经皮椎体成形术和经皮椎体后凸成形术再手术原因分析

Risk factors of reoperation after percutaneous vertebroplasty and kyphoplasty

目的分析经皮椎体成形术(PVP)和经皮椎体后凸成形术(PKP)再手术原因,提出再手术要点及预防措施。方法收集2012年6月至2017年12月河南省洛阳正骨医院收治的465例行PVP和PKP患者资料,其中41例行再手术治疗。男8例,女33例;年龄56～89岁,平均75岁;骨质疏松性骨折37例,椎体转移瘤2例,浆细胞骨髓瘤2例。病变节段:T92例,T103例,T116例,T126例,L111例,L25例,L33例,L43例,L52例。5例脊髓损伤患者美国脊柱损伤协会(ASIA)分级为A级1例,B级1例,C级2例,D级1例;2例神经根损伤患者出现持续性神经根疼痛、麻木,肌力2～3级。34例未合并脊髓和神经根损伤患者的疼痛视觉模拟评分(VAS)平均7.8分。7例脊髓和神经根损伤患者行后路开放性手术,其余34例患者行骨水泥强化治疗(14例行PKP,20例行PVP)。所有患者再手术时间为初次手术后2 h～1年。结果 41例患者均获得随访,随访时间为6～29个月,平均18个月。再手术原因有椎体内形成假关节(3/41,7.32%)、椎管内骨水泥渗漏(7/41,17.07%)、非手术椎体再骨折(31/41,75.61%)。末次随访时,2例神经根损伤患者疼痛完全消失,残留皮肤感觉麻木症状,肌力完全恢复正常;5例脊髓损伤患者中1例ASIA分级恢复至C级,1例恢复至D级,2例恢复至E级,1例A级患者无恢复;3例形成假关节患者术后VAS评分平均2.3分;31例非手术椎体再骨折患者VAS评分平均1.8分。结论 PVP、PKP术后再手术的主要原因包括椎管内骨水泥渗漏、椎体内假关节形成、非手术椎体再骨折等,序贯的骨水泥注入、PVP与PKP合理选择、常规病理组织检查、预防跌倒教育及康复功能锻炼能降低再手术率。

Objective To analyze the risk factors of reoperation after percutaneous vertebroplasty(PVP)and kyphoplasty(PKP),and to propose surgical tips during reoperation as well as preventive measures.Methods From June 2012 to December 2017,465 patients underwent PVP and PKP in our hospital.Among them,41 cases underwent reoperation.There were 8 males and 33 females,aged from 56 to 89 years(average,75 years).There were 37 cases of osteoporotic fracture,2 cases of vertebral metastases,and 2 cases of plasma cell myelom.The lesion segments were as follows:T9 in 2 cases,T10 in 3 cases,T11 in 6 cases,T12 in 6 cases,L1 in 11 cases,L2 in 5 cases,L3 in 3 cases,L4 in 3 cases,and L5 in 2 cases.According to the American Spinal Injury Association(ASIA)classification,5 patients with spinal cord injury were rated as follows:grade A in 1 cases,grade B in 1 cases,grade C in 2 cases,grade D in 1 cases.Two patients with nerve root injury had skin hypesthesia,and their muscle strength was gradeⅡ-Ⅲ.Thirty-four patients without spinal cord or nerve root injury had an average visual analogue scores(VAS)of 7.8 and underwent vertebral strengthening,including PKP in 14 patients and PVP in 20 patients,while the rest 7 with spinal cord and nerve root injury underwent open surgery.The patients received reoperation at 2 hours to 1 year following the first surgery.Results All 41 patients were followed up for 6 to 29 months(average,18 months).The reasons for reoperation were as follow:pseudoarthrosis in 3 cases(3/41,7.32%),bone cement leakage in the spinal canal in 7 cases(7/41,17.07%),and fracture in non-surgical vertebral segments in 31 cases(31/41,75.61%).At the final follow-up,2 patients with nerve root injury only had residual numbness;among the 5 patients with spinal cord injury,1 case improved to grade C,1 case to grade D,2 cases to grade E,and 1 case remained grade A according to the ASIA scales;the mean VAS score was 2.3 points in 3 patients who had pseudoarthrosis,while 31 patients with vertebral fractures of non-surgical segments had an average VAS score of 1.8.Conclusion The reasons for reoperation after PVP and PKP include intraspinal leakage of cement,pseudoarthrosis in vertebral body,and vertebral fractures of non-surgical segments.Sequential bone cement injection,critical selection of PVP and PKP cases,routine pathological examination,prevention of falls and rehabilitation exercises can reduce the risk of reoperation.