合并骨质疏松症的成人脊柱畸形骨质量的评估与术后近端交界性后凸或失败预防的研究进展  

Research progress in the evaluation of adult spinal deformities associated with osteoporosis and prevention of proximal junctional kyphosis or failure after corrective surgery

作　　者：宋达玮[1] 钮俊杰 王金宁[1] 颜奇 孙潇 杨惠林[1] 邹俊[1] Song Dawei;Niu Junjie;Wang Jinning;Yan Qi;Sun Xiao;Yang Huilin;Zou Jun(Department of Orthopaedics,The First Affiliated Hospital of Soochow University,Suzhou 215006,China)

机构地区：[1]苏州大学附属第一医院骨科,苏州215006

出　　处：《中华骨科杂志》2024年第11期778-786,共9页Chinese Journal of Orthopaedics

摘　　要：随着社会人口老龄化,合并骨质疏松症的成人脊柱畸形(adult spinal deformity,ASD)的发病率日益增长,对其评估和治疗成为新的挑战。尽管合理、规范的保守治疗仍是早期的首选方案,但对畸形严重、症状明显的患者则需要手术干预。近端交界性后凸或失败(proximal junctional kyphosis/failure,PJK/PJF)是ASD术后最严重的并发症之一,术前细致、全面的骨质量和躯体矢状面力线评估至关重要。基于CT影像获取的亨氏单位(Hounsfield unit,HU)及基于MRI的椎体骨质量(vertebral bone quality,VBQ)评分是近年被证实能可靠、有效、简易和可普遍用于评估局部椎体骨质量的方法。对ASD术后PJF的评估和预测而言,上端固定椎(upper instrumented vertebra,UIV)的骨质量可以通过HU值进行评估,以识别高危患者并实施预防措施。VBQ评分可预测ASD患者手术后PJK/PJF的发生率,较高的VBQ评分是ASD患者矫正术后发生PJK/PJF的危险因素之一。对于VBQ评分较高的患者可推迟手术,且在手术前使用抗骨质疏松药物,降低PJK/PJF的发生。同时,合理、个性化拟定ASD矢状面序列恢复参数有助于平衡疗效与并发症间的关系,使得收益最大化。术后近端交界区由于存在内固定区与原生未固定区间的应力落差,且在骨质疏松症患者中该应力落差愈发明显,给PJK/PJF的预防带来困难。一方面,需要适当增加近端交界区的固定强度和骨铆合力度;另一方面,需要平缓递减近端交界区的内固定强度,实现该区域内应力的平稳过渡,避免应力集中造成失效。相关的处理策略包括:(1)强化近端交界区的内固定,如椎体骨水泥强化术、骨水泥强化椎弓根螺钉固定术等;(2)缓冲近端交界区的应力差异,如Topping-off技术,该技术包括椎板钩或横突钩、动态棒、多节段稳定螺钉和多种韧带捆扎带技术等;(3)微创技术,可以更好地保护后方韧带复合体和肌肉等软组织,降低With the aging population,the increasing incidence of adult spinal deformity(ASD)associated with osteoporosis(OP)presents new challenges for evaluation and management.Although reasonable and standardized non-surgical treatment remains the first choice in the early stages of this disease,surgical treatment is necessary for patients with severe deformities and significant symptoms to achieve further improvement.Proximal junctional kyphosis/failure(PJK/PJF)is one of the most serious postoperative complications of ASD.Careful and comprehensive preoperative evaluation of bone quality and body sagittal alignment is crucial for the successful implementation of the operation.The Hounsfield unit(HU)based on CT imaging and the vertebral bone quality(VBQ)score based on MRI have proven to be reliable,effective,simple,and widely used in evaluating local vertebral bone quality in recent years.For the evaluation and prediction of PJF after ASD,the bone quality of the upper instrumented vertebra(UIV)can be assessed using HU values to identify high-risk patients and implement preventive measures.The VBQ score is predictive of the incidence of PJK/PJF in patients undergoing ASD surgery,with a high VBQ score being one of the risk factors for PJK/PJF after ASD correction.Patients with high VBQ scores can delay surgery and use anti-osteoporosis drugs before surgery to reduce the occurrence of PJK/PJF.Meanwhile,reasonable and personalized recovery parameters of ASD patients'sagittal sequence can help balance the benefits of efficacy and complications,maximizing the overall benefits.The prevention of PJK/PJF is challenging due to the stress gap between the internal fixation area and the original unfixed tissue area in the postoperative proximal junctional area,which is increasingly significant in OP patients.It is necessary to improve the fixation strength and bone riveting strength of the proximal junction area properly and to gradually decrease the fixed strength in the proximal junctional area to achieve a smooth transition of stres

关 键 词：骨质疏松 骨密度 脊柱融合术 成人脊柱畸形 近端交界性后凸/失败 亨氏单位 

分 类 号：R687.3[医药卫生—骨科学]