不同压力球囊扩张结合撬拨复位植骨固定治疗胸腰椎骨折的效果及术后再骨折的影响因素

Effect of different pressure balloon dilation combined with prying reduction and bone graft fixation in the treatment of thoracolumbar fractures and the risk factors of postoperative re-fracture

目的探讨不同压力球囊扩张结合撬拨复位植骨固定治疗胸腰椎骨折的效果及术后再骨折的影响因素。方法选取河北省沧州中西医结合医院2019年3月至2021年6月收治的胸腰椎骨折患者100例,采用前瞻性随机对照研究方法,应用随机数字表法分为3组,不完全扩张组33例,适度扩张组33例,完全扩张组34例。3组均采用球囊扩张结合撬拨复位植骨固定治疗,其中不完全扩张组、适度扩张组、完全扩张组球囊扩张压力分别为100、150 psi和不超过200 psi,球囊扩张容积分别为0.5∶1、1∶1、1.5∶1。比较3组手术时间、术中出血量、术后引流量、椎体前缘高度恢复率和住院时间,以及手术前后局部Cobb角、疼痛视觉模拟量表评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry dability index,ODI)评分。根据术后随访是否发生再骨折分组,比较再骨折组和未再骨折组的临床资料,分析胸腰椎骨折患者术后再骨折的危险因素。呈正态分布的计量资料以x¯±s表示,两组间比较采用独立样本t检验,3组间比较采用单因素方差分析或重复测量的方差分析,两两比较采用SNK-q检验;计数资料以例或例(%)表示,组间比较采用χ^(2)检验;应用Logistic回归分析胸腰椎骨折患者术后再骨折的危险因素。结果3组手术时间、术中出血量和术后引流量比较差异均无统计学意义(P值分别为0.096、0.328和0.344);适度扩张组椎体前缘高度恢复率高于不完全扩张组和完全扩张组[(84.15±4.21)%比(70.18±7.44)%、(75.94±6.56)%],住院时间短于不完全扩张组和完全扩张组[(10.38±2.35)d比(15.18±3.44)、(14.59±2.48)d](均P<0.001)。术前,3组患者的Cobb角、VAS和ODI评分比较差异均无统计学意义(均P>0.05);术后,3组患者Cobb角、VAS和ODI评分均低于术前,且适度扩张组均低于不完全扩张组和完全扩张组[(14.08±2.15)°比(16.48±4.85)°、(15.06±3.45)°,(1.81±0.53)分比(2.25±0.41)、(2.31±0.42)分,(18.16±2.18)分比(20.48±4.85)、(20.01±4.45)分](均P<0.001)。100例患者随访至骨折痊愈,根据术后是否发生再骨折分为再骨折组(15例)和未再骨折组(85例),多因素Logistic回归分析结果表明,体质量指数和骨密度是胸腰椎骨折患者术后再骨折的保护因素(比值比分别为0.66和0.15,95%置信区间:0.51~0.86、0.05~0.42,P值分别为0.006和<0.001),椎体有陈旧性楔形变和腰椎结构异常是导致术后再骨折的危险因素(比值比分别为4.22和6.36,95%置信区间:1.14~15.56、1.43~28.21,P值分别为0.027、0.015)。结论撬拨复位植骨固定治疗胸腰椎骨折术中选择球囊扩张压力为150 psi的效果更好。体重指数和骨密度是胸腰椎骨折患者术后再骨折的保护因素,椎体有陈旧性楔形变、腰椎结构异常是导致术后再骨折的危险因素。

Objective To investigate the effect of different pressure balloon dilation combined with prying reduction and bone graft fixation in the treatment of thoracolumbar fractures and the risk factors of postoperative re-fracture.Methods One hundred cases of thoracolumbar fracture patients admitted to Cangzhou Integrated Traditional Chinese and Western Medicine Hospital in Hebei Province from March 2019 to June 2021 were selected.Prospective randomized controlled study method was used and random number table method was used to divide them into three groups:incomplete expansion group(33 cases),moderate expansion group(33 cases)and complete expansion group(34 cases).All the 3 groups were treated with balloon dilation combined with prying reduction and bone graft fixation.The pressure of balloon dilation in incomplete dilation group,moderate dilation group and complete dilation group was 100 psi,150 psi and no more than 200 psi respectively,and the volume of balloon dilation was 0.5∶1,1∶1 and 1.5∶1 respectively.The operation time,intraoperative bleeding volume,postoperative drainage volume,vertebral anterior margin recovery rate and hospital stay,as well as local Cobb angle,visual analog scale(VAS)and Oswestry disability index(ODI)scores before and after operation were compared among the three groups.According to the follow-up of whether there is re-fracture after surgery,the clinical data of the re-fracture group and the non re-fracture group were compared,and the risk factors of the re-fracture after surgery were analyzed.The measurement data with normal distribution was expressed as:independent sample t-test was used for comparison between two groups,one-way ANOVA or repeated measurement ANOVA was used for comparison between three groups,and SNK-q test was used for comparison between two groups.Counting data were expressed in cases or cases(%),and compared between groups byχ^(2) Inspection.Logistic regression was used to analyze the risk factors of refracture after thoracolumbar fracture.Results There was no significant difference in operation time,intraoperative blood loss and postoperative drainage volume among the three groups(P=0.096,0.328 and 0.344,respectively).The recovery rate of vertebral anterior edge height in moderate expansion group was higher than that in incomplete expansion group and complete expansion group((84.15±4.21)%vs(70.18±7.44)%,(75.94±6.56)%),and the hospitalization time was shorter than that in incomplete expansion group and complete expansion group((10.38±2.35)d vs(15.18±3.44),(14.59±2.48)d)(all P<0.001).Before treatment,there was no significant difference in Cobb angle,VAS and ODI scores among the three groups(all P>0.05).After treatment,the Cobb angle,VAS and ODI scores of patients in the three groups were lower than those before treatment,and the moderate expansion group were lower than those in the incomplete expansion group and the complete expansion group((14.08±2.15)°vs(16.48±4.85)°,(15.06±3.45)°,(1.81±0.53)%vs(2.25±0.41),(2.31±0.42),(18.16±2.18)%vs(20.48±4.85),(20.01±4.45)points)(all P<0.001).100 patients were followed up until the fracture was healed.They were divided into re-fracture group(15 cases)and non re-fracture group(85 cases)according to whether there was re-fracture after operation.The results of multifactor logistic regression analysis showed that body mass index and bone mineral density were protective factors for patients with thoracolumbar fracture after operation(odds ratio was 0.66 and 0.15 respectively,95%confidence interval:0.51~0.86,0.05~0.42,P values were 0.006 and<0.001 respectively),The old wedge-shaped change of the vertebral body and the abnormal structure of the lumbar spine are the risk factors for postoperative re-fracture(odds ratio 4.22 and 6.36,95%confidence interval 1.14-15.56 and 1.43-28.21,respectively,P values were 0.027 and 0.015).Conclusions In the treatment of thoracolumbar fracture with prying reduction and bone grafting fixation,the effect of balloon expansion pressure of 150 psi is better.Body mass index(BMI)and bone mineral density(BMD)were protective factors for postoperative re-fracture of patients with thoracolumbar fracture.Old wedge-shaped change of vertebral body and abnormal lumbar structure are risk factors for postoperative re-fracture.