球囊复位椎体增强结合经伤椎螺钉固定治疗胸腰椎爆裂性骨折的远期疗效

Long-term efficacy of balloon-assisted endplate augmentation combined with transforaminal pedicle screw fixation in the treatment of thoracolumbar burst fractures

目的探讨球囊辅助终板复位、椎体增强结合经伤椎椎弓根螺钉固定治疗胸腰椎爆裂性骨折的远期疗效,并比较硫酸钙骨水泥(CSC)和磷酸钙骨水泥(CPC)的临床效果。方法本研究为回顾性队列研究。回顾性分析2013年11月至2017年12月安徽医科大学附属合肥医院收治的39例胸腰椎爆裂性骨折患者的临床资料。患者均采用经伤椎椎弓根螺钉复位固定、球囊辅助复位伤椎塌陷终板及注射型骨水泥增强技术治疗,且随访时间>5年。男性24例,女性15例,年龄(42.9±13.3)岁(范围:29~56岁)。术前Frankel脊髓神经功能障碍分级C级4例,D级7例,E级28例。其中接受CSC椎体增强21例(CSC组),CPC椎体增强18例(CPC组)。患者术后1周,1、2、5年及末次随访时复查X线片及CT检查,测量影像学指标,包括伤椎前缘高度比、伤椎中部高度比、伤椎楔变角及矢状面Cobb角。采用疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)评价患者临床效果,并观察神经功能恢复情况。组间比较采用独立样本t检验,组内比较采用配对样本t检验和重复测量方差分析。结果所有患者顺利完成手术,无脊髓神经功能损害发生。患者术后各影像学指标均较术前明显改善(P值均<0.01)。患者随访时间(6.7±2.8)年(范围:5~9年)。末次随访时,术前有神经功能损伤症状的11例患者中,9例完全恢复,2例由Frankel分级C级恢复至D级。CPC组术后1周与末次随访时相比,各影像学指标的变化均无统计学意义(P值均>0.05);CSC组术后1周与末次随访时相比,各影像学指标的差异均有统计学意义(P值均<0.05)。术后2年、5年、末次随访时,在伤椎前缘高度比、伤椎中部高度比、伤椎楔变角和矢状面Cobb角矫正丢失方面,CPC组均优于CSC组,差异均有统计学意义(P值均<0.05)。两组末次随访时VAS评分和ODI评分比较均无差异(P值均>0.05)。填充区CSC吸收后周边有硬化带形成,中央残留空洞,无骨组织填充。CPC吸收非常缓慢,至末次随访时CPC组仍填充较满意。结论球囊辅助终板复位、椎体增强结合经伤椎椎弓根螺钉固定治疗胸腰椎爆裂性骨折的远期疗效良好,CPC椎体增强较CSC能更好维持远期伤椎形态和脊柱序列,并可减少伤椎上间隙的塌陷。

Objectives To investigate the long-term efficacy of balloon assisted endplate reduction with vertebral augmentation combined with pedicle screw fixation in the treatment of thoracolumbar burst fractures,and to compare the clinical efficacy of calcium sulfate cement(CSC)and calcium phosphate cement(CPC).Methods This study is a retrospective cohort study.The clinical data of 39 patients with thoracolumbar burst fractures admitted to Hefei Hospital Affiliated to Anhui Medical University from November 2013 to December 2017 were retrospectively analyzed.All patients were treated with pedicle screw reduction and fixation of the injured vertebra,balloon-assisted reduction of the collapsed endplate of the injured vertebra,and artificial bone vertebral body augmentation,and the follow-up time was>5 years.There were 24 males and 15 females,aged(42.9±13.3)years(range:29 to 56 years).According to the Frankel spinal nerve dysfunction grading standard,there were 4 cases of grade C,7 cases of grade D and 28 cases of grade E.There were 21 cases of CSC augmentation(CSC group)and 18 cases of CPC augmentation(CPC group).X-ray and CT were performed at 1 week,1-,2-,5-year after surgery and at the last follow-up,and the imaging indicators were measured,including the injured vertebra anterior edge height ratio,the injured vertebra middle height ratio,the injured vertebra wedge angle,and the sagittal plane Cobb angle.The pain visual analogue scale(VAS)and the Oswestry disability index(ODI)was used for functional evaluation,nervous function was evaluated according to the Frankel spinal nerve dysfunction grading standard.Independent sample t test was used for inter-group comparison,and paired sample t test and repeated measure ANOVA were used for intra-group comparison.Results All operative procedures were successfully completed,no spinal nerve function damage occurred.The postoperative imaging indexes of the patients were significantly improved compared with those before surgery(all P<0.01).The follow-up time of patients was(6.7±2.8)years(range:5 to 9 years).Among the 11 patients with symptoms of neurological impairment before surgery,9 patients completely recovered at the last follow-up,and 2 patients recovered from Frankel grade C to D.There were no significant differences in imaging indexes between the first week after surgery and the last follow-up in the CPC group(all P>0.05),while there were significant differences in imaging indexes between the CSC group and the last follow-up(all P<0.05).CPC group was superior to CSC group in frontal height ratio,middle height ratio,wedge angle variation and sagittal Cobb angle correction loss at 2 year,5 year after surgery and the last follow-up,with statistical significance(all P<0.05).At the last follow-up,there were no differences in VAS and ODI between the two groups(all P>0.05).After absorption of CSC in the filling area,a hardened zone was formed around the area,and the central cavity remained without bone tissue filling.CPC absorption was very slow,and the CPC group was still filled satisfactorily at the last follow-up.Conclusions Balloon assisted endplate reduction and vertebral augmentation combined with pedicle screw fixation through the injured vertebra have good long-term efficacy in the treatment of thoracolumbar burst fractures.Compared with CSC,CPC vertebral augmentation can better maintain the shape and spinal sequence of the injured vertebra in the long term,and can effectively reduce the collapse of the space above the injured vertebra.