胸腰椎骨质疏松性椎体压缩骨折伴后凸畸形的分级手术策略  

Graded surgical strategy for osteoporotic vertebral compression fractures with kyphosis:application of balanced load concept

作　　者：徐宝山[1] 黎宁[1] 许海委[1] 王涛[1] 马信龙[1] 

机构地区：[1]天津市天津医院微创脊柱外科,天津300211

出　　处：《中华骨科杂志》2023年第11期677-686,共10页Chinese Journal of Orthopaedics

基　　金：国家自然科学基金(82072491,31900967);天津市自然科学基金(20JCYBJC00820);天津市医学重点学科(专科)建设资助项目(TJYXZDXK-026A)。

摘　　要：目的探讨胸腰椎骨质疏松性椎体压缩骨折(osteoporotic vertebral compression fracture,OVCFs)伴后凸畸形的分级手术治疗策略及均衡负载理念的应用价值。方法对胸腰椎OVCFs合并后凸畸形需要手术治疗的患者,根据是否存在神经压迫、后凸形态、矢状面指数(sagittal index,SI)、椎体是否严重塌陷(椎体前缘和中部高度小于相邻椎体平均高度的1/3)和骨折可复性,应用均衡负载理念制定分级手术策略。胸腰椎OVCFs伴后凸畸形患者56例,男11例、女45例,年龄(75.6±9.3)岁(范围61~85岁)。所有患者均有腰背部疼痛。24例无神经损害症状,行体位复位、经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)。32例有神经损害症状,5例伴弧形后凸且SI<20°者行Ponte截骨矫形手术;15例伴角状后凸或SI>15°者行经椎弓根截骨(pedicle subtraction osteotomy,PSO)或经椎间隙截骨矫形手术;11例椎体严重塌陷严重且SI>15°者和1例骨水泥松动移位者行椎体切除重建矫形融合术,4例采用后路脊椎切除(posterior vertebral column resection,PVCR)、8例采用前路椎体切除重建联合后路矫形融合术。采用疼痛视觉模拟评分(visual analog score,VAS)、Oswestry功能障碍指数(Oswestry dysfunction index,ODI)和患者症状较术前改善的满意度评估临床疗效。结果所有患者均获得随访,随访时间为(24.2±12.1)个月(范围12~60个月)。24例PKP术后症状明显改善,1例PKP术后相邻椎体骨折再次行PKP后好转。32例减压矫形术中出血量为(960±620)ml(范围400~1800 ml);术中出血量PVCR组>PSO组和前后联合组>Ponte截骨组。手术时间为(4.3±1.9)h(范围2~7 h)。32例患者术后症状均改善,末次随访时VAS评分自术前(7.0±2.6)分下降至(1.4±1.1)分,ODI自术前60.4%±16.2%下降至9.5%±5.8%,SI自术前18.1°±4.3°下降至5.6°±4.3°。随访期间发生人工椎体和钛网塌陷12例,8例塌陷1~2 mm、4例塌陷3~4 mm,均未发生椎体骨折、内固定移�Objective To explore the application value of graded surgical strategy and balanced load concept for thoracolumbar osteoporotic compression fractures(OVCFs)with kyphosis.Methods All of 56 patients of thoracolumbar OVCFs with kyphosis were studied,including 11 males and 45 females,with an average of 75.6±9.3 years old.All patients had back pain,and 32 patients had nerve compression,including 5 patients with aggravation of vertebral collapse after conservative treatment,and 1 patient with cement loosening after percutaneous kyphoplasty(PKP)in another hospital.A graded surgical strategy was developed according to the concept of balanced load,including whether there existed nerve compression,kyphosis,sagittal index(SI),vertebral collapse,load capacity of anterior and middle columns,and fracture reducibility.All patients were treated with anti osteoporosis therapy.24 patients without nerve compression underwent posture reduction and PKP;32 patients with nerve compression underwent open surgery:5 patients with arcuate ky-phosis and SI≤15°underwent Ponte osteotomy;15 patients with angular kyphosis or SI>15°underwent posterior pedicle subtraction osteotomy(PSO)or/and modified PSO including intervertebral space;11 patients with SI>15°and severe vertebral collapse(the height of anterior and middle vertebral bodies<1/3 of the average height of adjacent vertebral bodies)or cement loosen after PKP underwent vertebrectomy and reconstruction,of which 4 patients underwent posterior vertebral column resection(PVCR),and 8 patients underwent combined surgery including anterior subtotal vertebrectomy with support and posterior pedicle fixation.The clinical efficacy was evaluated by pain visual analog score(VAS)and Oswestry dysfunction index(ODI).Results All patients were followed up for 12-60 months,with an average of 24.2 months.For the 24 patients with PKP,the symptoms improved significantly,and 1 case had adjacent vertebral fracture that was improved after PKP again.For the 32 patients with open surgery,the intraoperative b

关 键 词：胸椎 腰椎 椎体 骨质疏松性骨折 脊柱后凸 治疗结果 

分 类 号：R687.3[医药卫生—骨科学]