后柱切除后伸压缩中柱矫治胸腰段骨质疏松性重度椎体压缩骨折伴后凸畸形

Posterior column resection followed by extension and middle column compression for thoracolumbar severe osteoporotic vertebral compressive fractures combined with kyphosis

中文关键词:  重度椎体压缩骨折  后凸畸形  骨质疏松  后柱切除  中柱压缩

英文关键词:Severe vertebral compressed fracture  Kyphosis  Osteoporosis  Posterior column resection  Middle column compression

中文摘要:

  【摘要】 目的：评价后柱切除后伸压缩中柱矫治胸腰段骨质疏松性重度椎体压缩骨折伴后凸畸形的安全性和临床效果。方法：2009年7月～2012年1月经后入路行后柱切除后伸压缩中柱矫治胸腰段骨质疏松性重度椎体压缩骨折伴后凸畸形患者14例，男2例，女12例；年龄62～81岁，平均68岁。骨折均位于T11～L2，其中单椎体骨折12例，两个椎体骨折2例；椎体高度压缩78.5%～92.4%，平均82.5%。后凸畸形的顶椎均位于胸腰段，其中L1 7例，T12 5例，L2 2例。后凸畸形Cobb角39°～59°，平均45°；脊柱矢状位C7铅垂线偏移距离为0.4～2.8cm，平均1.6cm；腰椎前凸41°～62°，平均58.4°，9例出现腰椎前凸代偿性加大。均有腰背部疼痛及疲劳感，疼痛视觉模拟评分（VAS）8.5分（7.5～9分）。神经功能按Frankel分级：E级12例，D级2例。其中10例采用注射型聚甲基丙烯酸甲酯骨水泥强化钉道。结果：手术时间187～221min，平均190min；术中出血量372～463ml，平均420ml。1例术中硬脊膜破裂，予以修补，术后未发生脑脊液漏。术后胸腰椎后凸Cobb角0°～9°，平均5°，平均矫正率达88.9%；矢状位C7铅垂线偏移距离0～0.8cm，平均0.3cm；腰椎前凸角28°～43°，平均37°。随访12～33个月，平均21个月。末次随访时，胸腰椎后凸Cobb角0～11°，平均7°；矢状位C7铅垂线偏移距离为0～1.2cm，平均0.4cm；腰椎前凸29°～45°，平均39°；神经功能按Frankel分级均为E级；腰背疼痛消失11例，明显缓解3例，VAS为1.9（0~3.5）分，与术前比较差异有统计学意义（P<0.05）；均植骨融合及骨折愈合良好，内固定无松动及拔出，固定邻近节段无继发骨折。结论：后柱切除后伸压缩中柱矫治胸腰段骨质疏松性重度椎体压缩骨折伴后凸畸形，与经椎弓根截骨术比较手术操作简单、创伤小。当骨质疏松性重度椎体压缩骨折伴后凸难以施行椎体成形术时，此技术是一种安全有效的补充方法。

英文摘要:

  【Abstract】 Objectives: To evaluate the clinical outcome and safety of posterior column resection plus middle column compression for thoracolumbar kyphosis caused by severe osteopororotic compressive vertebral fractures. Methods: From July 2009 to January 2012, 14 patients suffering from thoracolumbar kyphosis caused by severe osteopororotic compressive vertebral fractures were treated with posterior column resection followed by extension and middle column compression. There were 2 males and 12 females with an average age of 68 years(range, 62-81 years). All the fractured vertebral located at T11-L2, 12 patients had one vertebral involvement and 2 had two levels. The rate of loss of vertebral height ranged from 78.5% to 92.4%(mean, 82.5%). The apical vertebral located at L1 in 7 cases, T12 in 5 cases and L2 in 2 cases. The mean preoperative kyphosis Cobb angle was 45°(range, 39°-59°). The distance between the C7 plumb line and the center sacral line was 1.6cm on average(range, 0.4-2.8cm). The preoperative lumbar lordosis was 41°-62°(mean, 58.4°), of them, 9 cases had compensatory lumbar lordosis. All the 14 patients presented with low back pain with an average preoperative visual analogue score(VAS) of 8.5(range, 7.5-9). According to Frankel classification, there were 12 grade E and 2 grade D. 10 patients underwent bone cement augmentation surgery. Results: The average surgical time was 190 minutes(range, 187-221 minutes). The average blood loss was 420ml(range, 372-463ml). The dura tearing occurred in 1 case. The postoperative average thoracolumbar kyphosis Cobb angle was 5°(range, 0-9°) with a 88.9% correction rate and the sagittal imbalance was corrected to 0.3cm(range, 0-0.8cm). The postoperative lumbar lordosis ranged from 28° to 43°(mean, 37°). The mean follow-up period was 21 months(range, 12-33 months). The average thoracolumbar kyphosis Cobb angle was 7°(range, 0-11°). The sagittal imbalance was 0.4cm(range, 0-1.2cm). The lumbar lordosis ranged from 29° to 45°(mean, 39°). 2 patients with Frankel grade D had recovered to grade E. The average VAS score was significantly improved to 1.9(range, 0-3.5) after surgery. The back pain relieved completely in 11 patients and partially in 3 patients. Bony fusion was achieved in all patients with no instrument related complication. Conclusions: Posterior column resection followed by extension and middle column compression is a reliable treatment for thoracolumbar kyphosis caused by severe osteopororotic compressive vertebral fractures. It is simple and less invasive compared with transpedicular osteotomy, and can be used as an alternative in cases where PVP is not suited.