后路椎弓根螺钉钉道强化内固定治疗骨质疏松性椎体骨折的中长期临床疗效分析

Posterior approach with augmented pedicle screw instrumentation in the osteoporotic vertebral fracture: middle to long term follow-up

中文关键词:  骨质疏松性椎体骨折  后路  内固定  钉道强化

英文关键词:Osteoporotic vertebral fracture  Posterior approach  Instrumentation  Augmented pedicle screw

中文摘要:

  【摘要】 目的：观察钉道强化椎弓根螺钉内固定治疗骨质疏松性椎体骨折（osteoporotic vertebral fractures，OVF）的中长期临床疗效。方法：2008年1月～2015年12月41例OVF患者纳入研究，其中女37例，男4例；年龄72.0±5.8岁（66～88岁）；病程6.75±3.20个月（8h～27个月）；骨密度（bone mineral density，BMD）平均T值为-3.80±1.12SD（-2.9～-5.4SD）；52个椎体受累，责任椎体位于T5~L5，合并椎体内假关节33个（63.46%），陈旧骨折畸形愈合3个（5.77%），合并重度塌陷12个（23.08%），椎体最大塌陷率为（72.0±15.2）%（32%～95%），椎管占位率为（42.3±11.4）%（22.1%～71.4%）；术前神经功能ASIA分级为C级8例，D级10例，E级23例。手术方式采用后路椎弓根螺钉钉道强化内固定，再根据骨折类型联合伤椎骨水泥强化或椎管减压或截骨矫形等。记录术前、术后1周、末次随访时疼痛视觉模拟评分（VAS）、Oswestry功能障碍指数（ODI）及术前、术后1周、术后2年、末次随访时伤椎局部后凸角，评价患者功能恢复情况；记录相关并发症发生情况。结果：随访38.9±29.0个月（24～108个月），2例患者去世，4例患者失访，35例患者完成末次随访。术前、术后1周及末次随访时的VAS分别为8.07±1.52分、3.26±2.40分及2.66±1.49分，ODI分别为（72.30±11.80）%、（46.70±16.28）%及（35.89±11.90）%，术前、术后1周、术后2年及末次随访时的伤椎局部后凸角分别为26.85°±17.32°、7.64°±9.61°、11.18°±9.57°及11.43°±1.93°，三项指标术后各时间点均较术前明显改善，差异有统计学意义（P＜0.05），且末次随访时ODI与术后1周比较有统计学差异（P＜0.05），VAS、后凸角在术后各随访点间比较无统计学差异（P＞0.05）。末次随访时11例患者神经功能获得改善，其中术前ASIA分级C级恢复至D级3例、E级5例，术前D级恢复至E级3例、余7例仍为D级，8例术前E级患者下肢放射痛、麻木等症状明显减轻。13例（31.71%）出现无症状骨水泥渗漏，术后未予以特殊处理。术后新发椎体骨折6例10个（24.39%），其中相邻节段5例5个（12.20%）。随访期间，所有患者均未发生骨水泥脱落、内固定物松动等并发症。结论：后路椎弓根螺钉钉道强化内固定治疗OVF临床疗效满意，可明显缓解患者疼痛、改善功能，纠正后凸畸形，在中长期随访中未出现内固定失败等并发症。

英文摘要:

  【Abstract】 Objectives: To analyze the safety and effects of augmented pedicle screw instrumentation via posterior approach in treating the osteoporotic vertebral fracture with a medium to long term follow-up. Methods: From January 2008 to December 2015, 41 patients(37 females, 4 males) were enrolled with an average age of 72±5.8 years old(66-88y), whose mean disease course was 6.75±3.20 months(8h-27m) and BMD with T score at -3.80±1.12SD(-2.9 to -5.4SD). There was a total of 52 index vertebrae, among which 33 with intravertebral pseudo joints(63.46%), 3 with malunion(5.77%) and 12 with severe collapse(23.08%). The individual maximum collapse rate was from 32% to 95%[mean at(72.0±15.2)%], and the percentage of bony fragments occupying the spinal canal was 22.1% to 71.4%[mean at (42.3±11.4)%]. The pre-op neurological statuses on ASIA were grade C in 8 cases, grade D in 10 cases, and grade E in 23 cases. All received augmented pedicle screw instrumentation combined with individual index vertebral augmentation, decompression or osteotomy via posterior approach. The visual analogue scale(VAS) and Oswestry disability index(ODI) before operation, at 1 week post-op and final follow-up were recorded, and the kyphotic angles before operation, at 1 week, 2 years post-op and final follow-up were also measured, as well as the related complications. Results: 35 patients were followed for 24 to 108 months, with an average of 38.9±29.0 months. 2 patients were dead for surgery-unrelated reasons and the rest 4 patients were lost at final follow-up. The VAS scores decreased significantly from pre-op 8.07±1.52 to 3.26±2.40 at 1 week post-op and 2.66±1.49 at the last follow-up, and ODI decreased from pre-op (72.30±11.80)% to (46.70±16.28)% at 1 week post-op and (35.89±11.90)% at final follow-up. Kyphotic angles were significantly corrected from pre-op 26.73°±15.22° to 7.84°±9.18° at 1 week post-op, 11.18°±9.57° at 2 years post-op and 11.43°±1.93° at finalt follow-up(P<0.05). The three variables improved significantly postoperatively(P<0.05), and in addition, the disability function improved at final follow-up compared to that at 1 week post-op(P<0.05), while VAS and kyphotic angle showed equivalent change between the postoperative intervals(P>0.05). 11 patients got recovery from the neurological deficit at finalt follow-up, 3 cases from grade C to D, 5 cases from grade C to E, 3 cases from grade D to E and the rest 7 cases remained at grade D. Besides, 8 cases got rid of pre-op leg radicular pain and numbness. As for the complications, asymptomic cement leakage was observed in 13 cases(31.71%) and 10 new vertebral fractures(24.39%, 5 patients) occurred including 5 adjacent segments(12.20%, 5 patients). No cement migration or screw loose was detected. Conclusions: The patients with osteoporotic vertebral fractures acquired pain relief, function improvement and kyphotic deformity correction after the posterior approach with augmented pedicle screw instrumentation without fixation failure at the middle to long term follow-up.