短节段固定联合骨水泥螺钉椎体成形术治疗合并脊神经损伤的陈旧性骨质疏松性椎体骨折骨不连

Short-segmental flxation combined with vertebroplasty via bone cement-augmented screws for treatment of old osteoporotic thoracolumbar vertebral fracture nonunion accompanied by spinal nerve injury

目的探讨短节段固定联合骨水泥螺钉椎体成形术治疗合并脊神经损伤的陈旧性骨质疏松性椎体骨折骨不连(OOVFN)的疗效。方法采用回顾性病例系列研究分析2012年10月至2019年11月华中科技大学同济医学院附属同济医院收治的32例合并脊神经损伤的OOVFN患者临床资料,其中男10例,女22例;年龄50~76岁[(62.4±8.0)岁]。损伤节段:T_(11)4例,T_(12)7例,L_(1)7例,L_(2)6例,L_(3)5例,L_(4)3例。神经损伤Frankel分级:B级7例,C级13例,D级12例。均行短节段固定联合骨水泥螺钉椎体成形术治疗。记录手术时间、术中出血量、伤推骨水泥注入量。术前、术后1周及末次随访时测量伤椎前后缘高度、后凸Cobb角、椎管横截面积以评估椎体复位情况;采用视觉模拟评分(VAS)、Oswetry功能障碍指数(ODI)及Frankel分级评估临床疗效。观察术后并发症情况。结果患者均获随访12~85个月[(44.8±17.5)个月]。手术时间为90-135 min[(109.5±14.1)min],术中出血量为80~220 ml[(157.2±38.5)ml],伤椎骨水泥注入量为3.5~6.5 ml[(5.0±1.1)ml]。伤椎前缘高度由术前的(9.8±2.2)mm恢复至术后1周及末次随访的(19.8±2.7)mm、(19.7±2.5)mm;后凸Cobb角由术前的(21.8±4.7)。纠正至术后1周及末次随访的(5.4±2.7)°、(5.5±2.7)°;椎管横截面积由术前的(595.8±102.3)mm^(2)扩大至术后1周及末次随访的(1093.6±144.9)mm^(2)、(1103.9±147.9)mm^(2)(P均<0.01);而伤椎后缘高度在手术前后得到保持(P>0.05)。VAS、ODI分别由术前的(7.7±1.3)分、79.1±14.7下降至术后1周及末次随访的(2.5±0.8)分、31.8±9.8、(2.3±0.6)分、30.0±9.5(P均<0.01)。患者术后均未出现神经症状加重,末次随访时Frankel分级B级1例,C级6例,D级15例,E级10例,较术前改善(P<0.01)。术中出现骨水泥向后方椎管渗漏2例(椎管减压过程中顺利取出),末次随访时出现骨水泥局部渗漏5例,未见椎管渗漏。均未出现切口感染或内固定松动、失败等情况。结论对于合并脊神经损伤的OOVFN患者,短节段固定联合骨水泥螺钉椎体成形术能矫正伤椎后凸、维持矫形、缓解疼痛及促进神经功能恢复。

Objective To evaluate the clinical outcomes of short-segm ental fixation combined with vertebroplasty via bone cem ent-augmented screws in treating old osteoporotic thoracolum bar vertebral fracture nonunion(OOVFN)accompanied by spinal cord injury.Methods A retrospective case series study was made on 32 patients with OOVFN accompanied by spinal cord injury admitted to Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology between October 2012 and November 2019,including 10 males and 22 females.The age ranged from 50 to 76 years[(62.4±8.0)years].Level of injury was T_(11) in patients,T_(12) in 7,L_(1)in 7,L_(2) in 6,in 5,L_(4) in 3.Frankel classification for spinal nerve injury was grade B in 7 patients,grade C in 13 and grade D in 12.All underwent short-segmental fixation combined with vertebroplasty via bone cement-augmented screws.The operation tim e,intraoperative blood loss,and volume of bone cement injected in the fracture vertebra were documented.The anterior and posterior vertebral height,Cobb angle for local kyphosis and spinal canal volume at the fracture level were measured to evaluate the reduction,and the visual analog scale(VAS),Oswestry disability index(ODI)and Frankel classification were used to evaluate clinical outcomes pre-,post-operatively and at the last follow-up.The post-operative complications were recorded.Results All patients completed the follow-up,with the follow-up duration of 12-85 months[(44.8±17.5)months].The operation time was 90-135 minutes[(109.5±14.1)minutes]and intraoperative blood loss was 80-220 ml[(157.2±38.5)ml].The volume of bone cement injected in the fracture vertebra was 3.5-6.5 ml[(5.0±1.1)ml ].The anterior vertebral height was restored from(9.8±2.2)mm preoperatively to(19.8±2.7)mm at one week postoperatively and to(19.7±2.5)mm at the last follow-up(P<0.01).The Cobb angle was corrected from(21.8±4.7)°preoperatively to(5.4±2.7)° at one week postoperatively and to(5.5±2.7)°at the last follow-up(P<0.01).The crosssectional area of spinal canal was enlarged from(595.8±102.3)mm^(2) preoperatively to(1,093.6±144.9)mm^(2) at one week postoperatively and to(1,103.9±147.9)mm^(2) at the last follow-up(P<0.01).The posterior vertebral height was m aintained during the perioperative period(P>0.05).The VAS and NDI decreased from(7.7±1.3)points and 79.1±14.7 preoperatively to(2.5±0.8)points,31.8±9.8 at one week postoperatively and to(2.3±0.6)points and 31.8±9.8 at the final follow-up(P<0.01).The spinal nerve injury showed improvement at the final follow-up,with Frankel grade B in 1 patients,grade C in 6,grade D in 15 and grade E in 10(P<0.01).Two patients with hone cement leakage into spinal canal were observed intraoperatively,which was cleared during decompression.Five patients with local bone cem ent leakage and no leakage into spinal canal were recorded during the followup.There was no neurological symptom deterioration,wound infection or internal fixation loosening or failure during the follow-up.Conclusion For patients with OOVFN accompanied by spinal cord injury,short-segmental fixation combined with vertebroplasty via bone cement-augmented screws can restore and maintain vertebral alignment,relieve pain and promote neurological function recovery.