陈旧性胸腰椎骨质疏松性骨折伴后凸畸形手术截骨方式的选择

Choice of osteotomy methods for old thoracolumbar osteoporotic fracture with kyphosis

目的:探讨单节段或双节段经椎弓根椎体截骨(pedicle subtraction osteotomy,PSO)治疗陈旧性胸腰椎骨质疏松性骨折伴后凸畸形的临床疗效。方法:对2015年1月至2017年6月收治的26例陈旧性胸腰椎骨质疏松性骨折伴后凸畸形患者进行回顾性分析,其中男12例,女14例,年龄58~72岁,平均65.6岁。骨折至手术时间(8.2±1.5)年。根据手术方式不同分为单节段PSO组(A组)和双节段PSO组(B组)。记录两组患者围术期资料,通过比较术前及术后1个月影像学数据及术后并发症分析两种术式矫形效果,术前及末次随访采用Oswestry功能障碍指数(Oswestry Disability Index,ODI)和疼痛视觉模拟评分(visual analogue scale,V AS)分析临床疗效。结果:26例患者均获随访,时间6~24个月,平均14.5个月。两组患者手术时间、术中失血量比较差异有统计学意义(P<0.05),术后总引流量、住院时间比较差异无统计学意义(P>0.05)。单节段PSO组术后矫正角度为(33.3±9.4)°,矫正率为85.3%;双节段PSO组术后矫正角度为(41.0±13.5),矫正率为92.7%;两组比较差异有统计学意义(P<0.05)。两组患者术后腰椎前凸角(lumbar lordosis,LL)、矢状面垂直轴(sagittal vertical axis,SVA)及ODI、VAS比较差异无统计学意义(P>0.05)。单节段PSO组出现圆锥损伤1例,经治疗后恢复;双节段PSO组无脊髓损伤并发症。单节段PSO组3例患者术中螺钉松动,双节段PSO组为1例,两组差异有统计学意义(P<0.05),4例患者均使用骨水泥强化钉道后再次置入螺钉,随访未发现螺钉松动。两组患者均无脊柱前方血管及神经损伤、截骨未融合等并发症。结论:单节段PSO与双节段PSO治疗陈旧性胸腰椎骨质疏松骨折伴后凸畸形均可取得较好的矫形效果和临床疗效。对于矫正角度>40°的患者,双节段PSO可提供更好的矫正角度,且安全性更好,但双节段PSO手术时间更长,术中出血更多。

Objective:To investigate the clinical outcome of single or double-segment pedicle subtraction osteotomy(PSO) for the treatment of old thoracolumbar osteoporotic compression fractures with kyphosis.Methods:The clinical data of26 patients with old thoracolumbar osteoporotic compression fractures with kyphosis who underwent surgery from January 2015 to June 2017 were retrospectively analyzed.There were 12 males and 14 females,aged from 58 to 72 years old with an average of 65.6 years.The time interval from fracture to surgery was(8.2±1.5) years.According to different surgical methods,the patients were divided into single-segment PSO group(group A) and double-segment PSO group(group B).The perioperative data,preoperative and postoperative imaging data and postoperative complications were recorded,and the Oswestry Disability Index(ODI) and visual analogue scale(VAS) were used before and after surgery to evaluate the clinical effect.Results:All patients were followed up for 6-24 months with an average of 14.5 months.There was a statistically significant difference in operation time and intraoperative blood loss between the two groups(P<0.05).There was no significant difference in total drainage volume and length of hospital stay(P>0.05).The postoperative correction angle of the single-segment PSO group was(33.3±9.4)° with the correction rate of 85.3% and the double-segment PSO group was(41.0±13.5)° with the correction rate of92.7%,and there was statistical significance between two groups(P<0.05).There were no significant differences in postoperative lumbar lordosis(LL),sagittal vertical axis(SVA),and ODI,VAS between two groups(P>0.05).One case of cone injury occurred in the single-segment PSO group and recovered after treatment.There were no complications of spinal cord injury in the double-segment group.Loose screws occurred during surgery in three patients in the single-segment PSO group and one patient in the double-segment PSO group(P<0.05).All 4 patients were re-inserted with screws after using bone cement to reinforce the nail pathway.There were no complications such as anterior spinal vascular and nerve damage or osteotomy unfusion.Conclusion:Both single-segment PSO and double-segment PSO can achieve good orthopedic and clinical effects in the treatment of old thoracolumbar osteoporotic fractures with kyphosis.For patients with correction angles greater than 40°,the double-segment PSO provides a better correction angle and is safer,but it is with longer operation time and more intraoperative bleeding.