骨水泥强化椎弓根螺钉固定对骨质疏松患者有利无弊?

Pedicle screw fixation augmented with bone cement benefits osteoporosis patients?

背景:在对伴骨质疏松的腰椎疾病患者进行椎弓根螺钉固定手术时,椎体添加骨水泥可有效增加内固定稳定性,但对相邻节段的影响尚不明确。目的:观察伴骨质疏松的腰椎疾病患者进行椎体骨水泥强化内固定后,早中期随访中骨水泥强化对相邻节段的影响。方法:以87例伴骨质疏松的腰椎疾病患者为研究对象,均行椎弓根螺钉系统固定+后路椎管减压术,并分为3组:常规螺钉组,常规螺钉+骨水泥组,可灌注骨水泥螺钉+骨水泥组。样本平均随访6-18个月,平均随访为9个月。测量术前、术后3d、末次随访的Oswestry功能障碍指数评分、固定节段上位相邻椎间隙高度、固定节段上位相邻椎体变形指数、固定节段椎体上缘终板及相邻上位椎体下缘终板凹陷角度、固定节段Cobb角。结果与结论:①常规螺钉组、常规螺钉+骨水泥组、可灌注骨水泥螺钉+骨水泥组3组内末次随访功能障碍指数评分均较前明显减小(P<0.05),组间两两对比无显著差异(P>0.05)。表明骨质疏松患者脊柱后路固定时,是否添加骨水泥及不同添加方式,对早中期主观疗效影响无显著差异,且均可明显改善患者生活质量。②常规螺钉+骨水泥组、可灌注骨水泥螺钉+骨水泥组2组末次随访对术后3d固定节段Cobb角变化小于常规螺钉组(P<0.05),常规螺钉+骨水泥组、可灌注骨水泥螺钉+骨水泥组2组组间差异无统计学意义(P>0.05)。表明添加骨水泥辅助的内固定稳定性明显优于未添加骨水泥常规手术。③常规螺钉+骨水泥组、可灌注骨水泥螺钉+骨水泥组2组术后3d出现上终板凹陷角度增大;末次随访观察到相邻上位椎体下终板凹陷角度、椎体矩形指数及相邻椎间隙均减小,且前两项指标的改变程度明显大于常规螺钉组。表明添加骨水泥辅助内固定对相邻椎间盘退变程度无显著影响,但明显改变了相邻椎体终板及椎体的形态,增加了相邻椎体发生骨折的风险。

BACKGROUND：During the pedicle screw fixation for lumbar disease patients accompanied with osteoporosis, addition of bone cement in osteoporotic vertebral body can significantly increase the stability of internal fixation, but the effect on adjacent segments is not clear. OBJECTIVE：To observe the effect on adjacent segments of osteoporosis patients after pedicle screw fixation augmented with bone cement in early and medium-term fol ow-up period. METHODS：We reviewed the medical information of 87 patients suffering from lumbar disease accompanied with osteoporosis who underwent operation of pedicle screw fixation and posterior lumbar spinal decompression, and the patients were divided into three groups：conventional pedicle screw group, conventional pedicle screw＋bone cement group, novel perfusional pedicle screw＋bone cement group. The samples were fol owed-up for 6-18 months, averaged 9 months. The Oswestry disability index, intervertebral distance of the upper adjacent segments, deformation index of the upper adjacent vertebral body, concave angle of the fixed lumbar vertebrae superior end-plate and the upper adjacent vertebral body inferior end-plate, and Cobb angle were measured before operation, at 3 days postoperation and during final fol ow-up. RESULTS AND CONCLUSION：The Oswestry disability index of the final fol ow-up in the three groups were decreased when compared with that before operation （P〈0.05）, but there was no significant difference between any two groups （P〉0.05）. This showed that in posterior spinal fixation operation, there was no significant difference in the early and medium-term subjective effect between addition of bone cement or not and different adding ways, and addition of bone cement or not and different adding ways could remarkably improve the life quality of the patients. The change of Cobb angle of fixed lumbar vertebrae between the final fol ow-up and 3 days after operation in conventional pedicle screw＋bone cement group and novel perfusional pedicle screw＋bone cement group was both less than that in the conventional pedicle screw group （P〈0.05）, and there was no significant difference between conventional pedicle screw＋bone cement group and novel perfusional pedicle screw＋bone cement group （P〉0.05）. This showed that the stability of internal fixation augmented with bone cement was much better than the routine operation without bone cement. The concave angle of upper end-plate was increased in conventional pedicle screw＋bone cement group and novel perfusional pedicle screw＋bone cement group at 3 days after operation when compared with that in the conventional pedicle screw group;the lower end-plate concave angle of adjacent centrum, the rectangular index and the adjacent intervertebral space of conventional pedicle screw＋bone cement group and novel perfusional pedicle screw＋bone cement group were al decreased in the final fol ow-up, and the change of the first two indicators was significantly bigger than those in the conventional pedicle screw group. This showed that addition of bone cement in internal fixation operation had no significant effect on the degeneration degree of adjacent intervertebral disc, but it obviously changed the modality of adjacent vertebral endplate and vertebral body, and increased the fracture risk of adjacent vertebral body.