腰椎融合术后邻近节段椎体压缩性骨折的治疗方式及临床疗效

Treatment method and clinical outcomes of vertebral compression fractures of adjacent segments after lumbar fusion surgery

中文关键词:  骨质疏松症  腰椎退行性疾病  脊柱骨折  脊柱内固定术  邻近节段疾病

英文关键词:Osteoporosis  Degenerative lumbar disease  Vertebral fracture  Spinal instrumentation  Adjacent segment disease

中文摘要:

  【摘要】 目的：分析腰椎融合术后邻近节段椎体压缩性骨折（adjacent vertebral compression fracture，AVCF）的特点，并探讨其治疗方式及临床疗效。方法：回顾性分析2013年1月~2019年1月在我中心因腰椎退行性病变行腰椎固定融合术治疗的患者353例，有11例患者发生融合术后AVCF，均为女性，年龄70±7.2岁（61~83岁），其中T12椎体骨折1例，T12合并L1椎体骨折1例，L1椎体骨折4例，L2椎体骨折2例，L1合并L2椎体骨折1例，L3椎体骨折1例，L3合并T11椎体骨折1例。依据AVCF患者的骨折特点，予以不同的治疗方式，其中3例发现骨折时已趋于愈合或合并其他基础疾病不适合手术，采用抗骨质疏松等保守治疗；3例单纯骨折无严重神经损伤症状，采用局麻下后路经皮椎体后凸成形术（percutaneous kyphoplasty，PKP）；5例骨折合并下肢神经压迫症状，采用后路翻修、椎管减压、向上延长固定术治疗。随访24.5±6.4个月（24~31个月）。术前、术后1周和末次随访时进行腰痛、下肢痛视觉模拟量表（visual analogue scale，VAS）评分和腰椎日本骨科协会（Japanese Orthopaedic Association，JOA）评分，术后定期复查，记录围手术期及随访中并发症发生情况。结果：腰椎融合术后AVCF的发生率为3.1%（11/353）。腰痛VAS评分术前5.2±2.3分，术后1周3.5±1.8分（P＜0.05），末次随访时3.9±2.0分（P＜0.05）；下肢痛VAS评分术前7.1±2.2分，术后1周3.0±1.6分（P＜0.05），末次随访时3.7±1.9分（P＜0.05）；腰椎JOA评分术前14.8±5.6分，术后1周21.5±4.2分（P＜0.05），末次随访时18.7±3.9分（P＜0.05）。末次随访时依据JOA改善率（recovery rate，RR），优5例，良3例，可2例，差1例，临床疗效满意率72%。共有4例（36%）患者出现5例次并发症，其中1例患者术后出现伤口深部金黄色葡萄球菌感染，给予切开清创灌洗引流，使用敏感抗生素治疗后痊愈；1例患者术后双下肢无力加重，出现尿潴留，术后再次行椎管减压、骨水泥螺钉延长固定，翻修术后患者出现一过性心功能不全，经限盐限水、强心利尿等治疗后痊愈；1例患者术后再次出现椎体压缩骨折，给予PKP骨水泥强化治疗；1例患者术后再次出现AVCF合并椎间盘突出、椎管狭窄，再次翻修延长固定。结论：腰椎融合术后AVCF多发生在胸腰段，以老年女性多见，单纯AVCF不伴神经症状采取PKP治疗，合并椎间盘突出或椎管狭窄的AVCF采取腰椎翻修椎管减压内固定术，手术治疗腰椎融合术后AVCF可取得较好的临床效果。

英文摘要:

  【Abstract】 Objectives: To analyze the characteristics of adjacent vertebral compression fracture(AVCF) after lumbar spinal fusion, and to investigate its treatment modality and clinical efficacy. Methods: 353 patients treated with lumbar fixation and fusion for lumbar degenerative diseases at our center from January 2013 to January 2019 were retrospectively analyzed, and a total of 11 patients had AVCF after fusion, all were female, aged 70±7.2 years(61-83 years) old, including 1 case of T12 vertebral fracture, 1 case of T12 combined with L1 vertebral fracture, 4 cases of L1 vertebral fracture, 2 cases of L2 vertebral fracture, 1 case of L1 combined with L2 vertebral fracture, 1 case of L3 vertebral fracture, and 1 case of L3 combined with T11 vertebral fracture. The fractures were treated accordingly based on the AVCF characteristics, three cases underwent conservative treatments such as anti-osteoporosis due to healed fractures or other underlying diseases that were not suitable for surgery; Three cases of simple fractures without severe neurological damage symptoms were treated with percutaneous kyphoplasty（PKP） under local anesthesia; Five cases of fractures combined with lower limb nerve compression symptoms were treated with posterior revision surgery, spinal canal decompression, and upward extension and pedicle screws fixation. The mean follow-up time was 24.5±6.4 months(24-31 months). The visual analogue scale(VAS) score for low back pain and lower extremity pain and Japanese Orthopaedic Association(JOA) score for lumbar spine were performed preoperatively, 1 week postoperatively, and at the final follow-up, and the occurrence of complications during the perioperative period and the follow-up were recorded. Results: The incidence of AVCF after lumbar fusion was 3.1%(11/353). The VAS score for low back pain was 5.2±2.3 preoperatively, 3.5±1.8 at 1 week postoperatively(P<0.05), and 3.9±2.0 at the final follow-up(P<0.05); the VAS score for lower extremity pain was 7.1±2.2 preoperatively, 3.0±1.6 at 1 week postoperatively(P<0.05), and 3.7±1.9 at the final follow-up(P<0.05); The JOA score of lumbar spine was 14.8±5.6 before operation, 21.5±4.2 at one week after operation(P<0.05) and 18.7±3.9 at the final follow-up(P<0.05). According to the recovery rate(RR) of JOA at the final follow-up, 5 cases were excellent, 3 cases were good, 2 cases were fair and 1 case was poor, and the satisfaction rate of clinical efficacy was 72%. A total of 4 patients (36%) had 5 complications. One patient developed a deep infection of staphylococcus aureus in the wound was treated with incision, debridement, irrigation, drainage, and sensitive antibiotics, and was cured afterward; One patient suffered from increased weakness of both lower extremities and urinary retention after surgery, and was treated with vertebral canal decompression and bone cement screw lengthening and fixation again, while after revision surgery, the patient suffered from temporary cardiac insufficiency, and recovered after treatment of salt and water restriction, cardiotonic diuresis, etc; One patient developed vertebral compression fracture after surgery and was treated with PKP bone cement reinforcement; One patient developed AVCF again and combined with intervertebral disc herniation and spinal stenosis after surgery, who underwent further revision and extended fixation. Conclusions: AVCF after lumbar fusion mostly occurs in the thoracolumbar segment and in elderly women, and simple AVCF without neurological symptoms can be treated with PKP, while AVCF with intervertebral disc herniation or spinal stenosis can be treated with lumbar revision and spinal decompression, and good clinical results can be achieved.