骨填充网袋成形术治疗脊柱转移瘤致椎体后壁骨折

Bone-filling mesh container plasty for spinal metastases with damaged posterior wall of vertebra

目的探讨骨填充网袋成形术治疗转移瘤致椎体后壁骨折的疗效及安全性。方法回顾性分析2015年1月至2019年12月经骨填充网袋成形术治疗的65例转移瘤致椎体后壁骨折患者的资料。男21例、女44例;年龄(70.3±10.8)岁(范围46~90岁);原发肿瘤:肺癌25例,乳腺癌14例,消化系统癌症11例,泌尿系统癌症13例,淋巴瘤1例,卵巢癌1例;部位:T2椎体2例,T5椎体1例,T6椎体1例,T8椎体2例,T9椎体1例,T10椎体5例,T11椎体4例,T12椎体15例,L1椎体12例,L2椎体8例,L3椎体8例,L4椎体4例,L5椎体2例。根据术前CT影像测量椎体后壁破损的面积为s,测量完整椎体后壁的面积为S,后壁破坏率R=s/S,根据R值的大小将椎体后壁破损程度分为:Ⅰ型(R≤25%)21例、Ⅱ型(25%75%)8例。比较患者术前、术后第1天、术后1个月、术后3个月的视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)以及日常生活能力评分(activity of daily living,ADL),评估骨填充网袋成形术的疗效。观察骨水泥渗漏和术后并发症情况。结果65例患者均获得随访,随访时间3~6个月,平均3.8个月。术前、术后第1天、术后1、3个月,VAS评分分别为(7.32±0.99)分、(4.14±1.06)分、(4.11±0.97)分、(4.34±1.11)分,差异有统计学意义(F=149.20,P<0.001);ODI评分分别为69.45%±4.15%、36.65%±3.72%、36.84%±3.38%、37.78%±3.45%,差异有统计学意义(F=840.88,P<0.001);ADL评分分别为(71.31±12.81)分、(79.85±9.14)分、(78.92±8.95)分、(78.31±8.67)分,差异有统计学意义(F=149.20,P<0.001)。Ⅰ~Ⅳ型VAS、ODI、ADL评分和差异均无统计学意义(P>0.05)。11例发生渗漏,渗漏率为17%(11/65)。随R值的增大椎管内骨水泥渗漏率相应增加,其中Ⅰ、Ⅱ型渗漏率为0、Ⅲ型为7.1%(1/14)、Ⅳ型为38%(3/8)。术后均未出现出血、感染、神经根症状或骨水泥植入综合征等。结论骨填充网袋成形术能改善伴椎体后壁破损的脊柱转移瘤患者的疼痛症状,并能恢复一定的功能。椎体后壁破损的程度对手术的疗效无影响,但随着椎体后壁破损程度加大,发生椎管内骨水泥渗漏的风险相应增加。

Objective To study the efficacy and safety of bone-filling mesh container plasty in the treatment of posterior wall fracture of vertebra caused by spinal metastases.Methods This study is a retrospective analysis of 65 patients with pathological fractures of the vertebra caused by vertebral metastases treated with bone-filling mesh container plasty from January 2015 to December 2019.There were 21 males and 44 females,70.3±10.8(46-90)(years).According to primary tumor,there were 25 cases of lung cancer,14 cases of breast cancer,11 cases of digestive system cancer,13 cases of urinary system cancer,1 case of lymphoma and 1 case of ovarian cancer.In the segment of vertebral metastases,there were 2 cases of T2 vertebra,1 case of T5 vertebra,1 case of T6 vertebra,2 cases of T8 vertebra,1 case of T9 vertebra,5 cases of T10 vertebra,4 cases of T11 vertebra,15 cases of T12 vertebra,12 cases of L1 vertebra,8 cases of L2 vertebra,8 cases of L3 vertebra,4 cases of L4 vertebra,and 2 cases of L5 vertebra.According to the CT images of the patient's vertebra before operation,the area of the damaged posterior wall of the vertebra is measured as s,and the area of the posterior wall of the intact vertebra is measured as S.The ratio of posterior wall damage is calculated as R=s/S,and the value of R represents the degree of damage to the posterior wall of the vertebra.According to the size of the R value,the patients were divided into four groups,typeⅠ(R≤25%,21 cases),typeⅡ(25%<R≤50%,22 cases),typeⅢ(50%<R≤75%,14 cases),typeⅣ(R>75%,8 cases).The visual analog scale(VAS),Oswestry disability index(ODI)and activity of daily living(ADL)before and 1 day after surgery,1 month after surgery,and 3 months after surgery were analyzed and compared to evaluate the efficacy of bone-filling mesh container plasty.Pairwise comparisons were performed to verify whether there is a difference in efficacy,bone cement leakage and postoperative complications.Results All 65 patients were followed up for 3-6 months,with an average of 3.8 months.The VAS scores before surgery,postoperative day 1,postoperative 1,3 months were 7.32±0.99,4.14±1.06,4.11±0.97,and 4.34±1.11,respectively,with a statistically significant difference(F=149.20,P<0.001).ODI of preoperative,postoperative day 1,postoperative 1,and 3 months were 69.45%±4.15%,36.65%±3.72%,36.84%±3.38%,37.78%±3.45%,respectively,with a statistically significant difference(F=840.88,P<0.001).ADL score of preoperative,postoperative day 1,postoperative 1,and 3 months were 71.31±12.81,79.85±9.14,78.92±8.95,and 78.31±8.67,respectively,with a statistically significant difference(F=149.20,P<0.001).There was no significant difference in VAS,ODI and ADL scores between types Ⅰ and Ⅳ(all P>0.05),but with the increase of R value,the leakage rate of intraspinal bone cement would increase correspondingly.Eleven cases occurred bone cement leakage with the rate of 17%.The leakage rate of type Ⅰ and Ⅱ was 0,type Ⅲ was 7.1%(1/14),and type Ⅳ was 37.5%(3/8).All patients did not have systemic complications such as allergies,shock,decreased oxygen saturation,etc.,and there were no bleeding,infection,nerve root symptoms or cement insertion syndrome after surgery.Conclusion Bone-filling mesh container plasty can significantly improve the pain symptoms of patients with spinal metastases and recovery functions.The degree of damage to the posterior vertebra has no effect on the efficacy of the surgery.As the degree of damage to the posterior wall of the vertebra increases,the risk of complications of bone cement leakage in the spinal canal will increase.