基于微观辩证探讨伴裂隙的骨质疏松性椎体压缩骨折术后再塌陷的机制

发布时间：2018-06-13 00:33

本文选题：椎体内真空裂隙 + 骨质疏松性椎体压缩骨折　；参考：《广州中医药大学》2017年博士论文

【摘要】：研究一在骨质疏松性椎体压缩骨折中的椎体内真空裂隙对治疗效果影响背景:先前的研究发现,经皮椎体强化术治疗伴椎体内真空裂隙的骨质疏松性椎体压缩骨折在中长期随访过程中强化椎有较高的再塌陷率,因此椎体内真空裂隙被推测可能是强化椎再塌陷的一个重要诱发因素,但到目前为止仍不能找到椎体内真空裂隙与再塌陷之间的显著联系。目的:分析椎体内真空裂隙的发病机制及其特点,探讨椎体内真空裂隙对经皮椎体强化术治疗骨质疏松性椎体压缩骨折的疗效影响。方法:回顾分析广州中医药大学第一附属医院脊柱骨科于2010年1月-2014年12月连续收治因单节段的骨质疏松性椎体压缩骨折而接受经皮椎体强化术治疗符合纳入标准的患者148例,其中伴椎体内真空裂隙患者52例(IVC组),不伴椎体内真空裂隙患者96例(无IVC组)。两组随访时间均超过2年。分别比较两种患者术前基值包括性别、年龄、骨矿物密度的T值,伤椎分布节段、术前伤椎压缩率、局部后凸角及术前后背部VAS评分。比较两组患者在即时术后、术后1年及2年内伤椎高度和局部后凸角相关放射学参数以及VAS评分变化的差异。另外,分别比较两组患者在骨水泥渗漏及邻椎继发骨折率的差异。结果:椎体内真空裂隙在骨质疏松性椎体压缩骨折的发病率主要与更高的年龄和更严重的骨质去矿物化密切相关,两组患者在术前其他基值比较差异无统计学意义(P0.05)。术后两组患者伤椎高度及局部后凸角较术前显著矫正(P0.05),两组比较差异无统计学意义(P0.05)。术后2年随访,IVC组患者较术后发生显著的再塌陷,在术后2年强化椎垂直压缩率、局部后凸角、强化椎高度进展性丢失率、进展性增加的后凸角及VAS评分IVC组明显高于无IVC组(P0.05)。两组患者在骨水泥渗漏率及邻椎继发骨折率方面比较无统计学差异(P0.05)。结论:经皮椎体强化术治疗伴椎体内真空裂隙的骨质疏松性椎体压缩骨折患者在早期阶段是有效的;但在长期随访过程中强化椎容易出现再塌陷及后凸畸形,因此对此类患者我们推荐严密的观察和延长随访时间,必要时佩戴支具或内固定。研究二经皮椎体强化术治疗伴椎体内真空裂隙的骨质疏松性椎体压缩骨折术后强化椎再塌陷的风险因素背景:结合文献报道和我们的临床研究观察,发现经皮椎体强化术治疗伴椎体内真空裂隙的骨质疏松椎体压缩骨折在术后中长期的随访中强化椎有较高的塌陷率,但是到目前为止尚未见到对其再塌陷的风险因素进行研究报道。目的:探讨经皮椎体强化术治疗伴椎体内真空裂隙的骨质疏松性椎体压缩骨折术后强化椎再塌陷的风险因素。方法:收集伴椎体内真空裂隙的骨质疏松性椎体压缩骨折患者52例。将术后2年与即时术后相比强化椎高度丢失≥15%或局部后凸角进展性增加≥10 °作为再塌陷的标准,我们采用单因素和多因素logistic回归分析识别包括性别、年龄、骨矿物密度T值、伤椎分布节段、术前伤椎压缩程度、裂隙在伤椎内的分布位置、骨水泥在裂隙内填充样式、伤椎复位率和局部复位角等相关的风险因素。结果:若以术后2年与即时术后强化椎高度丢失≥15%为再塌陷的判定标准,仅骨水泥的裂隙填充样式作为唯一的风险因素(OR=21.58,P=0.001);若以术后2年与即时术后强化椎局部后凸角进展性增加≥10 °为再塌陷的判定标准,骨水泥的裂隙填充样式(OR=57.06,P=0.002)和局部后凸角矫正过大(0R=0.67,P=0.005)为两个显著重要的风险因素,而在其他临床和放射学参数方面未见显著性差异。结论:骨水泥的裂隙填充样式和局部后凸角矫正过大是经皮椎体强化术治疗伴椎体内真空裂隙的骨质疏松性椎体压缩骨折术后强化椎再塌陷的两个重要风险因素。因此,我们推荐对这类病人更应该严密的观察和延长随访。研究三骨水泥在不同位置的裂隙区域中的不同填充样式对强化椎的生物力学特性影响背景:充分牢固的固定及足够的稳定性是骨伤科疗效的保证。结合既往的微观辩证研究发现,椎体内裂隙在伤椎内的位置、骨水泥在裂隙区域的填充样式可能是经皮椎体强化术治疗伴椎体内真空裂隙的骨质疏松性椎体压缩骨折再塌陷的两个重要诱因。然而到目前为止,这两种风险因素对强化椎生物力学稳定性影响尚未见到相应的国内外文献进行报道。目的:借助于中医提出的"微观辩证"治疗理念和现代的诊疗技术,同时借助于先进的三维有限元技术来全面分析术后骨水泥在不同位置的裂隙区域中的不同的填充方式之间的生物力学性能差异,从微观辩证角度阐明经皮椎体强化术治疗伴椎体内裂隙的骨质疏松性椎体压缩骨折术后再塌陷提供生物力学实验依据。方法:建立胸11-腰1正常有限元模型,以胸12为伤椎并在此基础上建立伴椎体内裂裂隙的骨质疏松性椎体压缩骨折的有限元模型,在此基础上建立不同骨水泥填充样式的有限元模型,即:IVC偏上裂隙填充模型;IVC偏上嵌插填充模型;IVC偏下裂隙填充模型;IVC偏下嵌插填充模型。分别比较四种不同模型在皮质骨骨折区域、皮质骨未骨折区域、松质骨、邻椎终板的最大Von Mises应力之间的差异。结果:对于四种不同模型而言,强化椎皮质骨骨折区域最大应力主要分布在骨折区域后方,而皮质骨未骨折区域最大应力主要分布在邻近相应终板周边的区域。相对于裂隙填充样式而言,骨水泥的嵌插填充样式不仅可明显降低所有模型伤椎皮质骨骨折区域的最大应力,而且可降低骨水泥团块周边松质骨的最大应力。当椎体内裂隙偏上时,骨水泥嵌插填充样式亦可明显降低伤椎皮质骨未骨折区域的最大应力,但是当裂隙位置偏下时,骨水泥嵌插填充样式反而会增加伤椎皮质骨未骨折区域的最大应力。另外,椎体内裂隙的位置及骨水泥的填充样式对邻椎终板的最大应力无显著性的影响。结论:与裂隙填充样式相比,骨水泥的嵌插填充样式可明显提高强化椎生物力学稳定性。但当裂隙位置偏下时,嵌插填充样式虽可进一步降低伤椎皮质骨骨折区域和周边松质骨应力值,但有可能会进一步增加伤椎皮质骨未骨折区域的应力值,因此对此类应该慎重选择相应骨水泥的填充样式。
[Abstract]:Study a background of the effect of a vacuum fracture in the vertebral body in osteoporotic vertebral compression fractures. Previous studies have found that percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures with a vacuum fracture in the vertebral body has a higher rate of re subsidence of the vertebral body during the middle and long term follow-up, so the vacuum fissure in the vertebral body It is presumed that it may be an important inducer to strengthen the vertebral collapse, but so far there is no significant relationship between the vacuum fracture and the re collapse in the vertebral body. Objective: to analyze the pathogenesis and characteristics of the vacuum fracture in the vertebral body and to explore the treatment of osteoporotic vertebral compression by percutaneous vertebroplasty. Methods: retrospective analysis of 148 cases of osteoporotic vertebral compression fractures in the First Affiliated Hospital of Guangzhou University of Chinese Medicine in December -2014 January 2010 to receive percutaneous vertebroplasty for osteoporotic vertebral compression fractures, including 52 cases (group IVC) with vacuum fissures in the vertebral body. 96 cases (no IVC group) were free from the vertebral vacuum fissures. The two groups were followed up for more than 2 years. The preoperative base values of the two groups were compared to the sex, age, bone mineral density, the vertebral distribution segment, the compression rate before the operation, the local kyphosis and the back VAS score before and after the operation. The two groups were compared in 1 and 2 years after the operation. The difference between the height of the injured vertebra and the related radiological parameters of the local kyphosis and the VAS score. In addition, the differences of the bone cement leakage and the secondary fracture rate in the two groups were compared. Results: the incidence of the vacuum fracture in the vertebral body in the osteoporotic vertebral compression fracture was mainly with the higher age and the more serious bone mineral removal. There was no significant difference between the two groups before the operation (P0.05). The two groups of patients were significantly corrected (P0.05) than before the operation (P0.05). There was no significant difference between the two groups. After 2 years of follow-up, the patients in group IVC had a significant recurrence after the operation, and the vertebral vertical pressure was strengthened in 2 years after the operation. Shrinkage, local kyphosis, enhancement of progressive loss of vertebral height, progressing posterior horn and VAS score in IVC group were significantly higher than those in non IVC group (P0.05). There was no statistical difference between the two groups in the ratio of bone cement leakage and secondary vertebral fracture (P0.05). Conclusion: percutaneous vertebroplasty for the treatment of osteoporosis with the vacuum fracture in the vertebral body The patients with vertebral compression fracture are effective at the early stage, but it is easy to strengthen the vertebral collapse and kyphosis during the long-term follow-up, so we recommend strict observation and lengthening the follow-up time, wear the support or internal fixation when necessary. Study two percutaneous vertebroplasty for the treatment of the bone vacuum fissures in the vertebral body. Background of the risk factors for the enhanced vertebral collapse after the osteoporotic vertebral compression fracture: combined with the literature report and our clinical study, it is found that percutaneous vertebroplasty for osteoporotic vertebral compression fractures with a vacuum fracture in the vertebral body has a higher collapse rate during the middle and long term follow-up, but up to now. The risk factors for its re collapse have not been seen. Objective: To explore the risk factors for the enhanced vertebral collapse after percutaneous vertebroplasty with osteoporotic vertebral compression fractures with the vacuum fracture in the vertebral body. Methods: 52 patients with osteoporotic vertebral compression fractures with vacuum fractures in the vertebral body were collected for 2 years after operation. We used single factor and multi factor Logistic regression analysis to identify the gender, age, bone mineral density T, the vertebral distribution segment, the compression degree of the vertebra, the distribution of the fracture in the injured vertebra, the bone water, and the multiple factor Logistic regression analysis. The risk factors related to the filling style in the fissures, the reduction rate of the injured vertebra and the local reduction angle. Results: the only risk factor (OR= 21.58, P=0.001) was the fracture filling style of the bone cement only (OR= 21.58, P=0.001) if the height loss of the vertebral height was more than 15% after the operation. The progressive increase of the local posterior convex angle is more than 10 degrees as a criterion for re collapse. The fracture filling style (OR=57.06, P=0.002) and the local posterior convex angle are too large (0R=0.67, P=0.005) as two significant risk factors, but there is no significant difference in other clinical and radiological parameters. Conclusion: the fracture filling style of the bone cement The oversize correction of the local kyphosis is the two important risk factor for the enhanced vertebral collapse after percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures with the vacuum fracture of the vertebral body. Therefore, we recommend that these patients should be more closely observed and extended to study the three bone cement in different fracture areas. The influence of the different filling styles on the biomechanical properties of the fortified vertebrae: sufficient firm fixation and sufficient stability are the guarantee of the curative effect of the orthopedics. Combined with the previous microscopic study, the location of the fracture in the vertebral body is found, the filling style of the bone cement in the fracture area may be the treatment of the vertebral body with the percutaneous vertebroplasty. There are two important causes for the re collapse of osteoporotic vertebral compression fracture in the internal vacuum fracture. However, up to now, the two risk factors have not been reported at home and abroad on the effect of strengthening the biomechanical stability of vertebrae. With the help of advanced three-dimensional finite element technique, the biomechanical performance difference between the different filling modes in the fractured region of the bone cement after the operation is analyzed comprehensively. From the micro dialectic point of view, the percutaneous vertebroplasty for the treatment of the osteoporotic vertebral compression fracture with the fracture of the vertebral body is provided to provide the biology. Methods: the finite element model of 11- waist 1 normal finite element method was established. The finite element model of osteoporotic vertebral compression fracture with thoracolumbar fracture was established on the basis of thoracic 12 as the injured vertebra. On this basis, the finite element model of different bone cement filling styles was established, that is, the IVC partial fissure filling model, and the IVC inlay plug and fill. Filling model, IVC partial fissure filling model and IVC offset insert filling model. The difference between four different models in cortical bone fracture area, cortical bone unfractured area, cancellous bone, and maximum Von Mises stress of adjacent vertebral endplate were compared. Results: for four different models, the largest stress in the region of vertebral bone fracture was strengthened. In the area of the fracture area, the maximum stress in the area of the cortical bone not fractured is mainly located in the area adjacent to the adjacent end plate. In terms of the fissured filling style, the intercalation style of the bone cement can not only significantly reduce the maximum stress in the cortical bone fracture area of all models, but also reduce the cancellous bone around the bone cement mass. When the fracture of the vertebral body is up, the bone cement inserting filling style can also significantly reduce the maximum stress in the unfractured area of the injured vertebral cortex, but when the fracture position is down, the bone cement inserting filling style will increase the maximum stress in the unfractured area of the vertebral cortical bone. In addition, the position of the fracture in the vertebral body and the bone cement There is no significant effect of the filling style on the maximum stress of the adjacent vertebral endplate. Conclusion: compared with the fissured style, the intercalation style of the bone cement can obviously enhance the biomechanical stability of the vertebra. However, the intercalation filling style can further reduce the stress value of the fracture area and the surrounding cancellous bone when the fracture position is down. However, it is possible to further increase the stress value of the fractured area of the injured cortical bone. Therefore, the filling pattern of the corresponding bone cement should be carefully chosen.
【学位授予单位】：广州中医药大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R687.3

【参考文献】