后路长节段固定联合椎体成形术治疗重度骨质疏松胸腰椎压缩骨折疗效观察

EFFECTIVENESS OF LONG SEGMENT FIXATION COMBINED WITH VERTEBROPLASTY FOR SEVERE OSTEOPOROTIC THORACOLUMBAR COMPRESSIVE FRACTURES

目的观察经后路长节段固定联合椎体成形术（long segment fixation combined with vertebroplasty，LSF。VP）治疗重度骨质疏松胸腰椎压缩骨折合并后凸畸形的临床疗效。方法回顾性分析2006年3月一2012年5月，分别采用LSF—vP和经皮椎体后凸成形术（percutaneous kyphoplasty，PKP）治疗椎体前缘压缩超过50％或后凸畸形Cobb角〉40°的重度骨质疏松胸腰椎压缩骨折患者48例（LSF．vP组27例，PKP组21例）。均为T11～L2单椎体压缩骨折，两组患者性别、年龄、受累节段、骨密度T值等一般资料比较，差异均无统计学意义（P〉0．05），具有可比性。比较两组手术前、后疼痛视觉模拟评分（VAS）、胸腰椎后凸Cobb角、椎体前缘高度、椎体后缘高度和椎体压缩比等指标，对疗效进行评估。结果LSF．vP组手术时间、住院时间及骨水泥注射量均高于PKP组（P〈0．05）。LSF—VP组术中出血量为220～1050mL，平均517mL。两组均无肺、脑栓塞、脑脊液漏等并发症发生。LSF—vP组和PKP组分别有3例和2例发生无症状性骨水泥渗漏。两组患者均获随访，LSF．VP组随访时间16～78个月，平均41．1个月；PKP组随访时间12～71个月，平均42．1个月。LSF．VP组随访期间未见螺钉松动、断裂等内固定失败发生；无再骨折及邻近椎体骨折发生。PKP组2例分别在术后39、56个月胸腰痛复发、椎体高度维持欠佳且矫正角度丢失（Cobb角〉40。），另1例于术后16个月出现病椎前缘高度下降、邻近节段重度压缩骨折合并后凸畸形，3例患者二次手术均给予LSF．VP治疗。LSF—VP组除胸腰段后凸Cobb角、椎体后缘高度在出院当天和末次随访时比较差异无统计学意义（P〉0．05）外，其余各指标各时间点间比较差异均有统计学意义（P〈0．05）；PKP组除胸腰段后凸Cobb角、椎体压缩比在出院当天和末次随访时比较差异无统计学意义（P〉0．05）外，其余各指标各时间点间比较差异均有统计学意义（P〈0．05）。术后两组间除出院当天VAS评分和椎体后缘高度比较差异无统计学意义（P〉0．05）外，其余各指标各时间点LSF．VP组均显著优于PKP组，差异有统计学意义（P〈0．05）。结论与PKP相比，LSF—VP术治疗重度骨质疏松性胸腰椎压缩骨折合并后凸畸形，能够获得更好的畸形矫正和椎体高度维持，疗效更满意。

Objective To study the effectiveness of long segment fixation combined with vertebroplasty （LSF-VP） for severe osteoporotic thoracolumbar compressive fractures with kyphosis deformity. Methods Between March 2006 and May 2012, a retrospective analysis was made on the clinical data of 48 cases of severe osteoporotic thoracolumbar compressive fractures with more than 50% collapse of the anterior vertebral body or more than 40~ of sagittal angulation, which were treated by LSF-VP in 27 cases （LSF-VP group） or percutaneous kyphoplasty （PKP） in 21 cases （PKP group）. All patients suffered from single thoracolumbar vertebral compressive fracture at Tll to L2. There was no significant difference in gender, age, spinal segment, and T values of bone mineral density between 2 groups （P 〉 0.05）. The effectiveness of the treatment was appraised by visual analogue scale （VAS）, Cobb angle of thoracolumbar kyphosis, height of anterior/posterior vertebral body, and compressive ratio of vertebrae before and after operations. Results The LSF-VP group had longer operation time, hospitalization days, and more bone cement injection volume than the PKP group, showing significant differences （P 〈 0.05）. Intraoperative blood loss in LSF-VP group ranged from 220 to 1 050 mL （mean, 517 mL）. No pulmonaryor cerebral embolism or cerebrospinal fluid leakage was found in both groups. Asymptomatic bone cement leakage was found in 3 cases of LSF-VP group and 2 cases of PKP group. The patients were followed up for 16-78 months （mean, 41.1 months） in LSF-VP group, and 12-71 months （mean, 42.1 months） in PKP group. No fixation failure such as loosened or broken pedicle screw was found in LSF-VP group during the foUow-up, and no re-fracture or adjacent vertebral body fracture was found. Two cases in PKP group at 39 and 56 months after operation respectively were found to have poor maintenance of vertebral height and loss of rectification （Cobb angle was more than 40°） with recurrence of pain, which were treated by second surgery of LSF-VP; another case had compressive fracture of the adjacent segment and thoracolumbar kyphosis at 16 months after operation, which was treated by second surgery of LSF- VP. There were significant differences in the other indexes between each pair of the three time points （P 〈 0.05）, except the Cobb angle of thoracolumbar kyphosis, and the height of posterior vertebral body between discharge and last follow-up in LSF- VP group, and except the Cobb angle of thoracolumbar kyphosis and compressive ratio of bertebrae between discharge and last follow-up in PKP group （P 〉 0.05）. After operation, the other indexes of LSF-VP group were significantly better than those of PKP group at each time point （P 〈 0.05）, except the VAS score and the height of posterior vertebral body at discharge （P 〉 0.05）. Conclusion The effectiveness of LSF-VP is satisfactory in treating severe osteoporotic thoracolumbar compressive fractures with kyphosis deformity. LSF-VP can acquire better rectification of kyphosis and recovery of vertebral body height than PKP.