迟发性骨质疏松性椎体塌陷的手术方式选择

Surgical options for delayed osteoporotic vertebral collapse

目的：探讨迟发性骨质疏松性椎体塌陷的手术方式选择及临床疗效。方法：自2010年5月至2014年10月,对19例患者20个椎体的迟发性骨质疏松性椎体塌陷（Kümmell病）进行手术治疗,其中男7例,女12例;年龄65~87岁,平均（73.45±5.62）岁。按Li分期：Ⅱ期3例,Ⅲ期不伴神经功能损害13例14个椎体,Ⅲ期伴脊髓损害3例。规定术中体位复位满意者选择经皮椎体成形术（PVP组）,体位复位不满意者采用经皮球囊扩张椎体后凸成形术（PKP组）。观察骨水泥灌注量、骨水泥渗漏、椎体高度恢复及后凸畸形矫正。采用疼痛视觉模拟评分（VAS）,Oswestry功能障碍指数（ODI）,脊髓神经功能Frankel分级来评价临床疗效。结果 ：7个椎体行PVP,13个椎体行PKP,Ⅲ期3例合并脊髓损害者均同时联合后路减压短节段椎弓根螺钉固定术。术后随访10~48个月,平均21.2个月。共发生4个无症状骨水泥渗漏,其中PVP组1个（1/7）,PKP组3个（3/13）,两组比较差异无统计学意义（P=0.561）。PVP组骨水泥灌注量（6.40±术后3 d和术前比较椎体高度恢复（31.71±11.35）%,后凸畸形纠正（9.79±4.64）°,PKP组分别为（5.46±0.94）ml,1.09）ml、（24.77±8.51）%、（8.15±2.97）°,两组比较差异无统计学意义（P〉0.05）。术后3 d患者腰背痛VAS评分和ODI均较术前明显改善,两组间比较差异无统计学意义,末次随访时VAS评分和ODI与术后3 d比较差异无统计学意义。3例减压内固定术患者神经功能均由术前Frankel D级恢复至E级。结论：根据Li分期结合术中体位复位情况对迟发性骨质疏松性椎体塌陷患者进行个体化手术可以获得良好的临床疗效。术中体位复位不良可能是骨水泥渗漏的危险因素。

Objective：To investigate the surgical options and clinical effects of delayed osteoporotic vertebral collapse.Methods：From May 2010 to October 2014,19 patients（20 vertebrae） with delayed osteoporotic vertebral collapse（Kümmell＇s disease） were enrolled in this study. There were 7 males and 12 females,aged from 65 to 87 years old with a mean of（73.5 ±5.62） years. According to Li staging system of Kümmell＇s disease,3 cases were stageⅡ,13 cases（14 vertebrae） were stageⅢ without spinal cord injury,3 cases were stage Ⅲ with spinal cord injury. Patients were respectively treated with percutaneous vertebroplasty（PVP） or percutaneous kyphoplasty（PKP） on the basis of the degree of postural reduction during operation. Injected cement volume,cement leakage,vertebral height restoration and local kyphotic reduction were observed. Visual analogue scale（VAS） and Oswestry Disability Index（ODI） were respectively used to assess the pain and function before and after operation. Frankel grade were used to evaluate neurological status. Results：Seven vertebrae with satisfactory postural reduction were treated with PVP,13 vertebrae with unsatisfactory postural reduction were treated with PKP,3 patients with spinal cord injury were treated with decompression and posterior short segment fixation at the same time. All patients were followed up from 10 to 48 months with an average of 21.2 months. Cement leakage occurred in 4 cases with no symptom,1 cases in PVP group and 3 cases in PKP group,there was no significant difference between two groups（P=0.561）. The priming volume of cement was（6.40±0.94） ml in PVP group and（5.46±1.09） ml in PKP group（P〉0.05）. Three days after operation vs preoperation,the vertebral height restoration and kyphotic improvement was（31.71±11.35）%,（9.79±4.64）° in PVP group and（24.77±8.51）%,（8.15±2.97）° in PKP. There was no significant difference between two groups（P〉0.05）. Three days after operation,VAS of low back pain and ODI in all patients were improved than preoperative data（P〈0.05）,but there was no significant difference between two groups or between postoperative at 3 d and final follow-up（P〉0.05）. Nerve function of 3 patients underwent decompression and fixation from Frankel D to E. Conculsion：According to Li staging system and the degree of introperative postural reduction,individualized surgical treatment for Kümmell＇s disease can obtain good clinical results. Bad postural reduction during operation maybe a risk factor of cement leakage.