经皮椎体成形术后症状性骨水泥椎管内渗漏的个体化治疗选择及疗效评价

Individualized treatment selection and effect evaluation for intraspinal cement leakage after percutaneous vertebroplasty

目的探讨经皮椎体成形术(PVP)术后症状性骨水泥椎管内渗漏的外科治疗选择及疗效。方法采用冋顾性病例系列研究分析2016年5月至2020年1月山西省人民医院收治的5例骨质疏松性椎体压缩骨折(OVCF)行术后骨水泥椎管内渗漏并出现神经症状患者临床资料,其中男1例,女4例;年龄65~82岁[(75.4±7.5)岁.损伤节段:T_(12)-L_(1)1例,L_(1)1例,L_(2-4)1例,L_(3)1例,L_(4-5)1例美国脊髓损伤协会(ASIA)分级:C级2例,D级3例;肌力Ⅱ级2例.Ⅲ级3例3例椎管内骨水泥渗漏呈条片状或柱状,偏于椎管一侧,毗邻神经根,采用椎间孔镜取出骨水泥减压;2例硬膜内伴椎管内骨水泥渗漏,采用硬膜切开取出硬膜内骨水泥及经椎弓根椎体截骨取出椎管内骨水泥、植骨融合及内固定术。观察术前、术后3d、3个月及末次随访时视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、美国脊髓损伤协会(ASIA)分级及肌力改变情况.结果患者均获随访12-16个月[(13.6±1.8)个月].术后3d、3个月及末次随访时VAS分别为(2.6±0.6)分、(2.1±0.3)分、(1.9±0.5)分,均较术前的(7.1±1.5)分显著降低(P<0.01),但术后各时相点间差异均无统计学意义(P>0.05)术前、术后3d、3个月及末次随访时ODI分别为74.2±7.3、42.4±10.2、25.6±6.0、21.4±3.6,术后3d、3个月及末次随访时与术前比较,差异均有统计学意义(P<0.05或0.01),但术后3个月与末次随访时差异无统计学意义(P>0.05)。术前ASIA分级C级的2例患者末次随访时恢复至D级,术前分级D级的3例患者恢复至E级(P<0.05).术前肌力Ⅱ级的2例患者末次随汸时提高至Ⅳ级,可以脱拐行走;术前肌力Ⅲ级的3例患者提高至Ⅴ级(P<0.01),神经功能完全恢复。结论对于PVP术后骨水泥椎管内渗漏并出现神经症状的OVCF患者,若骨水泥渗漏于椎管一侧,毗邻神经根,应选择椎间孔镜取出骨水泥减压;若骨水泥渗漏发生在硬膜内,应切开硬膜取出骨水泥减压,可有效缓解疼痛、促进神经功能恢复。

Objective To explore different surgical treatment options and effect for intraspinal cement leakage after percutaneous vertebroplasty(PVP).Methods A retrospective case series study was earned out to analyze the clinical data of 5 patients with intraspinal cement leakage after PVP for osteoporotic vertebral compression fracture(OVCF)admitted to People's Hospital of Shanxi between May 2016 and January 2020,influding 1 male and 4 females,with the age of 65-82 years[(75.4±7.5)years].Injured segments were located at T_(12)-L_(1)in 1 patient,L_(1)in 1,L_(2-4)in 1,L_(3)in 1 and L_(4-5)in 1.The American Spinal Injury Association(ASIA)classification was grade C in 2 patients and grade D in 3.Muscle strength was gradeⅡin 2 patients and gradeⅢin 3.The leakage of bone cement in the spinal canal was strip or columnar in 3 patients,leaning to one side of the spinal canal and adjacent to the nerve root,and the bone cement was removed by transforaminal endoscope for decom pression.The leakage of hone cement in the dura mater and spinal canal was found in 2 patients.The intradural hone cement leakage was removed by durotomy,and the hone cement in the spinal canal was removed by transpedicular osteotomy,bone graft fusion and internal fixation.The visual analogue scale(VAS),Oswestry dysfunction index(ODI),ASIA grade and muscle strength were observed before operation,at 3 days,3 months after operation and at the last follow-up.Results All patients were followed up(or 12-16 months[(13.6±1.8)months].The VAS was significantly decreased at postoperative 3 days,3 months and at the last follow-up [(2.6±0.6)points,(2.1±0.3)points,(1.9±0.5)points]when compared to(7.1±1.5)points before operation(P<0.01).However,the VAS had no statistical difference at different time points after operation(P>0.05).The ODI was 42.4±10.2,25.6±6.0 and 21.4±3.6 at postoperative 3 days,3 months and at the last follow-up,significantly different from that before operation(74.2±7.3)(P<0.05 or 0.01).How ever,the ODI had no statistical difference at postoperative 3 months and at the last follow-up(P>0.05).Two patients with preoperative ASIA grade C recovered to grade D and 3 patients with preoperative grade D recovered to grade E at the last follow-up( P<0.05).Two patients could walk without crutches with muscle strength improved from grade Ⅱ preoperatively to grade Ⅳ at the last follow-up(P<0.01).Three patients had completed recovery of neurological function with muscle strength improved from grade Ⅲ preoperatively to grade Ⅴ at the last follow-up(P<0.01).Conclusions For OVCF patients with intraspinal canal cement leakage and neurological symptoms after PVP,if the hone cement is located on one side of the spinal canal and adjacent to the nerve root,the hone cement should he removed In foraminal endoscope for decom pression;if the cement leakage occurs in the dura mater,the dura mater should he cut to remove the hone cement for decom pression,which can effectively relieve pain and promote functional recovery.