经椎弓根椎体截骨长节段固定术治疗骨质疏松性椎体压缩骨折经皮椎体成形术后继发胸腰段后凸畸形的疗效分析

Efficacy of pedicle subtraction osteotomy combined with long segment fixation in treating thoracolumbar kyphosis secondary to percutaneous vertebroplasty for osteoporotic vertebral compression fractures

中文关键词:  椎体压缩骨折  骨质疏松  脊柱后凸  椎体成形术  截骨术

英文关键词:Vertebral compression fracture  Osteoporosis  Kyphosis  Vertebroplasty  Osteotomy

中文摘要:

  【摘要】 目的：探讨经椎弓根椎体截骨（pedicle subtraction osteotomy，PSO）长节段固定术治疗骨质疏松性椎体压缩骨折经皮椎体成形术（percutaneous vertebro plasty，PVP）术后继发胸腰段后凸畸形的临床疗效。方法：回顾性分析2017年1月~2022年12月我院收治的12例PVP术后继发胸腰段后凸畸形患者临床资料，其中男4例，女8例；年龄63~81岁（71.1±5.1岁）。损伤节段T11 1例，T12 2例，L1 4例，L2 5例。术前神经功能按美国脊髓损伤协会（American spine injury association，ASIA）分级C级2例，D级9例，E级1例。所有患者均采用PSO长节段椎弓根螺钉固定术治疗。记录手术时间、术中出血量。随访17~36个月（26.6±5.1个月）。术前、术后1周及末次随访时通过站立位全脊柱正侧位X线片测量伤椎后凸Cobb角、胸腰段后凸角（thoracolumbar kyphosis，TLK）及矢状面平衡轴（sagittal vertical axis，SVA）。采用视觉模拟量表（visual analogue scale，VAS）评分、Oswestry功能障碍指数（Oswestry disability index，ODI）评价疼痛程度及功能改善情况。记录随访期间术后并发症发生情况。末次随访时ASIA分级改善及融合情况。结果：所有患者均顺利完成手术，手术时间为187~275min（221.4±30.5min），术中出血量为425~900mL（540.8±125.7mL）。术中1例发生硬脊膜破裂并发脑脊液漏，术中缝合硬脊膜后切口一期愈合；术后1例出现残余腰痛，经我科活血方定向透药联合康复锻炼后好转。术后1周及末次随访时，伤椎后凸Cobb角、TLK、SVA、VAS评分及ODI较术前显著改善，差异有统计学意义（P<0.05）；与术后1周比较，末次随访时SVA有所增加，VAS和ODI则进一步显著降低，差异具有统计学意义（P<0.05）。伤椎后凸Cobb角和TLK丢失不明显，差异无统计学意义（P＞0.05）。末次随访ASIA分级D级1例；E级11例，较术前改善明显（P<0.05）。末次随访时12例患者均融合，其中11例Bridwell分级Ⅰ级融合，1例Ⅱ级融合，未见内固定松动、假关节形成等。结论：经PSO长节段椎弓根螺钉固定术治疗PVP术后继发胸腰段后凸畸形可明显缓解疼痛及改善日常活动与神经功能功能，矫形效果显著且维持良好。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical efficacy of posterior pedicle subtraction osteotomy(PSO) plus long segment fixation for thoracolumbar kyphosis secondary to percutaneous vertebroplasty(PVP). Methods: A retrospective case series study was conducted on the clinical data of 12 patients with thoracolumbar kyphosis secondary to PVP treated in our hospital from January 2017 to December 2022. There were 4 males and 8 females, aged 63-81 years(71.1±5.1 years). Injured segment: one case at T11, two cases at T12, four cases at L1, and five cases at L2. According to the American Spinal Injury Association(ASIA) classification, the spinal injuries were rated as grade C in two patients, grade D in nine and grade E in one. All the patients underwent PSO combined with long segment fixation. The operative time and intraoperative blood loss were recorded. All the patients were followed up for 17-36 months(26.6±5.1 months). The Cobb angle of injured vertebra, thoracolumbar kyphosis(TLK) angle and sagittal vertical axis(SVA) were measured on the standing full-spine radiographs of spine before operation, at one week after operation, and at final follow-up. Visual analogue scale(VAS) score, and Oswestry disability index(ODI) were recorded to evaluate the pain and improvement in function. ASIA grade and fusion status at final follow-up, and complications were recorded. Results: All operations were successfully completed. The operative time was 187-275min(221.4±30.5min), and the intraoperative blood loss was 425-900mL(540.8±125.7mL). One case of dural tear was complicated with cerebrospinal fluid leakage occurred during operation, and the incision healed in one stage after suturing; One other patient developed residual lower back pain after surgery, which improved after targeted therapy with a herbal formula for promoting blood circulation and rehabilitation. The kyphotic Cobb angle of the injured vertebra, TLK, SVA, VAS score and ODI at 1 week and final follow-up significantly improved versus preoperative values(P<0.05). Compared with 1 week postoperatively, SVA at final follow-up significantly increased(P<0.05), while VAS score and ODI significantly decreased(P<0.05). In contrast, the final follow-up kyphotic Cobb angle of the injured vertebra and TLK showed no significant changes from the values at 1 week after operation(P>0.05). ASIA grades at final follow-up were significantly improved(P<0.05), with 1 patient of grade D and 11 patients of grade E. During the final follow-up, all 12 patients achieved fusion, with 11 rated as Bridwell grade Ⅰ and 1 as grade Ⅱ. Furthermore, there was no radiographic evidence of instrumentation loosening or pseudarthrosis. Conclusions: Posterior PSO plus long segment fixation can significantly reduce back pain and promote daily activities and neurological functional recovery in treating thoracolumbar kyphosis secondary to PVP, which can correct the deformity remarkably with durable orthopedic outcome.