长节段椎弓根螺钉复位内固定联合椎体后凸成形术治疗Ⅲ期可复型Kummell病的临床效果

Efficacy observation of long-segment pedicle screw reduction and internal fixation combined with kyphoplasty in the treatment of stageⅢreducible Kummell disease

目的:探讨长节段椎弓根螺钉复位内固定联合椎体后凸成形术治疗Ⅲ期可复型Kummell病的临床效果。方法:回顾性分析2012年1月至2017年3月浙江大学医学院附属邵逸夫医院骨科收治的32例Ⅲ期可复型Kummell病患者的临床资料。其中男性7例,女性25例,年龄(71.8±6.7)岁(范围:61~86岁)。损伤节段:T_(10)1例,T_(11)8例,T_(12)13例,L_(1)7例,L_(2)2例,L_(3)1例。患者术前美国脊柱损伤协会(ASIA)脊髓损伤分级均为D级。术前均行脊柱X线、CT、MRI及骨密度检查。所有患者术中先行体位复位,再行长节段椎弓根螺钉复位内固定联合椎体后凸成形术治疗。记录患者手术时间、术中出血量、住院时间、术后并发症等情况;评估患者手术前后疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、髋部骨密度;测量手术前后受累节段后凸Cobb角、病椎前缘高度、矢状位椎管前后径、横断面椎管前后径、横断面椎管面积。手术前后数据比较采用配对样本t检验或重复测量方差分析。结果:患者均顺利完成手术,手术时间(131.3±16.9)min(范围:95~180 min),出血量(82.5±27.1)ml(范围:50~150 ml),住院时间(8.3±2.4)d(范围:5~14 d)。患者术后均获得12个月以上随访。术后3 d、3个月、6个月、12个月的VAS较术前降低,差异均有统计学意义(P值均<0.01)。术后3个月、6个月、12个月的ODI较术前明显改善,差异均有统计学意义(P值均<0.01)。术后3 d的矢状位椎管前后径、横断面椎管前后径、横断面椎管面积均较术前明显提高(P值均<0.05)。受累节段后凸Cobb角由术前的(35.2±7.6)°降至术后12个月的(4.3±1.7)°(t=22.630,P<0.01)。病椎前缘高度由术前的(4.3±1.0)mm升至术后12个月的(16.9±2.5)mm(t=-25.845,P<0.01)。术后12个月患者髋部骨密度T值为-(2.2±0.6),较术前的-(2.8±0.6)的差异有统计学意义(t=-0.040,P<0.01)。截至末次随访,2例患者发生远端椎弓根螺钉松动,1例发生近端交界性后凸,无新发椎体骨折,ASIA脊髓损伤分级均恢复至E级。结论:结合体位复位,行长节段椎弓根螺钉复位内固定联合椎体后凸成形术治疗Ⅲ期可复型Kummell病是安全有效的治疗方式,可重建病椎稳定性。

Objective To investigate the clinical efficacy of long-segment pedicle screw reduction and internal fixation combined with kyphoplasty in the treatment of stageⅢreducible Kummell disease.Methods The clinical data of 32 patients with stageⅢreducible Kummell disease treated at the Department of Orthopedics,Sir Run Run Shaw Hospital,Zhejiang University College of Medicine from January 2012 to March 2017 were analyzed retrospectively.There were 7 males and 25 females,aged(71.8±6.7)years(range:61 to 86 years).The injured segment was T10 in 1 patient,T11 in 8 patients,T12 in 13 patients,L1 in 7 patients,L2 in 2 patients and L3 in 1 patient.Preoperative American spinal injury association(ASIA)classification of patients all showed grade D.Bone mineral density(BMD),spinal X-ray,CT and MRI were examined before operation.All patients were treated with postural reduction,long-segment pedicle screw reduction and internal fixation combined with kyphoplasty.The operation time,intraoperative blood loss,length of stay and postoperative complications were recorded.The visual analogue scale(VAS)and Oswestry dysfunction index(ODI)as well as the BMD of hip were collected before and after operation.The Cobb angle of involved segment kyphosis and the height of anterior edge of diseased vertebrae were measured before operation,3 days and 12 months after operation.CT-related parameters were measured before and 3 days after operation,including sagittal anterior and posterior diameter of spinal canal,cross-sectional anterior and posterior diameter of spinal canal and cross-sectional spinal canal area.Paired sample t test and repeated measures were used to compare the data before and after operation.Results All patients received the operation successfully.The operation time was(131.3±16.9)minutes(range:95 to 180 minutes),the blood loss was(82.5±27.1)ml(range:50 to 150 ml),and the length of stay was(8.3±2.4)days(range:5 to 14 days).All patients were followed up for more than 12 months.The VAS decreased gradually at 3 days,3 months,6 months and 12 months after operation,and the differences were statistically significant compared with the VAS before surgery(all P<0.01).ODI at 3,6 and 12 months after surgery was significantly improved compared with that before surgery(All P<0.01).The CT-related parameters at 3 days after operation were significantly higher than those before operation(All P<0.05).At 12 months after surgery,the Cobb angle decreased from(35.2±7.6)°preoperatively to(4.3±1.7)°(t=22.630,P<0.01),the height of anterior edge of diseased vertebrae increased from(4.3±1.0)mm preoperatively to(16.9±2.5)mm(t=-25.845,P<0.01),the bone mineral density of hip increased from-(2.2±0.6)preoperatively to-(2.8±0.6)(t=-0.040,P<0.01).Up to the last follow-up,2 patients had distal pedicle screw loosening,1 patient had proximal junctional kyphosis,and there was no new vertebral fracture.Conclusions Based on postural reduction,long-segment pedicle screw reduction and internal fixation combined with kyphoplasty is a safe and effective treatment method for stageⅢreducible Kummell disease,which can reconstruct the stability of the diseased vertebrae.Postoperative standard anti-osteoporosis treatment is the basis to ensure the efficacy.