经肋骨入路椎体强化术适应证的影像解剖学观察及临床应用效果

Imagine observation of indications and therapeutic effects of vertebral augmentation via rib approach

目的探讨经肋骨入路行椎体强化术的适应证和治疗效果。方法回顾性研究。纳入无锡市第九人民医院影像科数据库2019年1—12月100例患者的胸椎CT影像资料,其中男女各50例,年龄20~70岁。利用CT影像模拟经肋骨入路沿通道中心轴插入直径4 mm穿刺针,观察穿刺针在横断面和矢状面上可到达椎体内的位置。纳入2018年1月—2020年6月无锡市第九人民医院和武威市人民医院骨科临床应用经肋骨入路椎体强化术治疗的胸椎疾病患者26例共35个胸椎节段,其中男11例、女15例,年龄41~88岁,包括胸椎压缩骨折18例、血管瘤5例、转移性肿瘤3例。对比观察患者手术前后疼痛视觉模拟评分法(VAS)评分、Oswestry功能障碍指数(ODI)、椎体高度的变化以及并发症情况。结果(1)影像解剖学观察:横断面上仅T5~10节段模拟穿刺针100%能够到达椎体中矢线中央,但矢状面上模拟穿刺针均不能到达椎体下部。(2)临床应用:26例患者单侧穿刺9个节段、双侧穿刺26个节段,骨水泥注射剂量3.0~8.0 mL,术后疼痛均缓解。术后随访6~28个月,平均13个月。术前、术后1周和末次随访时,患者VAS评分分别为(8.0±1.6)、(2.4±0.8)和(1.2±0.7)分,ODI分别为85.1%±10.2%、13.4%±5.9%和12.4%±5.8%,椎体前缘相对高度分别为52.4%±12.4%、82.2%±13.7%和80.7%±12.0%,椎体后缘相对高度分别为58.8%±15.5%、86.3%±13.2%和84.6%±10.7%;与术前相比,术后1周及末次随访时患者VAS评分、ODI均下降,椎体前、后缘相对高度增加,且末次随访时患者VAS评分较术后1周进一步下降,差异均有统计学意义(P值均<0.05)。椎旁静脉、邻近软组织内或椎间隙内骨水泥渗漏共5例7个节段,无椎管内骨水泥渗漏和神经损伤。结论经肋骨入路椎体强化术适用于T5~10椎体中、上部压缩骨折或占位性病变切除术后患者,具有操作简单、并发症少和尤其适合局部麻醉手术的特点。

Objective To investigate the indications and therapeutic effects of vertebral augmentation via rib approach.Methods This was a retrospective study,in which the data of thoracic vertebrae CT scanning of 100 cases were selected from the imaging database of Wuxi the Ninth People's hospital.The position of the puncture needle(with a diameter of 4 mm)that reached the vertebral body through the rib was measured by CT simulation.In our two hospitals from January 2018 to June 2020,35 thoracic segments of 26 patients(11 males and 15 females in the age range of41-88 years old),18 cases of thoracic compression fractures,5 cases of thoracic hemangioma,and 3 cases of metastatic tumor on whom vertebral augmentation via rib approach was performed were included.The pain(visual analogue scales,VAS),Oswestry disability index(ODI),height of the vertebral body,and complications were observed.Results In the transverse plane,the needle reached the center of the median-sagittal line of the vertebral body only in T5-10.While in the sagittal plane,the needle did not reach the lower part of the vertebral body.Nine segments were punctured unilaterally and 27 segments were punctured bilaterally.The dosage of bone cement injection was 3.0-8.0 mL.Pain relief was felt by all 26 patients.The postoperative follow-up was from 6 months to 28 months,with an average of 13 months.Before surgery at the 1st week after surgery and at the last follow-up VAS scores of the patients were(8.0±1.6),(2.4±O.8),and(1.2±O.7);ODIs were 85.1%±10.2%,13.4%±5.9%,and 12.4%±5.8%;the vertebral anterior margin heights were 52.4%±12.4%,82.2%±13.7%,and 80.7%±12.0%;and the vertebral posterior margin heights were 58.8%±15.5%,86.3%±13.2%,and 84.6%±10.7%,respectively.Compared with the preoperative,the VAS and ODI of patients decreased at the 1st week after surgery.At the last follow-up,and the relative heights of anterior and posterior vertebral bodies increased.The VAS scores of the patients at the last follow-up decreased compared with the 1st week after surgery,with statistical significance(all P values<0.05).Leakage of bone cement in the paravertebral vein,adjacent soft tissue,or intervertebral space was found in seven segments of five cases.Leakage of bone cement into the spinal canal and nerve injury were not observed.Conclusion Vertebral augmentation via rib approach is indicated for T5-10 segments with the fractures or space-occupying lesions located in the middle and upper parts of the vertebral body.The procedure has the characteristics of simple operation,few complications,and particular suitability for local anesthesia.