脊柱后凸柔韧性在骨质疏松性脊柱骨折伴后凸畸形治疗中的意义

Clincal significance of kyphosis flexibility in the treatment of osteoporotic spinal fractures with kyphosis

目的探讨脊柱后凸柔韧性在骨质疏松性脊柱骨折伴后凸畸形治疗中的临床意义。方法回顾分析2016年4月-2018年9月于本院治疗的24例骨质疏松性脊柱骨折伴后凸畸形患者男4例,女20例,年龄4778(66.50±7.25)岁;骨密度T值为-3.8-2.3(-3.0±0.8)。患者术前行俯卧位脊柱全长加压CT定位像检查,术前、术后2周及末次随访行站立位脊柱全长X线片检查。测量局部后凸Cobb角(local kyphosis Cobb angle,LKCA)和胸腰段后凸Cobb角(thoracolumbar kyphosis,TLK)。定义脊柱后凸柔韧度:(站立位LKCA-俯卧位LKCA)/站立位LKCA×100%;根据柔韧度和俯卧位脊柱全长CT定位像制定手术方案。统计学分析术前、术后2周及末次随访LKCA、TLK、拟截骨级别、实际截骨级别、腰背疼痛视觉模拟评分(visual analog score,VAS)、Oswestry功能障碍指数(Oswestry dysfunction index,ODI)。结果 24例患者均获随访12-33(24.79±6.70)个月,腰背部疼痛较术前均明显缓解,内固定无断裂,无神经脊髓损伤等并发症发生。影像学参数:LKCA术前站立位=(48.94±12.76)°,LKCA术前俯卧位=(34.00±13.52)°,TLK术前站立位=(48.44±12.11)°,TLK术前俯卧位=(33.40±12.64)°,站立位与俯卧位影像学差异有统计学意义(P<0.05)。脊柱后凸柔韧度3.74%74.43%,平均(31.94±18.01)%。LKCA术后2周站立位=(10.36±4.24)°,TLK术后2周站立位=(10.37±4.01)°,LKCA末次随访站立位=(10.97±4.30)°,TLK末次随访站立位=(11.24±4.03)°。术前影像学参数与术后差异有统计学意义(P<0.05),术后2周与末次随访差异无统计学意义(P>0.05)。术后2周及末次随访VAS评分和ODI评分均较术前有显著改善(P<0.05)。术前拟截骨级别Ⅳ级以上19例,Ⅲ级4例,Ⅱ级1例;实际截骨级别Ⅳ级以上8例,Ⅲ级8例,Ⅱ级4例,Ⅰ级1例,未截骨3例。结论骨质疏松性脊柱骨折伴后凸畸形具有一定的柔韧性,根据俯卧位CT定位像及脊柱后凸柔韧性制定的手术方案可达到较好的临床效果,可降低截骨级别。

Objective To explore the clinical significance of kyphosis flexibility in the treatment of osteoporotic spinal fractures with kyphosis.Methods The clinical data of 24 patients with osteoporotic spinal fracture with kyphosis treated in our hospital from April 2016 to September 2018 were retrospectively analyzed,including 4 males and 20 females,aged(66.50±7.25)years(47-78 years).The T-value of bone mineral density was(-3.0±0.8)(-3.8^-2.3).Preoperative full-length compression CT scan and X-ray of the spine in the prone position was performed.Spinal full-length X-ray was taken at 2 weeks postoperatively and final follow-up.The local kyphosis Cobb angle(LKCA)and thoracic lumbar Cobb angle(TLK)were measured.The kyphosis flexibility was defined as(standing LKCA-prone LKCA)/standing LKCA×100%.The operation plan was made according to the flexibility and the full-length CT image of the prone spine.LKCA,TLK,pseudoosteotomy grade,actual osteotomy grade,visual analogue score(VAS)for low back pain,and Oswestry dysfunction index(ODI)were statistically analyzed before operation,2 weeks after operation and at the last follow-up.Results All 24 patients were followed up for(24.79±6.70)months(12-33 months),and the pain in the lower back was significantly relieved compared with preoperation.No internal fixation rupture,neurospinal injury and other complications occurred.Imaging parameters:preoperative LKCA standing position=(48.94±12.76)°,LKCA prone position=(34.00±13.52)°,TLK standing position=(48.44±12.11)°,preoperative TLK prone position=(33.40±12.64)°,the imaging differences between standing position and prone position were statistically significant(P<0.05).Kyphosis flexibility was 3.74%~74.43%,with an average of(31.94±18.01)%.At 2 weeks after operation,the LKCA and TLK of standing position were(10.36±4.24)°,(10.37±4.01)°.At the last follow-up,the LKCA and TLK of standing position were(10.97±4.30)°,(11.24±4.03)°.The differences between preoperative and postoperative imaging parameters were statistically significant(P<0.05),and the differences between 2 weeks after surgery and the last follow-up were not statistically significant(P>0.05).VAS score and ODI score were significantly improved at 2 weeks after operation and the last follow-up(P<0.05).Pseudoosteotomy grade was Ⅳ or above in 19 cases,grade Ⅲ in 4 cases,grade Ⅱ in 1 case.The actual osteotomy grade was grade Ⅳ or above in 8 cases,grade Ⅲ in 8 cases,grade Ⅱ in 4 cases,grade Ⅰ in 1 case,and no osteotomy in 3 cases.Conclusions Osteoporotic spinal fracture with kyphosis has a certain degree of flexibility.According to the CT positioning image of prone position and kyphosis flexibility,the surgical plan can achieve good clinical effect and lower the level of osteotomy.