骨水泥钉道强化与否治疗伴骨质疏松的单节段腰椎退行性疾病的临床对照研究

Comparison of pedicle screw fixation with or without cement augmentation in osteoporotic spine combined with single-segment lumbar degenerative disease

中文关键词:  骨质疏松  椎弓根螺钉  腰椎退变性疾病  骨水泥钉道强化

英文关键词:Osteoporosis  Pedicle screws  Degenerative lumbar disease  PMMA

中文摘要:

  【摘要】 目的：探讨骨水泥钉道强化治疗伴骨质疏松的单节段腰椎退行性疾病的必要性。方法：回顾性分析2012年1月~2014年12月采用后路腰椎融合术治疗的74例伴骨质疏松的单节段腰椎退行性疾病患者，均随访2年以上，且规律抗骨质疏松治疗。根据椎弓根螺钉周围有无骨水泥强化，分为两组：骨水泥钉道强化（polymethylmethacrylate augmented pedicle screw，PMMA-PS）组，36例，男3例，女33例，年龄70.61±6.37岁，手术节段L4/5 32例、L5/S1 4例，骨密度-3.38±0.77SD；普通椎弓根螺钉（conventional pedicle screw，CPS）组，38例，男2例，女36例，年龄69.79±5.90岁，手术节段L4/5 32例、L5/S1 6例，骨密度-3.32±0.57SD。比较两组手术时间、术中出血量、术后住院时间、手术并发症情况；术前、术后6个月及末次随访时行VAS、Oswestry功能障碍指数（Oswestry disability index，ODI）评价临床疗效。根据末次随访时的X线片或CT检查，比较两组的融合率、螺钉松动发生率。结果：两组患者均顺利完成手术，CPS组平均手术时间147.21±17.11min，术中出血量138.03±42.45ml，平均住院天数8.82±1.07d；PMMA-PS组平均手术时间185.75±18.37min，术中出血量142.64±35.08ml，平均住院天数9.36±1.17d。两组平均手术时间相比具有统计学差异（P<0.05），平均住院天数、术中出血量相比无统计学差异（P>0.05）。CPS组与PMMA-PS组术前、术后6个月和末次随访时VAS评分分别为7.16±0.82分、6.93±10.88分；1.74±0.49分、1.92±0.47分；1.76±0.43分、1.81±0.40分；ODI分别为（51.84±4.41）%、（52.50±4.71）%；（18.03±2.74）%、（18.89±3.61）%；（17.24±2.77）%、（16.67±2.67）%；两组间不同时间点VAS评分和ODI对比无统计学差异（P>0.05）；两组内术后6个月、末次随访时VAS评分和ODI较术前有统计学差异（P<0.05）。PMMA-PS组中无螺钉松动，CPS组中1例（2.7%，1/36）患者的2枚（1.3%，2/152）螺钉出现松动，两组间无统计学差异（P>0.05）。PMMA-PS组融合成功率（100%）相比CPS组（97.3%）无统计学差异（P>0.05）。PMMA-PS组有27枚钉道周围（18.7%，27/144）发生骨水泥渗漏，未出现相应的神经并发症。结论：对于伴骨质疏松的单节段腰椎退行性疾病行融合术时，在规律抗骨质疏松的基础上，骨水泥螺钉强化与普通椎弓根螺钉组均可获得相似的临床疗效和融合率，但普通椎弓根螺钉组减少手术时间，避免骨水泥发生渗漏造成潜在并发症的发生，故不推荐常规行骨水泥钉道强化。

英文摘要:

  【Abstract】 Objectives: To explore the necessity of cement augmented pedicle screw fixation in osteoporotic patients combined with single-segment lumbar degenerative disease. Methods: 74 cases followed up for a minimum of 2 years with single-segment degenerative lumbar disease combined with osteoporosis spine receiving posterior lumbar fusion and routine anti-osteoporosis treatment from January 2012 to December 2014 were reviewed retrospectively. 36 cases(3 males and 33 females; 70.61±6.37 years old on average; average bone density -3.38±0.77SD; surgical segment, L4/5 32 cases and L5/S1 4 cases) were in the polymethylmethacrylate-augmented pedicle screw group(PMMA-PS) and the other 38 cases(2 males and 36 females; 69.79±5.90 years old on average; average bone density -3.32±0.57SD; surgical segment, L4/5 32 cases and L5/S1 6 cases) in the conventional pedicle screw group(CPS). Surgical data including operation time, intra-operative blood loss, hospitalization day and surgical complications were recorded, as well as the radiological parameters measured from postoperative X-rays and CT scans including the rates of fusion and screw loosening. In addition, the visual analogue scores(VAS) and Oswestry disability index(ODI) were evaluated preoperatively, at 6 months and last follow-up postoperatively. Results: In CPS group, the average operation time was 147.21±17.11min, the blood loss was 138.03±42.45ml, and the average hospital stay was 8.82±1.07d. PMMA-PS group was 185.75±18.37min, 142.64±35.08ml, 9.36±1.17d, respectively. Compared with PMMA-PS group, operation time in CPS group decreased significantly(P<0.05). While no statistical difference for the average hospital stay or blood loss was found between 2 groups(P>0.05). The VAS scores of CPS group and PMMA-PS group on pre-operation, at 6 months after operation and final follow-up were 7.16±0.82, 6.93±10.88; 1.74±0.49, 1.92±0.47; 1.76±0.43, 1.81±0.40 respectively. The ODI were (51.84±4.41)%, (52.50±4.71)%; (18.03±2.74)%, (18.89±3.61)%; (17.24±2.77)%, (16.67±2.67)%; respectively. After surgeries, VAS and ODI at 6 months and final follow-up improved significantly in two groups(P<0.05). There were no significant differences of VAS and ODI preoperatively and postoperatively between 2 groups(P>0.05). In PMMA-PS group, no screw loosening occurred, and the fusion rate was 100%. In CPS group, 2 screws loosened(1.3%, 2/152) in 1 patient(2.7%, 1/36), and the fusion rate was(97.3%, 37/38), however, no significant difference was found between 2 groups(P>0.05). Besides, 27 (18.7%, 27/144) asymptomatic trajectory PMMA leakages were detected. Conclusions: It is not recommended conventional application of PMMA augmented screw in osteoporotic spine with single-segment lumbar degenerative disease due to the similar clinical efficacy and fusion rate achieved on the basis of routine anti-osteoporosis treatment with or without augmentation, besides, less operation time needed and potential complications caused by cement leakagein CPS.