骨质疏松性椎体骨折椎体强化术后进展性局部后凸的研究进展  

Review on the etiology and risk factors of progressive local kyphosis after vertebral augmentation for osteoporotic vertebral fractures

作　　者：王佳东 刘磊[2] 徐玉柱 樊攀 张乐乐 干文武 张峰 王运涛[2] Wang Jiadong;Liu Lei;Xu Yuzhu;Fan Pan;Zhang Lele;Gan Wenwu;Zhang Feng;Wang Yuntao(Department of Spine Surgery,Zhongda Hospital Affiliated to Southeast University,Nanjing 210009,China;Medical School,Southeast University,Nanjing 210009,China;Department of Spine Surgery,Xuyi People's Hospital,Huaian 211700,China)

机构地区：[1]东南大学医学院,南京210009 [2]东南大学附属中大医院脊柱外科中心,南京210009 [3]盱眙县人民医院骨科,淮安211700

出　　处：《中华骨科杂志》2024年第21期1424-1431,共8页Chinese Journal of Orthopaedics

基　　金：江苏省自然科学基金青年项目(BK20220832)。

摘　　要：随着社会人口老龄化,骨质疏松性椎体骨折(osteoporotic vertebral fracture,OVF)的发病率日益增长,个性化治疗策略的制定成为新的挑战。对保守治疗失败的OVF患者,椎体强化术(percutaneous vertebroplasty/percutaneous kyphoplasty,PVP/PKP)因其手术创伤小、恢复快仍是最常用的手术方式。术后进展性局部后凸(progressive local kyphosis,PLK)是PVP/PKP术后严重的并发症之一,发生率为1.5%~25.8%,常伴有胸腰背痛复发,严重者出现下肢麻木、疼痛等椎管狭窄表现。因其局部后凸程度不同,临床症状不一,可予以保守治疗、骨水泥再灌注、内固定或截骨矫形术。目前研究证实伤椎再骨折、椎间盘退变及骨坏死可能是其潜在的发生机制,上述病变发生后会导致轴向载荷前移,促使术后PLK发生并有随时间延长不断进展的趋势。术后PLK与患者基本特征、骨折特点、手术因素、术后抗骨质疏松治疗等密切相关:(1)骨质疏松严重程度可通过骨密度T值评估,可预测术后PLK的发生;除此之外,合并糖尿病患者术后PLK风险更高。既往研究证实年龄、性别等因素影响骨质疏松程度,但目前研究未证实其与术后PLK的直接关系。(2)患者胸腰段骨折、陈旧性骨折骨不连、终板型骨折或术前存在严重压缩改变伴局部后凸畸形等因素均会增加术后PLK风险,手术因素包括应用球囊扩张、植入物使用、骨水泥注射及分布,依据患者一般情况和影像学检查制定个性化治疗方案,促进骨水泥充分弥散,增强骨与骨水泥整合可以降低术后PLK风险。(3)术后抗骨质疏松治疗同样重要,长期抗骨质疏松治疗尤其是促骨形成药物特立帕肽的应用能预防术后PLK。随着对相关危险因素的认识,建立预测模型有助于临床工作者实现个性化治疗,其中大数据背景下的机器学习模型更能处理多样的相互关联的危险因素,预测性能更佳,将是未来个性化治疗的重With an aging population,the incidence of osteoporotic vertebral fractures(OVFs)is on the rise,posing new challenges for developing personalized treatment strategies.For patients who do not respond to conservative treatment,percutaneous vertebroplasty or percutaneous kyphoplasty(PVP/PKP)remains the preferred surgical option due to its minimal invasiveness and rapid recovery time.However,progressive local kyphosis(PLK)is one of the most severe complications following PVP/PKP,with an incidence rate of 1.5%-25.8%.PLK often presents with recurring thoracic and lower back pain,and in severe cases,spinal stenosis,causing symptoms like numbness and pain in the lower limbs.The severity of PLK varies,and treatments can range from conservative management and bone cement reinforcement to internal fixation or osteotomy.Current studies suggest that refracture of the affected vertebra,intervertebral disc degeneration,and osteonecrosis may be underlying mechanisms.These conditions shift the axial load forward,promoting postoperative PLK,which tends to progress over time.Postoperative PLK is closely associated with patient characteristics,fracture details,surgical factors,and post-surgery osteoporosis management.1)The severity of osteoporosis,as indicated by the T-score from bone mineral density testing,can help predict postoperative PLK.While factors like age and gender influence osteoporosis severity,no direct relationship has been established between these factors and PLK.2)Thoracolumbar fractures,old nonunion fractures,endplate fractures,or severe preoperative compression changes with kyphosis can increase PLK risk.Surgical factors,including the use of balloons or implants and the distribution of bone cement,also play a role.Personalized treatment plans should be developed based on the patient's general condition and imaging results to ensure adequate bone cement diffusion,as enhanced integration can reduce PLK risk.3)Postoperative anti-osteoporosis therapy is also crucial;long-term therapy,particularly with teriparatide,can

关 键 词：椎体 骨质疏松性骨折 椎体成形术 椎体后凸成形术 脊柱后凸 危险因素 预测 

分 类 号：R687.3[医药卫生—骨科学]