后路伤椎切除术联合钉道强化脊柱短缩治疗伤椎极重度塌陷Ⅲ期Kümmell病的疗效分析

Posterior vertebral column resection combined with polymethylmethacrylate-augmented pedicle screw instrumentation and shortening of spinal column for stageⅢKümmell's disease with very severe collapse of fractured vertebra

目的探讨后路全椎体切除术(PVCR)联合钉道强化脊柱短缩治疗极重度塌陷Ⅲ期Kümmell病的疗效。方法回顾性分析2017年1月至2021年9月山东省潍坊市人民医院收治的9例伤椎极重度塌陷Ⅲ期Kümmell病的患者资料,其中男1例,女8例;年龄(66.9±5.8)岁;损伤节段:T112例,T124例,L12例,L21例。患者均行PVCR联合钉道强化脊柱短缩内固定治疗。记录患者手术时间、术中出血量、并发症的发生情况、植骨融合情况、术前和末次随访时的美国脊髓损伤协会(ASIA)分级,比较患者术前、术后1周、3个月、末次随访时视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、后凸cobb角。结果所有患者均成功完成手术,伤椎切除植骨后上下邻椎闭合紧实。手术时间(240.6±23.2)min,术中出血量(505.6±95.0)mL。9例患者术后随访(17.3±5.6)个月。术后均未出现神经损伤症状加重、脑脊液漏及其他严重并发症,未发现内固定松动或断裂、邻椎骨折等。末次随访时所有患者植骨区骨性融合。与术前比较,所有患者术后1周、3个月、末次随访时的VAS评分、ODI、后凸cobb角均较术前显著降低,差异均有统计学意义(P<0.05);术后1周、术后3个月及末次随访时VAS评分、后凸cobb角比较差异均无统计学意义(P>0.05),但ODI术后不同时间点两两比较差异均有统计学意义(P<0.05),术后1周>术后3个月>末次随访时。末次随访时ASIA分级:2例由术前C级改善至术后D级,1例由术前C级改善至术后E级,5例由术前D级改善至术后E级。结论PVCR联合钉道强化脊柱短缩治疗极重度塌陷Ⅲ期Kümmell病是一种切实可行、有效的手术方法。

Objective To investigate the feasibility and clinical efficacy of posterior vertebral column resection(PVCR)combined with polymethylmethacrylate-augmented pedicle screw instrumentation and shortening of spinal column for stageⅢKümmell's disease with very severe collapse of fractured vertebra.Methods From January 2017 to September 2021,9 patients with stageⅢKümmell's disease with very severe collapse of fractured vertebra underwent PVCR combined with polymethylmethacrylate-augmented pedicle screw instrumentation and shortening of spinal column.Their medical records were retrospectively analyzed.There were 1 male and 8 females,aged(66.9±5.8)years.The injured vertebra was located at T11 in 2 patients,at T12 in 4,at L1 in 2 and at L2 in 1.X-ray,CT and MRI were performed before operation.The posterior intervertebral heights of adjacent vertebral bodies of the fractured vertebra in the median sagittal position were measured on CT or MRI to evaluate the shortening of the spinal column before PVCR.Recorded were intraoperative bleeding volume,operation time,complications,bone graft fusion,and American Spinal Injury Association(ASIA)grading at preoperation and the last follow-up.The visual analogue scale(VAS)pain scores,Oswestry disability index(ODI)scores,and kyphotic cobb angles at preoperation,1 week and 3 months postoperation,and the last follow-up were compared to evaluate the clinical efficacy of PVCR.Results All patients underwent surgery successfully,with tight closure of adjacent vertebrae after resection of the injured vertebra and bone grafting.Operation time was(240.6±23.2)min and intraoperative bleeding(505.6±95.0)mL.The 9 patients were followed up for(17.3±5.6)months.No worsening symptoms of nerve injury,cerebrospinal fluid leakage,or other serious complications were found after operation,nor such complications as loosening or breakage of internal fixation or adjacent vertebral fractures.Bone fusion was achieved at the bone graft sites in all patients by the last follow-up.The VAS and ODI scores and cobb angles at 1 week and 3 months postoperation and at the last follow-up were significantly decreased compared with preoperation(P<0.05).There were no significant differences in VAS scores or cobb angles among postoperative 1 week and 3 months and the last follow-up(P>0.05),but pairwise comparisons between different time points after operation showed significant differences in ODI,with postoperative 1 week>postoperative 3 months>the last follow-up(P<0.05).The ASIA grading at the last follow-up was improved from preoperative grade C to grade D in 2 cases,from preoperative grade C to grade E in 1 case and from preoperative grade D to grade E in 5 cases.Conclusion PVCR combined with polymethylmethacrylate-augmented pedicle screw instrumentation and shortening of spinal column is a feasible and effective surgical treatment for stageⅢKümmell's disease with very severe collapse of fractured vertebra,leading to good clinical efficacy.