05). But there is no significant different among3groups preoperatively and postoperatively (F,=2.326, P>0.05; F2=2.075,P>0.05)
the Cobb's angle measurement shows the significant different inside any group compared with the preoperative and postoperative value (t1=2.698,P<0.05;t2=2.953, P<0.05; t3=3.107, P<0.05). And there is no significant different among3groups preoperatively (F,=2.373, P>0.05), But there is significant different of the Cobb's angle improvement rate among3groups postoperatively (F2=2.865, P<0.05) Compared with each other, there is significant different between PVP and manipulative PVP group or PVP and PKP group, no significant different between PKP and manipulative groups.
The JOA score shows the significant different inside any group compared with the preoperative and postoperative score (t1=3.118, P<0.05; t2=2.976, P<0.05; t3=2.853,P<0.05). But there is no significant different among3groups preoperatively and postoperatively (F,=2.413, P>0.05; F2=2.652, P>0.05)。The fineness rate among3groups has no significant different (X2=1.853, P>0.05)
The bone cement disperse style composition among3groups is significant different (X2=17.631, P<0.05). the bone cement leak rate shows no significant different among3groups (X2=2.633, P>0.05) The radiological exposure shows significant different among3groups (F,=12.751, P<0.05). Compared with each other, there is significant different between each2groups, the PVP group shows the least exposure, the PKP group shows the most exposure.
the operation time shows significant different among3groups (F=11.652, P<0.05). Compared with each other, there is significant different between each2groups, the PVP group shows the least operation time, the PKP group shows the most operation time. The tolerant competence of the patient shows significant different among3groups (X2=7.623, P<0.05), the PVP group shows the best tolerance.
2The effect of different bone cement disperse style to therapeutic efficacity
The VAS score shows the significant different inside any group compared with the preoperative and postoperative score (t1=2.724, P<0.05; t2=3.159, P<0.05;t3=3.263,p<0.05). But there is no significant different among3groups preoperatively and postoperatively (F,=2.357, P>0.05; F2=2.289, P>0.05)
the vertebral compression rate shows the significant different inside any group compared with the preoperative and postoperative value (t,=2.963, p<0.05; t2=3.027, p<0.05; t3=2.726, p<0.05). And there is no significant different among3groups preoperatively (F1=2.238, P>0.05), there is significant different among3groups postoperatively (F2=6.351, p<0.05).Compared with each other, there is significant different between PVP and manipulative PVP group or PVP and PKP group, no significant different between PKP and manipulative groups.
The JOA score shows the significant different inside any group compared with the preoperative and postoperative score (t1=2.983, p<0.05; t2=3.125, P<0.05; t3=3.257, P<0.05). But there is no significant different among3groups preoperatively and postoperatively (F1=1.867, P>0.05; F2=2.113, P>0.05). The fineness rate among3groups has no significant different (X2=0.846, P>0.05)
The bone cement leak rate shows no significant different among3groups (X2=1.536, P>0.05)
3The clinical application comparison of double-side and single-side vertevral approach PVP
The VAS score shows the significant different inside any group compared with the preoperative and postoperative score (t1=3.231, P<0.05; t2=3.352, P<0.05). But there is no significant different between2groups preoperatively and postoperatively(t1=3.231, P<0.05; t2=3.352, P<0.05)
The vertebral compression rate shows the significant different inside any group compared with the preoperative and postoperative value (t1=3.389,P<0.05;t2=3.265, P<0.05).And there is no significant different between2groups preoperatively and preoperatively (t1=1.574, P>0.05; t2=1.692, P>0.05)
The JOA score shows the significant different inside any group compared with the preoperative and postoperative score (t1=3.236, P<0.05; t2=3.186, P<0.05). But there is no significant different between2groups preoperatively and postoperatively(t1=1.358, P>0.05; t2=1.524, P>0.05). The fineness rate between2groups has no significant different (u=1.156, P>0.05)
The radiological exposure time and dose area product show significant different between2groups (t1=3.164, P<0.05; t2=3.235, P<0.05), the single-side approach PVP group shows the less radiological exposure. The operation time shows significant different between2groups (t=4.635, P<0.05), the single-side approach PVP group shows the less operation time. The tolerant competence of the patient shows significant different between2groups (X2=4.157, P<0.05),the PVP group shows the better tolerance.
4The clinical application comparison of different bone cement quantity
The VAS score shows the significant different inside any group compared with the preoperative and postoperative score(t1=3.168, P<0.05;t2=3.563, P<0.05). But there is no significant different between2groups preoperatively and postoperatively(t1=1.231,P<0.05; t2=1.352,P<0.05)
The vertebral compression rate shows the significant different inside any group compared with the preoperative and postoperative value (t1=2.653,P<0.05; t2=3.117,P<0.05).And there is no significant different between2groups preoperatively and preoperatively (t1=1.365, P>0.05; t2=1.286, P>0.05)
The JOA score shows the significant different inside any group compared with the preoperative and postoperative score (t1=3.974, P<0.05; t2=3.821,P<0.05). But there is no significant different between2groups preoperatively and postoperatively(t1=1.532, P>0.05; t2=1.163, P>0.05).The fineness rate between2groups has no significant different (u=0.956, P>0.05)
The bone cement leak rate shows significant different between2groups (X2=4.936, P<0.05), infusing more bone cement quantity can increase the leak rate.
The blood pressure of some patients descended slightly during the operation, but no serious blood pressure descending to shock in any case.
Conclusion
1The clinical therapeutic efficacity is similar among the PVP, PKP and manipulative PVP, but the PVP method shows better operation tolerance, less operation time and radiological exposure. The PKP method is some better in kyphosis correcting.
2The bone cement disperse style makes no different effect to therapeutic efficacity in early term.
3The single-side approach shows the equivalent efficacity as the double-side approach, but the single-side approach shows the better operation tolerance and less operation time, less radiological exposure.
4More or less bone cement infusion quantity during the operation may creat the similar therapeutic effect, but the more quantity makes higher bone cement leak rate.
5The simple PVP can be used in treating the osteoporosis vertebral compression fracture and get satisfied therapeutic efficacity. It can increase the operationg tolerance and decrease the radiological exposure, much applicable to old ages.
6The choice of operation style depends on the specific patient and specific circumstance. If the operation index is approciated, the technique is skilled, the operation procedure is monitored well, the therapeutic outcome will be good.
引文
[1]Svejme 0, Ahlborg HG, Nilsson JA, etc. Early menopause and risk of osteoporosis, fracture and mortality:a 34-year prospective observational study in 390 women[J]. BJOG.2012,119(7):810-816.
[2]Svedbom A; Alvares L; Cooper C; etc. Balloon kyphoplasty compared to vertebroplasty and nonsurgical management in patients hospi tal ised wi th acute osteoporot ic vertebral compression fracture: a UK cost-effectiveness analysis[J]. Osteoporos Int.2013, 24(1):355-67.
[3]Molina GS, Campero A, Feito R, etc. Kyphoplasty in the treatment of osteoporotic Vertebral Compression Fractures (VCF):procedure description and analysis of the outcomes in 128 patients[J].Acta Neurochir Suppl.2011,10(8):163-70.
[4]ReileyMA, WongW, Garfin S. Verterbroplasty/Kyphoplasty[J]. Journal of Womens'Imaging,2000,2(3):117.
[5]Tomita, McLain RF, Yerby SA. Reinforcement of thoracolumbar burst fractureswith calcium phosphate cement:a biomechanical study [J]. Spine,2007,23(6):664-671.
[6]Yan D, Duan L, Li J, etc. Comparative study of percutaneous vertebroplasty and kyphoplasty in the treatment of osteoporotic vertebral compression fractures [J]. Arch Orthop Trauma Surg.2011,131(5):645-50.
[7]郑召民,邝冠明,李佛保,等.Sky骨扩张器在经皮后凸成形术中的临床应用.中国脊柱脊髓杂志,2005,15：166-169.
[8]邓忠良,柯珍勇,陈富,等.Sky骨扩张器系统在经皮后凸成形术中初步临床应用.中国脊柱脊髓杂志,2005,15：166-169.
[9]John Steinmann, BrownerWS, Palermo L, et al. Vertebral fractures andmortality in olderwomen:a prospective study[J]. ArchIntern Mod,2005,159(6):1215-1220.
[10]Belkoff, Yuan HA, Reiley MA. New technologies in spine:kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures[J].Spine, 2004,26(14):1511-1515.
[11]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,2003,23(5)：262-265.
[12]Hulme PA, Krebs J, Ferguson SJ, et al. Vertebroplasty and kyphoplast:a systematic review of 69 clinical studies [J]. Spine, 2006,31(8):1983-1984.
[13]Miller DL, Balter S, Cole PE, et al. Radiation doses ininterventional radiology procedures:The RAD IVR study:Part II: Skin Dose [J].J Vasc Interv Radiol,2003,14 (8):977-990.
[14]Hadley C, Awan OA, Zoarski GH. Biomechanics of vertebral bone augmentation[J]. Neuroimaging Clin N Am.2010,20(2):159-67.
[15]张建邹,金梅,邹容等.36例经皮椎体成形术的临床应用分析[J].介入放射学杂志.2012,21(10)：864-868.
[16]史丽娜,吴春根,李文彬等.椎体压缩性骨折MRI信号特点与PVP术后疗效相关性分析[J]介入放射学杂志.2011,20(1)：32-36.
[17]郭锦明,章东明,刘俊等.牵引复位结合PVP治疗老年创伤性椎体压缩性骨折[J].实用骨科杂志.第18卷,第5期,2012,18(5)：434-436.
[18]张亮,高梁斌,李健,等.椎体成形术中椎体骨密度对骨水泥弥散体积的影响[J].中国脊柱脊髓杂志.2011,21(11)：915-918.
[19]John Steinmann, BrownerWS, Palermo L, et al. Vertebral fractures andmortality in olderwomen:a prospective study[J]. ArchIntern Med,2005,159(6):1215-1220.
[20]Guarnieri G, Ambrosanio G, Pezzullo MG,etc. Management of vertebral refractures after vertebroplasty in osteoporotic patients[J]. Interv Neuroradiol.2009,15(2):153-7.
[21]Belkoff[14] [14] Belkoff, Yuan HA, Reiley MA. New technologies in spine:kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures[J]. Spine,2004,26(14):1511-1515.
[22]Muller CW, Gosling T, Mameghani A. Vertebral fractures due to osteoporosis. Kyphoplasty and vertebroplasty vs conservative treatment[J]. Orthopade.2010,39(4):417-24.
[23]郑毅,代洪宾,朱建林.PVP结合药物治疗骨质疏松性椎体压缩性骨折[J].中国骨质疏松杂志.2011,17(3)：226-229.
[24]许峰,杨小龙.联合软组织封闭治疗骨质疏松性胸腰椎压缩性骨折疗效观察[J]颈腰痛杂志.2012,33(1)：43-44.
[25]Walter J, Haciyakupoglu E, Waschke A, etc. Cement leakage as a possible complication of balloon kyphoplasty--is there a difference between osteoporotic compression fractures and incomplete burst fractures[J].Acta Neurochir (Wien).2012,154(2):313-9.
[26]Wang HL, Jiang ZG, Wang ZG, etc. Analysis of the complication and prevention on treatment of osteoporotic vertebral compressive fractures by percutaneous vertebroplasty (PVP)[J]. Zhongguo Gu Shang.2009,22(10):783-784.
[27]Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures [J]. Spine,2003,28:45-53.
[28]Nieuwenhuijse MJ, Muijs SP, van Erkel ARA, etc. clinical comparative study on low versus medium viscosity polymethylmetacrylate bone cement in percutaneous vertebroplasty: viscosity associated with cement leakage[J]. Spine (Phila Pa 1976).2010,35(20):1037-44.
[29]Petridis AK, Maslehaty H, Eichenhofer T, Pulmonary embolism associated with poly(methyl methacrylate) (PMMA) after vertebroplasty. A complication more often than one thinks[J]. Acta Neurochir (Wien).2012,52(1).
[30]Wang HL, Jiang ZG, Wang ZG, etc. Analysis of the complication and prevention on treatment of osteoporotic vertebral compressive fractures by percutaneous vertebroplasty (PVP)[J]. Zhongguo Gu Shang.2009,22(10):783-784.
[31]Blasco J, Martinez-Ferrer A, Macho J, etc. Effect of vertebroplasty on pain relief, quality of life, and the incidence of new vertebral fractures:a 12-month randomized follow-up, controlled trial[J]. J Bone Miner Res.2012,27(5):1159-66.
[32]Marcia S, Boi C, Dragani M, etc. Effectiveness of a bone substitute (CERAMENT) as an alternative to PMMA in percutaneous vertebroplasty: 1-year follow-up on clinical outcome[J]. Eur Spine J.2012,21(1):112-118.
[33]Qian G, Dong Y, Yang W, etc. Injectable calcium phosphate cement and fibrin sealant recombined human bone morphogenetic protein-2 composite in vertebroplasty:an animal study[J]. Bosn J Basic Med Sci.2012,12(4):231-235.
[2]Svedbom A; Alvares L; Cooper C; etc. Balloon kyphoplasty compared to vertebroplasty and nonsurgical management in patients hospi tal ised wi th acute osteoporot ic vertebral compression fracture: a UK cost-effectiveness analysis[J]. Osteoporos Int.2013, 24(1):355-67.
[3]Molina GS, Campero A, Feito R, etc. Kyphoplasty in the treatment of osteoporotic Vertebral Compression Fractures (VCF):procedure description and analysis of the outcomes in 128 patients[J].Acta Neurochir Suppl.2011,10(8):163-70.
[4]ReileyMA, WongW, Garfin S. Verterbroplasty/Kyphoplasty[J]. Journal of Womens'Imaging,2000,2(3):117.
[5]Tomita, McLain RF, Yerby SA. Reinforcement of thoracolumbar burst fractureswith calcium phosphate cement:a biomechanical study [J]. Spine,2007,23(6):664-671.
[6]Yan D, Duan L, Li J, etc. Comparative study of percutaneous vertebroplasty and kyphoplasty in the treatment of osteoporotic vertebral compression fractures [J]. Arch Orthop Trauma Surg.2011,131(5):645-50.
[7]郑召民,邝冠明,李佛保,等.Sky骨扩张器在经皮后凸成形术中的临床应用.中国脊柱脊髓杂志,2005,15：166-169.
[8]邓忠良,柯珍勇,陈富,等.Sky骨扩张器系统在经皮后凸成形术中初步临床应用.中国脊柱脊髓杂志,2005,15：166-169.
[9]John Steinmann, BrownerWS, Palermo L, et al. Vertebral fractures andmortality in olderwomen:a prospective study[J]. ArchIntern Mod,2005,159(6):1215-1220.
[10]Belkoff, Yuan HA, Reiley MA. New technologies in spine:kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures[J].Spine, 2004,26(14):1511-1515.
[11]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,2003,23(5)：262-265.
[12]Hulme PA, Krebs J, Ferguson SJ, et al. Vertebroplasty and kyphoplast:a systematic review of 69 clinical studies [J]. Spine, 2006,31(8):1983-1984.
[13]Miller DL, Balter S, Cole PE, et al. Radiation doses ininterventional radiology procedures:The RAD IVR study:Part II: Skin Dose [J].J Vasc Interv Radiol,2003,14 (8):977-990.
[14]Hadley C, Awan OA, Zoarski GH. Biomechanics of vertebral bone augmentation[J]. Neuroimaging Clin N Am.2010,20(2):159-67.
[15]张建邹,金梅,邹容等.36例经皮椎体成形术的临床应用分析[J].介入放射学杂志.2012,21(10)：864-868.
[16]史丽娜,吴春根,李文彬等.椎体压缩性骨折MRI信号特点与PVP术后疗效相关性分析[J]介入放射学杂志.2011,20(1)：32-36.
[17]郭锦明,章东明,刘俊等.牵引复位结合PVP治疗老年创伤性椎体压缩性骨折[J].实用骨科杂志.第18卷,第5期,2012,18(5)：434-436.
[18]张亮,高梁斌,李健,等.椎体成形术中椎体骨密度对骨水泥弥散体积的影响[J].中国脊柱脊髓杂志.2011,21(11)：915-918.
[19]John Steinmann, BrownerWS, Palermo L, et al. Vertebral fractures andmortality in olderwomen:a prospective study[J]. ArchIntern Med,2005,159(6):1215-1220.
[20]Guarnieri G, Ambrosanio G, Pezzullo MG,etc. Management of vertebral refractures after vertebroplasty in osteoporotic patients[J]. Interv Neuroradiol.2009,15(2):153-7.
[21]Belkoff[14] [14] Belkoff, Yuan HA, Reiley MA. New technologies in spine:kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures[J]. Spine,2004,26(14):1511-1515.
[22]Muller CW, Gosling T, Mameghani A. Vertebral fractures due to osteoporosis. Kyphoplasty and vertebroplasty vs conservative treatment[J]. Orthopade.2010,39(4):417-24.
[23]郑毅,代洪宾,朱建林.PVP结合药物治疗骨质疏松性椎体压缩性骨折[J].中国骨质疏松杂志.2011,17(3)：226-229.
[24]许峰,杨小龙.联合软组织封闭治疗骨质疏松性胸腰椎压缩性骨折疗效观察[J]颈腰痛杂志.2012,33(1)：43-44.
[25]Walter J, Haciyakupoglu E, Waschke A, etc. Cement leakage as a possible complication of balloon kyphoplasty--is there a difference between osteoporotic compression fractures and incomplete burst fractures[J].Acta Neurochir (Wien).2012,154(2):313-9.
[26]Wang HL, Jiang ZG, Wang ZG, etc. Analysis of the complication and prevention on treatment of osteoporotic vertebral compressive fractures by percutaneous vertebroplasty (PVP)[J]. Zhongguo Gu Shang.2009,22(10):783-784.
[27]Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures [J]. Spine,2003,28:45-53.
[28]Nieuwenhuijse MJ, Muijs SP, van Erkel ARA, etc. clinical comparative study on low versus medium viscosity polymethylmetacrylate bone cement in percutaneous vertebroplasty: viscosity associated with cement leakage[J]. Spine (Phila Pa 1976).2010,35(20):1037-44.
[29]Petridis AK, Maslehaty H, Eichenhofer T, Pulmonary embolism associated with poly(methyl methacrylate) (PMMA) after vertebroplasty. A complication more often than one thinks[J]. Acta Neurochir (Wien).2012,52(1).
[30]Wang HL, Jiang ZG, Wang ZG, etc. Analysis of the complication and prevention on treatment of osteoporotic vertebral compressive fractures by percutaneous vertebroplasty (PVP)[J]. Zhongguo Gu Shang.2009,22(10):783-784.
[31]Blasco J, Martinez-Ferrer A, Macho J, etc. Effect of vertebroplasty on pain relief, quality of life, and the incidence of new vertebral fractures:a 12-month randomized follow-up, controlled trial[J]. J Bone Miner Res.2012,27(5):1159-66.
[32]Marcia S, Boi C, Dragani M, etc. Effectiveness of a bone substitute (CERAMENT) as an alternative to PMMA in percutaneous vertebroplasty: 1-year follow-up on clinical outcome[J]. Eur Spine J.2012,21(1):112-118.
[33]Qian G, Dong Y, Yang W, etc. Injectable calcium phosphate cement and fibrin sealant recombined human bone morphogenetic protein-2 composite in vertebroplasty:an animal study[J]. Bosn J Basic Med Sci.2012,12(4):231-235.