终板骨折与椎体强化后伤椎高度丢失、后凸畸形及慢性疼痛的相关性

Correlation of endplate fractures with height loss of injured vertebral body,kyphosis and chronic pain after vertebral augmentation

背景:椎体强化虽能迅速稳定骨折,缓解疼痛症状,纠正后凸畸形,但随着病例数的不断增加,临床中发现部分患者术后远期后凸畸形及慢性疼痛问题也日渐突出。目的:探究终板骨折对椎体强化(经皮椎体成形/经皮椎体后凸成形)后伤椎高度丢失、后凸畸形及慢性疼痛的影响。方法:回顾性调查了82例接受经皮椎体成形/经皮椎体后凸成形治疗的骨质疏松性椎体压缩骨折患者的病历资料,依据术前CT有无终板骨折将患者分为无终板骨折组、上终板骨折组及下终板骨折组。测量患者的椎体压缩率、手术椎体高度恢复率、Cobb角及骨密度,并记录疼痛目测类比评分、骨水泥弥散类型、骨水泥分布区域及骨水泥渗漏情况。采用单因素分析与卡方检验分析终板骨折与术后伤椎高度丢失、后凸畸形及慢性疼痛是否相关,以及终板骨折对骨水泥弥散分布的影响。结果与结论:(1)3组患者在术后早期伤椎高度和后凸畸形均得到明显改善;而在末次随访中,3组患者均观察到椎体前高度明显下降及Cobb角明显增大,其中上终板骨折组及下终板骨折组的伤椎高度丢失率和Cobb角均比无终板骨折组大(P<0.05);(2)各组术前目测类比评分相比差异无显著性意义(P>0.05),3组术后目测类比评分均显著低于术前(P<0.05);但上终板骨折组及下终板骨折组末次随访目测类比评分高于术后,而无终板骨折组末次随访与术后目测类比评分相比,差异无显著性意义(P>0.05);(3)终板骨折组(上终板骨折组+下终板骨折组)的骨水泥团块状分布、骨水泥未同时与两终板接触占比明显高于无终板骨折组(P<0.05),骨折处骨水泥分布不足在终板骨折组及无终板骨折组之间差异无显著性意义(P>0.05);(4)提示经皮椎体成形/经皮椎体后凸成形可显著改善伤椎高度、后凸畸形及疼痛,但在术后远期终板骨折不仅与术后椎体高度丢失和后凸畸形的发生率增加有关,而且是引起患者慢性疼痛的重要原因;影响术后远期椎体高度丢失和后凸畸形发生的其他因素还包括骨水泥弥散程度、骨密度、手术方式以及骨水泥材料,其中骨水泥的弥散程度又受终板骨折影响,而骨密度越低终板也更易骨折;因此,手术不仅应恢复伤椎的压缩高度并纠正后凸畸形,还应纠正终板的畸形,以有效治疗伴有终板骨折的患者。

BACKGROUND:Although vertebral augmentation can quickly stabilize fractures,relieve pain symptoms,and correct kyphosis,as the number of cases continues to increase,it has been clinically found that some patients have long-term kyphosis and chronic pain problems after surgery.OBJECTIVE:To explore the effects of endplate fractures on the loss of injured vertebral height,kyphosis and chronic pain after percutaneous vertebroplasty/percutaneous kyphoplasty.METHODS:A retrospective study investigated the medical records of 82 patients with osteoporotic vertebral compression fracture,who treated with percutaneous vertebroplasty/percutaneous kyphoplasty.The patients were divided into three groups according to the presence or absence of endplate fractures:unfractured group,superior vertebral endplate fracture group,and inferior endplate fracture group.The vertebral compression rate,vertebral height recovery rate,Cobb angle,and bone mineral density of each patient were measured and visual analogue scale,bone cement dispersion type,bone cement distribution area,and cement leakage were recorded.Univariate analysis and chi-square test were used to analyze whether endplate fractures were related to postoperative injury vertebral height loss,kyphosis and chronic pain,and the influence of endplate fractures on the distribution of bone cement.RESULTS AND CONCLUSION:(1)The height of the injured vertebrae and kyphosis in the three groups were significantly improved.In the last followup,all patients observed a significant decrease in the height of the anterior vertebrae and an increase in Cobb angle.The loss rate of injured vertebral height and Cobb angle in the superior vertebral and inferior endplate fracture groups were greater than those in the unfractured group(P<0.05).(2)There was no significant difference in the preoperative visual analogue scale scores between the groups(P>0.05).The postoperative visual analogue scale scores of the three groups were significantly lower than the preoperative scores(P<0.05),but the last follow-up visual analogue scale scores of the endplate fracture group were higher than those of the postoperative group,while the unfractured group had no significant difference in visual analogue scale scores during the last follow-up and after operation(P>0.05).(3)The proportion of bone cement masses and the bone cement not contacting the two endplates at the same time was significantly higher in the superior vertebral and inferior endplate fracture groups than that of the unfractured endplate group(P<0.05).There was no significant difference between the groups with insufficient bone cement distribution at the fracture site(P>0.05).(4)It is suggested that percutaneous vertebroplasty/percutaneous kyphoplasty can significantly improve the height of injured vertebrae,kyphosis and pain.However,long-term endplate fractures after surgery are not only related to the increased incidence of postoperative vertebral height loss and kyphosis,but also an important cause of chronic pain in patients.Other factors that affect the long-term loss of vertebral body height and the occurrence of kyphosis include the degree of bone cement dispersion,bone density,surgical methods,and bone cement materials.The degree of bone cement dispersion is affected by endplate fractures,and the lower the bone density,the more likely to fracture the endplate.Therefore,surgery should not only restore the compression height of the injured vertebrae and correct the kyphosis,but also correct the deformity of the endplate to effectively treat patients with endplate fractures.