椎体压缩骨折的处置：椎体成型术与后凸成形术的对比研究

发布时间：2018-06-04 15:27

本文选题：椎体压缩骨折 + 骨质疏松症　；参考：《大连医科大学》2017年硕士论文

【摘要】：背景脊椎压缩骨折(VC)因其连带的社会经济负担正受到越来越广泛的关注。VC被认为是骨质疏松的标志之一,能够导致一系列直接及间接的健康问题,同时对社会卫生系统也带来了不小的负担。随着全球老龄化的不断增长,骨质疏松性VC及相关并发症的发生率将不断增加。VC的主要症状为腰部局部疼痛,约84%的VC患者存在上述表现。日常活动受限,自理能力降低,抑郁,行动不便及平衡性降低共同导致了这部分病人存在较高的整体疾病发病率和死亡率。治疗此类骨折仍存在挑战,虽然目前存在多种手段,但均存在一定限制。近年来由于微创技术的不断成熟,经皮椎体成形及后凸成形术渐渐取代了传统手术方法,成为治疗VC的标准术式。骨水泥的增强作用缓解了药物治疗无效的椎体骨折,缓解了疼痛并改善了功能。椎体成形术藉由向椎体内注入骨水泥实现缓解疼痛症状的同时预防椎体进一步塌陷的目的。后凸成形术则在注入骨水泥前使用球囊将拟注射区域进行扩张,有利于恢复椎体高度,并能够预防低压注射相关的骨水泥渗出。本研究拟比较在局麻和全麻操作下进行的症状性骨质疏松椎体骨折患者椎体成形术及后凸成形术两种手术方式的效果及预后,相关评价指标包括疼痛缓解程度、后凸矫正率及椎体前缘高度的重建效果。方法回顾性分析在大连医科大学附属第二医院脊柱外科行椎体重建手术的47例(11例男性,36例女性)患者资料。其中13例行椎体成形术、34例行后凸成形术。34例在局麻下进行,13例行全麻。共计治疗63节椎体,涉及节段含T8-L5水平;椎体成形治疗17节椎体,后凸成形治疗46节椎体。全部操作在C臂辅助下完成。术前术后的侧位平片用于测量椎体高度和和局部后凸角度。使用SPSS 22.0进行数据分析。结果47例患者(平均年龄74.57±8.38岁)分成两组:椎体成形组(13例,平均年龄75.38±5.36岁)及后凸成形组(34岁,平均年龄74.26±9.33岁),组间年龄无统计学差异(t=0.046,p=0.687)。11例男性患者平均年龄78.91±6.95岁,36例女性患者平均年龄73.25±8.41岁,男女年龄差存在统计学差异(t=2.025,p=0.049)。34例患者在局麻下手术(平均年龄75.71±9.02岁),其余13例全麻下进行手术(平均年龄71.62±5.67岁),组间无统计学差异(t=1.518,p=0.136)。椎体成形组含1例男性,其余12例为女性。后凸成形组含10例男性和24例女性,男女构成在两组间无统计学差异(χ2=2.475,p=0.116)。47例患者存在1到4节椎体骨折,17例行椎体成形,46例行后凸成形。骨折涉及节段包括T8-L5。平均椎体前缘高度(AVH)在后凸成形组为(21.65±3.66 mm),相比椎体成形组(21.35±4.12 mm)更高但无统计学差异(t=-0.278,p=0.782)。术后后凸成形组AVH为(23.39±3.54 mm),与椎体成型组(22.53±3.92 mm)相比更高,但同样没有统计学差异(t=-0.833,p=0.408)。两组治疗前后比较,可见术后AVH均均较术前明显增加(椎体成形组:术前21.35±4.12,术后22.53±3.92 mm,t=-3.305,p=0.004;术前21.65±3.66 mm,术后23.39±3.54 mm,t=-9.676,p=0.000)。椎体成形组术后AVH高度增加6.09±7.61%,与后凸成形术组的高度增加幅度(8.53±6.42%)相比,增幅较小,但组间无统计学差异(t=-1.269,p=0.209)。全麻患者AVH增加幅度较大(全麻:9.08±6.00%,局麻:7.22±7.16%),但两组间无统计学差异(t=-1.037,p=0.304)。具体到组内,椎体成形组中局麻患者的AVH恢复程度更高(局麻6.41±7.37%,全麻3.75±12.37%),但无统计学差异(t=0.452,p=0.658)。后凸成形组中全麻患者的AVH恢复程度更高(全麻9.61±5.34%,局麻7.69±7.14%),但无统计学差异(t=-1.006,p=0.320)。在局麻患者中行椎体成形术者的AVH恢复程度稍低(椎体成形:6.41±7.37%,后凸成形:7.69±7.14%),但不存在统计学差异(7.69±7.14%)。全麻患者中同样存在类似现象(椎体成形:3.75±12.37%,后凸成形:9.61±5.34%),但同样不存在统计学差异(t=-1.342,p=0.195)。术前后凸角度(LKA)在后凸成形组更大(后凸成形组:21.65±3.66°,椎体成形组:14.65±9.38°),但无统计学差异(t=0.056,p=0.956)。术后LKA在椎体成型组更大(椎体成形组:14.06±9.33°,后凸成形组:13.30±6.87°),但同样没有统计学差异(t=0.350,p=0.728)。行椎体成型治疗患者的术前及术后LKA无统计学差异(术前14.65±9.38°,术后14.06±9.33°;t=1.571,p=0.136)。行后凸成形治疗患者的术前及术后LKA存在统计学差异(术前:14.52±7.28°,术后13.30±6.87°;t=4.085,p=0.000)。相较术前角度,后凸成形组的LKA矫正率{(术后角度-术前角度)/术前角度}更大,但两治疗组间比较无统计学差异(后凸成形组:-9.12±19.77%,椎体成形组:-4.55±12.43%;t=0.887,p=0.379)。在全部行局麻处置的患者,平均LKA矫正率为-8.90±21.61%,在全麻处置的患者这一数据为-5.99±8.48%,二者相比不存在统计学差异(t=-0.604,p=0.548)。在椎体成形组,依据麻醉方法细分:行全麻的患者LKA矫正率为-13.33±4.71%,局麻患者LKA矫正率为-3.38±12.75%,两种麻醉方式并不影响LKA矫正率(t=1.068,p=0.302)。在后凸成形组同样依据麻醉方法细分:行全麻的患者LKA矫正率为-5.26±8.49%,局麻患者LKA矫正率为-12.08±25.05%,两种麻醉方式并不影响LKA矫正率(t=-1.165,p=0.250)。在全部行局麻患者中,后凸成行者的LKA矫正率较大(后凸成行者:-12.08±25.05%,椎体成形者:-3.38±12.75%),两种术式间不存在统计学差异。在全部行全麻患者中,后凸成行者的LKA矫正率较小(后凸成行者:-5.26±8.49%,椎体成形者:-13.33±4.71%),两种术式间不存在统计学差异。结论我们的研究显示椎体加强手术——包括椎体成形和后凸成形术都能缓解椎体骨折患者的腰痛症状并提升椎体前缘高度,但二者间上述指标不存在优劣之分。虽然后凸成形术在减小LKA方面的表观作用更佳,但数据分析提示其与椎体成形术的效果没有统计学差异。另外,两种治疗方式在采用局麻或全麻时并不存在疗效差异。
[Abstract]:Background spinal compression fracture (VC) is becoming more and more widely concerned with its social and economic burden. It is considered to be one of the signs of osteoporosis. It can lead to a series of direct and indirect health problems, and it also brings a little burden to the social health system. With the growing global aging, the osteoporotic VC The incidence of the associated complications will increase the main symptoms of.VC for local pain in the lumbar region, and about 84% of the VC patients have the above performance. Limited daily activities, lower self-care ability, depression, mobility and reduction of balance result in higher overall morbidity and mortality in this part of the patients. Treatment of such fractures still remains. In recent years, although there are many kinds of means, there are some restrictions. In recent years, due to the continuous maturation of minimally invasive techniques, percutaneous vertebroplasty and kyphoplasty have gradually replaced the traditional surgical method and become the standard operation for the treatment of VC. The enhancement of bone cement relieves the fracture of the vertebral body, relieves the pain and changes the pain. Good function. Vertebroplasty is aimed at alleviating pain symptoms by injecting bone cement into the vertebral body to prevent further collapse of the vertebral body. Kyphoplasty is used to expand the area of the injected area before injection of bone cement. It is beneficial to restore the height of the vertebral body and to prevent the infiltration of bone cement related to low pressure injection. The results and prognosis of two surgical methods of vertebroplasty and kyphoplasty in patients with symptomatic osteoporotic vertebral fractures under local anesthesia and general anesthesia are compared. The related evaluation indexes include the degree of pain relief, the correction rate of kyphosis and the reconstruction effect of the height of the anterior edge of the vertebral body. Methods a retrospective analysis was attached to the Dalian Medical University. The data of 47 cases (11 men and 36 women) were performed in spinal surgery in second hospital, of which 13 cases were vertebroplasty, 34 cases were performed under local anesthesia and 13 cases were performed under local anesthesia, 13 were treated with 47 vertebral bodies, involving the segment containing T8-L5 level, vertebral body formation for 17 vertebrae, and kyphoplasty for 46 vertebrae. All operations were performed with C arm assistance. The preoperative and postoperative lateral plate was used to measure the vertebral height and the local kyphosis angle. Data analysis was performed using SPSS 22. Results 47 patients (average age 74.57 + 8.38 years old) were divided into two groups: Vertebroplasty group (13 cases, average age 75.38 + 5.36 years) and kyphosis group (34 years old, average age 74.26 + 9.3 3 years old), there was no statistical difference between groups (t=0.046, p=0.687), the average age of male patients with.11 was 78.91 + 6.95 years old, and the average age of 36 female patients was 73.25 + 8.41 years old. The difference of age between men and women was statistically different (t=2.025, p=0.049).34 patients operated under local anesthesia (average age 75.71 + 9.02 years old), and the other 13 cases were operated under general anesthesia (average age). There was no statistical difference between 71.62 + 5.67 years (t=1.518, p=0.136). There were 1 males and 12 women in the vertebroplasty group. There were 10 males and 24 females in the kyphoplasty group. There was no statistical difference between the two groups (x 2=2.475, p=0.116). There were 1 to 4 vertebral fractures, 17 vertebroplasty, 46 kyphoplasty. The segmental segment included the T8-L5. average vertebral anterior edge height (AVH) in the kyphoplasty group (21.65 + 3.66 mm), higher than the vertebroplasty group (21.35 + 4.12 mm), but there was no statistical difference (t=-0.278, p=0.782). The postoperatively kyphoplasty group AVH was (23.39 + 3.54 mm), and was higher than the vertebral body forming group (22.53 + 3.92 mm), but there was no statistical difference. T=-0.833, p=0.408). The comparison of the two groups before and after treatment showed that all the postoperative AVH were significantly increased (vertebroplasty group: preoperative 21.35 + 4.12, 22.53 + 3.92 mm postoperatively, t=-3.305, p=0.004; 21.65 + 3.66 mm before operation, 23.39 + 3.54 mm, t=-9.676, p=0.000). The height of AVH in the group of vertebral bodies was increased by 6.09 + 7.61%, and the height of the protruding group was increased. Compared with the amplitude (8.53 + 6.42%), the increase was small, but there was no statistical difference between the groups (t=-1.269, p=0.209). The increase of AVH in the patients with general anesthesia was larger (9.08 + 6% and 7.22 + 7.16%), but there was no statistical difference between the two groups (t=-1.037, p=0.304). The degree of AVH recovery was higher in the group in the group. (local anesthesia 6.41 + 7.37%,) The general anesthesia was 3.75 + 12.37%), but there was no statistical difference (t=0.452, p=0.658). The degree of AVH recovery in the patients with general anesthesia in the kyphosis group was higher (9.61 + 5.34% and 7.69 + 7.14%), but there was no statistical difference (t=-1.006, p=0.320). The degree of AVH recovery was slightly lower in the patients who underwent vertebroplasty in the local anesthesia patients (6.41 + 7.37%, and kyphoplasty: 7.69 +. 7.14%), but there was no statistical difference (7.69 + 7.14%). There were similar phenomena in general anesthesia (vertebroplasty: 3.75 + 12.37%, and kyphosis: 9.61 + 5.34%), but there was no statistical difference (t=-1.342, p=0.195). The protruding angle (LKA) before and after operation was larger in the kyphoplasty group (kyphosis group: 21.65 + 3.66 degrees, vertebroplasty group: 14.65 + 9.38 degrees. But there was no statistical difference (t=0.056, p=0.956). The postoperative LKA was larger in the vertebroplasty group (14.06 + 9.33 degrees and 13.30 + 6.87 degrees in the kyphoplasty group), but there was no statistical difference (t=0.350, p=0.728). There was no statistical difference between preoperative and postoperative LKA (14.65 + 9.38 degrees before operation, 14.06 + 9.33 degree after operation), t=1.571, P=0.136). There were statistical differences between preoperative and postoperative LKA (preoperative: 14.52 + 7.28 degrees, 13.30 + 6.87 degrees, t=4.085, p=0.000). Compared with the pre operation angle, the LKA correction rate {(after operation angle to preoperative angle) / preoperative angle} was greater, but there was no statistical difference between the two treatment groups (kyphoplasty group: -9.12 19.77%, vertebroplasty: -4.55 + 12.43%; t=0.887, p=0.379). The average correction rate of LKA was -8.90 21.61% in all patients treated with local anesthesia. The data was -5.99 8.48% in the patients treated with general anesthesia, and there was no statistical difference between the two (t=-0.604, p=0.548). In the vertebroplasty group, the anesthesia was subdivided: LKA in general anesthesia patients. The correction rate was -13.33 + 4.71% and the correction rate of LKA in the local anesthesia patients was -3.38 12.75%. The two anesthesia methods did not affect the correction rate of LKA (t=1.068, p=0.302). In the kyphosis group, the same according to the anesthesia method subdivision: the LKA correction rate of the patients undergoing general anesthesia was -5.26 + 8.49%, the LKA correction rate of the local anesthesia patients was -12.08 + 25.05%, and the two anesthesia methods did not affect LKA. The correction rate (t=-1.165, p=0.250). In all patients with local anesthesia, the correction rate of LKA was larger in the kyphosis Walker (kyphosis traveler: -12.08 + 25.05%, vertebroplasty: -3.38 12.75%), and there was no statistical difference between the two types of operation. In all patients with general anesthesia, the correction rate of LKA was smaller (kyphotic Walker: -5.26 + 8.49%, vertebral body formation). Conformers: -13.33 + 4.71%), there is no statistical difference between the two types of operation. Conclusion our study showed that vertebral augment surgery, including vertebroplasty and kyphosis, could relieve the symptoms of lumbago and enhance the height of the vertebral anterior edge of vertebral fractures, but the above indicators did not exist between the two. Although kyphoplasty was reduced by L The apparent effect of KA is better, but data analysis suggests that there is no statistical difference in the effect of vertebroplasty. In addition, there is no difference in efficacy between the two treatments in the use of local anesthesia or general anesthesia.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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