自制经椎弓根椎体内植骨装置在经皮椎弓根螺钉内固定术治疗胸腰椎骨折中的应用及疗效观察

Clinical application and efficacy observation of a self-designed transpedicular intravertebral bone grafting device in percutaneous pedicle screw fixation for thoracolumbar fractures

中文关键词:  胸腰椎骨折  自制植骨装置  经椎弓根植骨  椎体内植骨  椎体内骨缺损

英文关键词:Thoracolumbar fractures  Self-designed bone grafting device  Transpedicular bone grafting  Intravertebral bone grafting  Intravertebral bone defect

中文摘要:

  【摘要】 目的：探讨自制经椎弓根椎体内植骨装置经皮椎弓根螺钉内固定术治疗胸腰椎骨折中的应用效果，评估其安全性以及对“空壳”现象的预防作用。方法：回顾性分析2018年1月~2023年1月49例在我院接受经皮椎弓根螺钉内固定椎体内植骨术治疗的胸腰椎骨折患者，其中25例应用自制经椎弓根椎体内植骨装置植骨[自制装置组，男8例，女17例，年龄48.0±9.7岁，体质指数21.6±2.7kg/m2，T11 3例，T12 9例，L1 7例，L2 6例；胸腰椎损伤分型及损伤程度（thoracolumbar injury classification and severity，TLICS）评分4.3±0.5分；AO分型A3型18例，A4型7例]；24例应用传统植骨漏斗植骨（传统技术组，男11例，女13例，年龄48.2±10.7岁，体质指数21.4±2.7kg/m2，T11 6例，T12 6例，L1 8例，L2 4例；TLICS评分4.3±0.5分；AO分型A3型17例，A4型7例）。两组患者的年龄、性别比、体质指数、骨折部位、AO分型和TLICS评分均无统计学差异（P＞0.05）。比较两组总手术时间、植骨操作时间、植骨透视次数、出血量、住院时间及术中并发症发生情况等。术前、术后3个月和1年时采用疼痛视觉模拟量表（visual analog scale，VAS）评分评估腰痛程度，采用Oswestry功能障碍指数（Oswestry disability index，ODI）以及日本骨科协会（Japanese Orthopaedic Association，JOA）评分评估腰椎功能。测量并比较术前和术后即刻、3个月、1年时的局部后凸角（local kyphotic angle，LKA）、伤椎前缘高度比（anterior vertebral height ratio，AVHR）。术后即刻CT检查观察植入骨粒的位置分布、是否出现“空壳”现象，评估伤椎椎弓根及前壁是否存在医源性损伤；术后1年复查CT评估伤椎骨性愈合情况以及“空壳”现象的转归。结果：所有患者均顺利完成手术并获得12个月以上（17.0±3.1个月）随访。自制装置组透视次数显著性少于传统技术组（11.0±1.5次 vs 13.5±1.7次，P<0.05），自制装置组植操作时间长于传统技术组（15.0±1.7min vs 12.7±1.9min，P＜0.05），两组总手术时间无显著性差异（P>0.05）。传统技术组3例（12.5%）发生椎弓根损伤，9例（37.5%）发生椎体前壁损伤，12例（50.0%）出现植骨材料外漏；自制装置组未观察到椎弓根或椎体前壁损伤，4例（16%）发生植骨材料外漏，两组并发症发生率有统计学差异（P＜0.05）。两组术后即刻、术后3个月、术后1年的LKA、AVHR较术前显著性改善，术后3个月、1年时VAS评分、ODI以及JOA评分均较术前显著性改善（P＜0.05）。术后自制装置组5例发生“空壳”现象，术后1年随访时愈合1例；传统技术组8例发生“空壳”，术后1年时愈合2例，差异无统计学意义（P＞0.05）。结论：在经皮椎弓根螺钉内固定联合椎体内植骨术治疗胸腰椎骨折术中应用自制微创经椎弓根椎体内植骨装置植骨可减少术中透视次数及并发症，提高手术安全性。

英文摘要:

  【Abstract】　Objectives: To investigate the application effect of a self-designed transpedicular intravertebral bone grafting device in percutaneous pedicle screw fixation for thoracolumbar fractures, and to evaluate its safety and the role in preventing the "shell" phenomenon. Methods: A retrospective analysis was performed on 49 patients with thoracolumbar fractures who underwent percutaneous pedicle screw fixation combined with intravertebral bone grafting at our hospital from January 2018 to January 2023. Among them, 25 patients were treated with a self-designed transpedicular intavertebral bone grafting device[Self-designed device group: 8 males, 17 females, aged 48.0±9.7 years; Body mass index(BMI) 21.6±2.7kg/m2; T11 3 cases, T12 9 cases, L1 7 cases, L2 6 cases; Thoracolumbar injury classification and severity(TLICS) score 4.3±0.5; AO classification: A3 18 cases, A4 7 cases]. The other 24 patients were treated with a conventional technique bone grafting funnel(Conventional technique group: 11 males, 13 females, aged 48.2±10.7 years; Body mass index 21.4±2.7kg/m2; T11 6 cases, T12 6 cases, L1 8 cases, L2 4 cases; TLICS score 4.3±0.5; AO classification: A3 17 cases, A4 7 cases). There were no statistically significant differences between the two groups in age, gender ratio, body mass index, fracture level, AO classification, or TLICS score(P>0.05). The total operativetime, graft implantation time, fluoroscopy frequency during bone grafting, intraoperative blood loss, hospital stay, and intraoperative complications were compared between the two groups. Low back pain was assessed using visual analogue scale(VAS) score, lumbar function was evaluated using Oswestry disability index(ODI) and Japanese Orthopaedic Association(JOA) score preoperatively, at 3 months and 1 year postoperatively. The local kyphotic angle(LKA) and anterior vertebral height ratio(AVHR) were measured and compared preoperatively, immediately postoperatively, at 3 months and 1 year postoperatively. Immediate postoperative CT scan was performed to determine bone graft distribution, assess iatrogenic injuries to the pedicle or anterior vertebral wall, and identify the "shell" phenomenon. Follow-up CT at 1 year postoperatively was performed to evaluate bony fusion and the outcomes of the "shell" phenomenon. Results: All the patients successfully completed the surgery and were followed up for over 12 months(17.0±3.1 months). The self-designed device group was significantly lower in fluoroscopy frequency during bone grafting(11.0±1.5 vs. 13.5±1.7, P<0.05) and longer in graft implantation time(15.0±1.7min vs. 12.7±1.9min, P<0.05) than the conventional technique group, but there was no significant difference in total operative time between the two groups(P>0.05). In the conventional technique group, 3 cases(12.5%) had pedicle injuries, 9 cases(37.5%) had anterior vertebral wall injuries, and 12 cases(50.0%) had bone graft material leakage; In contrast, the self-designed device group had no pedicle or anterior wall injuries, and there were 4 cases(16%) of bone graft leakage. The difference in complication rates between the two groups was statistically significant(P<0.05). Both groups showed significant improvement in LKA and AVHR immediately postoperatively, at 3 months, and at 1 year compared to preoperative values(P<0.05). VAS score, ODI, and JOA score also significantly improved at 3 months and 1 year postoperatively compared to preoperative scores(P<0.05). The "shell" phenomenon occurred in 5 cases in the self-designed device group, with 1 case healed at the 1-year follow-up, which occurred in 8 cases in the conventional technique group, with 2 cases healed at 1 year, and the difference was no statistically significant(P>0.05). Conclusions: The application of the self-designed minimally invasive transpedicular vertebral bone grafting device in percutaneous pedicle screw fixation combined with vertebral bone grafting for thoracolumbar fractures can reduce intraoperative fluoroscopy frequency and complications, therefore to improve surgical safety.