骨水泥强化椎弓根螺钉内固定治疗老年胸腰椎结核合并重度骨质疏松

Polymethylmethacrylate-augmented screw fixation in treatment of senile thoracolumbar tuberculosis combined with severe osteoporosis

目的探讨骨水泥强化椎弓根螺钉内固定(polymethylmethacrylate-augmented screw fixation,PASF)治疗老年胸腰椎脊柱结核合并重度骨质疏松的安全性及有效性。方法回顾性分析2012年12月—2014年12月收治且符合选择标准的20例接受前路或后路病灶清除植骨术后行PASF的老年胸腰椎脊柱结核合并重度骨质疏松患者。男8例,女12例;年龄65~72岁,平均68.5岁。骨密度T值-4.2^-3.6,平均-3.9。胸椎结核12例,胸腰椎结核3例,腰椎结核5例。病变节段累及T3~L4,其中单节段病变11例,双节段病变6例,多节段病变3例。病程3~9个月,平均6个月。脊髓神经功能采用美国脊髓损伤协会(ASIA)分级:A级2例,B级5例,C级6例,D级4例,E级3例。术后影像学检查评价植骨融合和椎旁脓肿吸收情况,测量节段Cobb角以评价脊柱后凸改善情况。测量红细胞沉降率(erythrocyte sedimentation rate,ESR)、C反应蛋白(C-reactive protein,CRP)水平。术前、术后1个月及末次随访时采用疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)和ASIA分级评价临床疗效。同时评价结核临床治愈情况。结果患者均顺利完成手术,手术时间154~250 min,平均202 min;术中失血量368~656 mL,平均512 mL。20例患者均获随访,随访时间18~42个月,平均26.8个月。所有患者术后疼痛及结核中毒症状改善,椎旁脓肿吸收,达到脊柱结核临床治愈标准。术后1年内患者均获满意植骨融合。术后仅1例发生无症状骨水泥渗漏至椎旁静脉,其余患者未出现椎管内骨水泥渗漏、肺栓塞以及神经血管损伤等严重并发症。末次随访时脊髓神经功能较术前显著改善,其中ASIA分级为C级7例、D级8例、E级5例,与术前比较差异有统计学意义(Z=2.139,P=0.000)。术后1个月及末次随访时VAS评分、ODI评分、节段Cobb角、ESR和CRP均较术前显著改善(P<0.05);术后1个月和末次随访间差异无统计学意义(P>0.05)。随访期间无内固定物失败、近端交界性后凸等并发症或结核复发发生。结论对于胸腰椎脊柱结核合并重度骨质疏松的老年患者,PASF治疗安全有效。

Objective To explore the safety and effectiveness of polymethylmethacrylate-augmented screw fixation(PASF)in the treatment of elderly thoracolumbar tuberculosis combined with severe osteoporosis.Methods The clinical data of 20 elderly patients with thoracolumbar tuberculosis and severe osteoporosis who underwent PASF after anterior or posterior debridement and bone grafting and met the selection criteria between December 2012 and December 2014 were retrospectively analyzed.There were 8 males and 12 females with an average age of 68.5 years(range,65-72 years).T value of bone mineral density was-4.2 to-3.6,with an average of-3.9.There were 12 cases of thoracic tuberculosis,3 cases of thoracolumbar tuberculosis,and 5 cases of lumbar tuberculosis.The diseased segments involved T3-L4,including 11 cases of single-segment disease,6 cases of double-segment disease,and 3 cases of multi-segment disease.The disease duration was 3-9 months,with an average of 6 months.The preoperative spinal nerve function of the patients was evaluated by the American Spinal Injury Association(ASIA)grading.There were 2 cases of grade A,5 cases of grade B,6 cases of grade C,4 cases of grade D,and 3 cases of grade E.Postoperative imaging examination was used to evaluate the bone graft fusion and paravertebral abscess absorption,and to measure the Cobb angle of the segment to evaluate the improvement of kyphosis.The levels of erythrocyte sedimentation rate(ESR)and Creactive protein(CRP)were tested.The visual analogue scale(VAS)score,Oswestry disability index(ODI),and ASIA grading were used to evaluate the effectivreness before operation,at 1 month after operation,and at last follow-up.The clinical cure of tuberculosis was also evaluated.Results All operation successfully completed.The operation time was154-250 minutes,with an average of 202 minutes;the intraoperative blood loss was 368-656 mL,with an average of512 mL.All 20 patients were followed up 18-42 months,with an average of 26.8 months.The postoperative pain and symptoms of tuberculosis in all patients relieved,and the paravertebral abscess was absorbed,reaching the cure standard for spinal tuberculosis.All bone grafts fusion achieved within 1 year after operation.Only 1 case had asymptomatic bone cement leakage into the paravertebral veins,and the remaining patients had no serious complications such as bone cement leakage in the spinal canal,pulmonary embolism,and neurovascular injury.At last follow-up,spinal cord nerve function significantly improved when compared with preoperative one.Among them,ASIA grading were 7 cases of grade C,8 cases of grade D,and 5 cases of grade E,showing significant difference when compared with preoperative one(Z=2.139,P=0.000).VAS score,ODI score,segmental Cobb angle,ESR,and CRP at 1 month after operation and at last follow-up were significantly improved when compared with preoperative ones(P<0.05);there was no significant difference between1 month after operation and last follow-up(P>0.05).During the follow-up,no complications such as failure of internal fixation,proximal junctional kyphosis,or tuberculosis recurrence occurred.Conclusion For elderly patients with thoracolumbar tuberculosis and severe osteoporosis,PASF treatment is safe and effective.