EPS在骨质疏松性脊柱固定手术中的应用
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摘要
目的：评价膨胀式椎弓根螺钉(expandable pedicle screw, EPS)在骨质疏松情况下的胸腰椎疾病经椎弓根固定的可靠性。
方法：回顾性分析2008年1月至2010年05月我院收治且定期随访至少12个月的骨质疏松合并腰椎疾患行后路手术病人56例(随机、非盲),男25例,女31例；年龄45岁～72岁,平均61.3岁；病程2个月～5年,平均13.5个月。其中腰椎间盘突出症9例,腰椎管狭窄症14例,腰椎滑脱(按Meyerding分级)：Ⅰ度7例,Ⅱ度6例,Ⅲ度3例,胸腰椎结核2期后路融合手术6例,压缩性骨折7例、翻修手术4例。术前均采用双能X线吸收法(DXA),按照国际临床骨密度学会ISCD的质量控制要求,采用美国GE公司骨密度仪,检测腰椎骨密度(bone mineral density,BMD),证实BMD平均下降2.7个标准差。手术方式均采用腰椎后路椎弓根螺钉系统固定,患者被随机分组,采用EPS螺钉固定28例,普通椎弓根螺钉固定28例；随访观察患者疼痛视觉模拟评分(visual analogue scale,VAS)、改良Prolo功能评分,重点通过X线、CT的影像学检查评估螺钉稳定性及融合情况。
结果：所有患者均获15～24月随访,平均18月；EPS组术后1年有85.7%的患者螺钉位置稳定,脊柱融合率为85.7%,在EPS组中1例患者在第二次手术取钉时出现断钉情况；CPS组术后1年仅有60.0%的患者螺钉位置稳定,脊柱融合率为85.0%,未出现螺钉取出困难情况；术前、术后3个、术后6个月、术后12个月的VAS及改良Prolo功能评分显示较术前改善,但两组间差异不具统计学意义；同时所有患者中出现并发症的有16例(33.3%)、输血病例22例(45.8%),但两组之间并发症比较不具统计学意义。
结论：在胸腰椎疾病患者合并骨质疏松条件下采用EPS固定是相对稳定、有效的,EPS相比CPS可获得更强的固定能力,能够解决术后螺钉松动、脱落等问题,适宜用于在骨质疏松性脊柱疾病的融合固定手术中使用。且操作较为简单,不会增加手术时间及出血量。同时因骨质疏松性脊柱疾病多为年龄较大患者,故手术并发症相对较多,应更重视围手术期管理。
Objective：To evaluate the reliability and clinical efficacy of expandable pedicle screw (EPS) affixation for thoracolumbar patients afflicted with osteoporosis.
Method:A retrospective analysis was adopted. For at least twelve months from January 2008 to May 2010,56 thoracolumbar patients with osteoporosis were treated and regularly monitored; of them,25 were male,31 female, and aged 45 to 72 years, with an average age of 61.3 years. For these patients, the course of the disease was between 2 months and 5 years, with an average course of 13.5months; Among the 56 patients, lumbar disc herniation 9 cases, lumbar spine canal stenosis 14 cases, lumbar spondylolisthesis 16 cases, lumbar tuberculosis 6 cases, lumbar compression fractures 7 cases, and revision surgery 4 cases. Among the patients with spondylothisthesis,7 were in the 1st degree,6 were in the 2nd degree, and 3 were in the 3rd degree. All patients underwent bone mineral density testing before surgery, which indicated bone mass density averaging 2.7 standard deviations below the norm. The patients were divided into two groups,28 patients with EPS posterior spinal fixation,28 patients with conventional posterior spinal fixation, Efficacy of the surgery was evaluated using a pain visual analogue scale (visual analogue scale, VAS), modified Prolo functional scores and X rays, and CT and other imaging assessments of screw stability and integration.
Result:All patients were observed for 15 to 24 months post operation, for an average of 18 months. Both VAS and modified Prolo functional scores showed a significant improvement 3 months after operation,6 months after operation, and 12 months after operation. One year after operation in EPS,85.7% of the screw placements were stable, and the spinal fusion rate was 85.7%. One year after operation in CPS,60.0% of the screw placements were stable, and the spinal fusion rate was 85.0%. Eight patients (33.3%) developed complications (including systemic complications and spine-specific complications),22 cases (45.8%) required blood transfusions, and 1 patient's EPS broke during the process of removal.
Conclusion:For thoracolumbar patients suffering from severe osteoporosis, EPS may be simpler and more effective than other forms of screw fixation. EPS fixation is on average stronger and can solve several postoperative problems such as screw loosening and screw loss.Decreased rate of postoperative complications is especially important due to the fact that osteoporosis patients with spinal disease are typically older and more susceptible to complications. Age of the patient should be paid close attention.
方法：回顾性分析2008年1月至2010年05月我院收治且定期随访至少12个月的骨质疏松合并腰椎疾患行后路手术病人56例(随机、非盲),男25例,女31例；年龄45岁～72岁,平均61.3岁；病程2个月～5年,平均13.5个月。其中腰椎间盘突出症9例,腰椎管狭窄症14例,腰椎滑脱(按Meyerding分级)：Ⅰ度7例,Ⅱ度6例,Ⅲ度3例,胸腰椎结核2期后路融合手术6例,压缩性骨折7例、翻修手术4例。术前均采用双能X线吸收法(DXA),按照国际临床骨密度学会ISCD的质量控制要求,采用美国GE公司骨密度仪,检测腰椎骨密度(bone mineral density,BMD),证实BMD平均下降2.7个标准差。手术方式均采用腰椎后路椎弓根螺钉系统固定,患者被随机分组,采用EPS螺钉固定28例,普通椎弓根螺钉固定28例；随访观察患者疼痛视觉模拟评分(visual analogue scale,VAS)、改良Prolo功能评分,重点通过X线、CT的影像学检查评估螺钉稳定性及融合情况。
结果：所有患者均获15～24月随访,平均18月；EPS组术后1年有85.7%的患者螺钉位置稳定,脊柱融合率为85.7%,在EPS组中1例患者在第二次手术取钉时出现断钉情况；CPS组术后1年仅有60.0%的患者螺钉位置稳定,脊柱融合率为85.0%,未出现螺钉取出困难情况；术前、术后3个、术后6个月、术后12个月的VAS及改良Prolo功能评分显示较术前改善,但两组间差异不具统计学意义；同时所有患者中出现并发症的有16例(33.3%)、输血病例22例(45.8%),但两组之间并发症比较不具统计学意义。
结论：在胸腰椎疾病患者合并骨质疏松条件下采用EPS固定是相对稳定、有效的,EPS相比CPS可获得更强的固定能力,能够解决术后螺钉松动、脱落等问题,适宜用于在骨质疏松性脊柱疾病的融合固定手术中使用。且操作较为简单,不会增加手术时间及出血量。同时因骨质疏松性脊柱疾病多为年龄较大患者,故手术并发症相对较多,应更重视围手术期管理。
Objective：To evaluate the reliability and clinical efficacy of expandable pedicle screw (EPS) affixation for thoracolumbar patients afflicted with osteoporosis.
Method:A retrospective analysis was adopted. For at least twelve months from January 2008 to May 2010,56 thoracolumbar patients with osteoporosis were treated and regularly monitored; of them,25 were male,31 female, and aged 45 to 72 years, with an average age of 61.3 years. For these patients, the course of the disease was between 2 months and 5 years, with an average course of 13.5months; Among the 56 patients, lumbar disc herniation 9 cases, lumbar spine canal stenosis 14 cases, lumbar spondylolisthesis 16 cases, lumbar tuberculosis 6 cases, lumbar compression fractures 7 cases, and revision surgery 4 cases. Among the patients with spondylothisthesis,7 were in the 1st degree,6 were in the 2nd degree, and 3 were in the 3rd degree. All patients underwent bone mineral density testing before surgery, which indicated bone mass density averaging 2.7 standard deviations below the norm. The patients were divided into two groups,28 patients with EPS posterior spinal fixation,28 patients with conventional posterior spinal fixation, Efficacy of the surgery was evaluated using a pain visual analogue scale (visual analogue scale, VAS), modified Prolo functional scores and X rays, and CT and other imaging assessments of screw stability and integration.
Result:All patients were observed for 15 to 24 months post operation, for an average of 18 months. Both VAS and modified Prolo functional scores showed a significant improvement 3 months after operation,6 months after operation, and 12 months after operation. One year after operation in EPS,85.7% of the screw placements were stable, and the spinal fusion rate was 85.7%. One year after operation in CPS,60.0% of the screw placements were stable, and the spinal fusion rate was 85.0%. Eight patients (33.3%) developed complications (including systemic complications and spine-specific complications),22 cases (45.8%) required blood transfusions, and 1 patient's EPS broke during the process of removal.
Conclusion:For thoracolumbar patients suffering from severe osteoporosis, EPS may be simpler and more effective than other forms of screw fixation. EPS fixation is on average stronger and can solve several postoperative problems such as screw loosening and screw loss.Decreased rate of postoperative complications is especially important due to the fact that osteoporosis patients with spinal disease are typically older and more susceptible to complications. Age of the patient should be paid close attention.
引文
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