PVP联合高粘度骨水泥治疗重度骨质疏松性椎体压缩骨折的临床应用
发布时间：2019-07-05 11:54
【摘要】：研究背景和目的:骨质疏松症是骨量减少、骨组织微细结构被破坏,从而导致骨脆性的增加,骨折风险增高的全身性骨骼疾病。流行病学调查发现,在女性的一生中,其患骨质疏松性骨折的危险性高达40%,大于女性常见三大恶性肿瘤(子宫内膜癌、乳腺癌、卵巢癌)的总和。骨质疏松性骨折通常发生于包括椎体、髋部、手腕和脚踝骨折。椎体的骨折发生的频率随年龄的增加而增加。近年来,微创外科等到了迅猛的发展,随着外科技术的不断进步,现代高科技设备的高速发展,各国专家开始探索更新的技术和方法。对于微创脊柱外科领域而言,椎体成形术(Vertebroplasty,VP)作为一种最新的技术受到了学者们的广泛关注。1984年,法国学者Galibert等第一次对椎体侵袭性海绵状血管瘤使用经皮穿刺椎体术,取得了良好的手术效果,他借助外科手术进行填塞骨水泥的经验,从而奠定了椎体成形术的基础。美国于1997年第一次因对骨质疏松性椎体压缩性骨折保守治疗无效,而采用经皮椎体成形术(Pereutaneous Vertebroplasty,PVP),病人症状缓解明显。2000年中国也将椎体成形术用于治疗骨质疏松性椎体压缩性骨折同时伴后凸畸形,同样获得良好的效果。在临床上椎体成形术作为治疗骨质疏松性椎体压缩性骨折微创的一种手术方式得以逐渐推广,因为该手段可有效缓解骨折引起的疼痛,对于广大骨质疏松性椎体压缩性骨折患者群体是巨大的福音。PVP在治疗老年OVCF引起的疼痛时具有手术创伤小、安全性高、操作简单、见效快等特点,在临床的应用得以快速使用,特别在治疗脊柱转移肿瘤、血管瘤、骨质疏松压缩性骨折引起的局部疼痛,取得了良好的疗效[1]。但对于重度OVCF(椎体高度严重塌陷,椎体高度不到原高度的1/3)的治疗,因操作难度大,骨水泥渗漏风险高,目前尚存争议,许多学者将其视为PVP治疗的相对禁忌证[2]。临床有关PVP治疗重度OVCF的文献报道相对少见。在本研究中,我们通过改变传统穿刺模式,于正位透视确立穿刺针内外位置、侧位确立穿刺针上下位置,将穿刺套筒精确放置于重度骨质疏松椎体压缩性骨折正中,同时运用高粘度骨水泥采取先慢后快的注入方式,最大限度减少骨水泥渗漏的发生。研究方法:收集2013年1月-2015年1月收治的应用PVP治疗的重度胸腰椎OVCF患者176例,其中男61例,女115例,年龄58~78岁;平均67.7岁。跌伤94例,扭伤31例,无明显诱因51例。共累及204个椎体,其中T10 23椎,T11 22椎,T12 49椎,L1 43椎,L2 29椎,椎体后壁破坏38椎,椎体高度压缩均大于2/3。比较手术前后受伤椎体高度、后凸Cobb角、视觉模拟评分(Visual Analogue Scale,VAS)和Oswestry功能障碍指数(Oswestry disability index,ODI)变化情况,观察骨水泥灌注、渗漏及其他并发症。纳入标准:(1)所有患者MRI提示为新鲜骨折,骨密度测定T值≤-2.5 SD,确诊为原发性或者继发性骨质疏松症;(2)入院前患者均出现明显腰背疼痛感并伴有活动受限;(3)术前X线片显示受伤椎体压缩程度2/3,诊断为重度OVCF。排除标准:MRI检查提示患者椎管狭窄或椎管内占位,合并神经损伤。研究结果:共纳入PVP治疗重度胸腰椎压缩性骨折患者176例,其中男61例,女115例;年龄58~78岁,平均67.7岁。致伤原因:跌伤94例,扭伤31例,无明显诱因51例。共累及204个椎体,其中T10 23椎,T11 22椎,T12 49椎,L1 43椎,L2 29椎,椎体后壁破坏38椎。64例患者出现骨水泥渗漏情况,渗漏率36.4%,其中椎旁静脉渗漏7例,椎间隙渗漏38例,椎前软组织渗漏19例。5例患者腰背部疼痛部分缓解,4例患者注入骨水泥后5分钟出现下肢烧灼感,10分钟后缓解,所有患者均未出现明显的不良反应,包括脊髓神经压迫或受损症状及体征、硬膜外血肿、肺部感染、肺栓塞、褥疮等,无心脑血管意外发生。患者术后ODI[(31.73±7.98)分]及VAS[(2.33±0.91)分]均优于术前[(75.40±8.17)分、(7.23±0.88)分](p0.05)。术后(术后3 d及术后1年)的椎体前缘高度、椎体中线高度、后凸Cobb角、VAS评分及ODI与术前相比,差异均有统计学意义(p0.05)。但术后1年与术后3 d的椎体前缘高度、椎体中线高度、后凸Cobb角、VAS疼痛评分、ODI脊柱评分差异无统计学意义(p0.05)。研究结论:PVP使用高粘度骨水泥治疗重度OVCF,能显著缓解疼痛、改善运动功能,且发生骨水泥渗漏的几率较传统骨水泥低,具有良好的安全性和有效性,因此,该新技术方法在临床上具有广泛的应用前景,可为广大骨质疏松患者带来福音。
文内图片：
图片说明：椎体成形后凸器械（注释：a：压力泵的加压手柄要逆时针旋转到底，再拔下螺旋手柄
[Abstract]:Background and purpose of the study: osteoporosis is the amount of bone, and the microstructure of the bone tissue is destroyed, resulting in an increase in bone fragility and an increased risk of fracture of the bone. The epidemiological survey found that in a woman's life, the risk of osteoporotic fracture is as high as 40%, which is greater than the sum of the three major malignancies (endometrial cancer, breast cancer, and ovarian cancer) common to women. Osteoporotic fractures often occur in a fracture that includes a vertebral body, a hip, a wrist, and an ankle. The frequency of the fracture of the vertebral body increases with increasing age. In recent years, minimally invasive surgery has been waiting for rapid development. With the development of surgical technology and the high-speed development of modern high-tech equipment, national experts begin to explore new technologies and methods. Vertebroplasty (VP) has been widely concerned by the scholars in the field of minimally invasive spinal surgery. For the first time in 1984, the French scholar, Galibert et al., used the percutaneous puncture of the vertebral body for the first time, and achieved a good surgical effect. The experience of filling bone cement with the aid of a surgical procedure lays the foundation for vertebroplasty. In the first time in 1997, the conservative treatment of the osteoporotic vertebral compression fracture was not effective, and the patient's symptoms were relieved by percutaneous vertebroplasty (PVP). In 2000, the vertebroplasty was also used to treat osteoporotic vertebral compression fractures with kyphosis, A good effect is also obtained. In the treatment of osteoporotic vertebral compression fractures, a minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures has been gradually promoted, since the means can effectively relieve the pain caused by the fracture, and is a great gospel for patients with a wide range of osteoporotic vertebral compression fractures. The PVP has the characteristics of small operation wound, high safety, simple operation, quick effect and the like in the treatment of the pain caused by the old OVCF, and can be used for rapid use in the clinical application, in particular to the local pain caused by the treatment of the spinal metastatic tumor, the hemangioma, the osteoporosis and the compression fracture, Good results[1] were obtained. However, for severe OVCF (the height of the vertebral body is severely collapsed, the height of the vertebral body is less than 1/3 of the original height), because the operation is difficult, the risk of bone cement leakage is high, there is still a dispute, and many scholars regard it as the relative contraindication of the treatment of PVP[2]. The literature on the treatment of severe OVCF with PVP is relatively rare. in the present study, by changing the traditional puncture pattern, the internal and external positions of the puncture needle are established in the normal position, the upper and lower positions of the puncture needle are established at the side positions, the puncture sleeve is accurately placed in the middle of the compression fracture of the severe osteoporosis vertebral body, At the same time, high-viscosity bone cement is used to take a slow and fast injection mode to minimize the occurrence of bone cement leakage. Methods:176 patients with severe thoracic and lumbar OVCF treated with PVP from January 2013 to January 2015 were collected, including 61 males and 115 females, aged from 58 to 78 years, with an average of 67.7 years. There were 94 cases of traumatic injury,31 cases of sprain, and 51 cases with no obvious inducement. 204 vertebral bodies were involved, of which T10 23 vertebra, T11 22 vertebra, T12 49 vertebra, L1 43 vertebra, L2 29 vertebra, the vertebral body posterior wall damaged 38 vertebra, the vertebral body height compression is more than 2/3. The changes of the height of the injured vertebral body, the post-convex Cobb angle, the visual analogue scale (VAS) and the Oswestry disability index (ODI) were compared before and after the operation, and the cement perfusion, leakage and other complications were observed. Inclusion criteria: (1) All patients with MRI showed fresh fracture, and the bone mineral density was measured with T-value of 1-2.5 SD, and the diagnosis was primary or secondary osteoporosis; (2) the patient had obvious back-and-back pain and limited activity before admission; (3) The preoperative X-ray showed that the degree of compression of injured vertebral body was 2/3 and the diagnosis was severe OVCF. Exclusion criteria: MRI examination revealed spinal stenosis or intravertebral space occupying, and combined nerve injury. Results: A total of 176 patients with severe thoracolumbar compression fractures were treated with PVP, including 61 males and 115 females. The age was 58 to 78 years, with an average of 67.7 years. The cause of injury:94 cases of traumatic injury,31 cases of sprain, and 51 cases with no obvious inducement. A total of 204 vertebral bodies were involved, including T10 23, T11 22, T12 49, L1 43, L2 29, and posterior wall of the vertebral body in 38 cases. The leakage of bone cement in 64 patients was 36.4%, including 7 cases of paravertebral venous leakage and 38 cases of disc space leakage. There were 19 cases of soft tissue leakage in the front of the disc. The pain in the back and back of 5 patients was relieved, and the burning sensation of the lower limbs was observed in 4 patients after injection of the bone cement for 5 minutes. After 10 minutes, no obvious adverse reaction was observed in all patients, including spinal cord compression or impaired symptoms and signs, and epidural hematoma. Pulmonary infection, pulmonary embolism, bedsore, etc., no cardiovascular and cerebrovascular accident. The postoperative ODI[(31.73-7.98) scores] and VAS[(2.33-0.91) scores] were superior to the preoperative[(75.40-8.17) scores] (7.23-0.88) scores] (p0.05). The height of the anterior edge of the vertebral body, the height of the midline of the vertebral body, the Cobb angle of the posterior convex Cobb, the VAS score and the ODI of the post-operative (3-d and 1-year post-operative) were statistically significant (p0.05). However, there was no significant difference in the height of the anterior edge of the vertebral body, the midline of the vertebral body, the post-convex Cobb angle, the VAS pain score and the ODI spinal score in one year and the third day after the operation (p0.05). Conclusion: The use of high-viscosity bone cement in the treatment of severe OVCF can significantly relieve the pain, improve the function of exercise, and the rate of bone cement leakage is lower than that of the conventional cement, and it has good safety and effectiveness. And can bring the gospel to a large number of patients with osteoporosis.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R687.3;R580
本文编号：2510502
文内图片：
图片说明：椎体成形后凸器械（注释：a：压力泵的加压手柄要逆时针旋转到底，再拔下螺旋手柄
[Abstract]:Background and purpose of the study: osteoporosis is the amount of bone, and the microstructure of the bone tissue is destroyed, resulting in an increase in bone fragility and an increased risk of fracture of the bone. The epidemiological survey found that in a woman's life, the risk of osteoporotic fracture is as high as 40%, which is greater than the sum of the three major malignancies (endometrial cancer, breast cancer, and ovarian cancer) common to women. Osteoporotic fractures often occur in a fracture that includes a vertebral body, a hip, a wrist, and an ankle. The frequency of the fracture of the vertebral body increases with increasing age. In recent years, minimally invasive surgery has been waiting for rapid development. With the development of surgical technology and the high-speed development of modern high-tech equipment, national experts begin to explore new technologies and methods. Vertebroplasty (VP) has been widely concerned by the scholars in the field of minimally invasive spinal surgery. For the first time in 1984, the French scholar, Galibert et al., used the percutaneous puncture of the vertebral body for the first time, and achieved a good surgical effect. The experience of filling bone cement with the aid of a surgical procedure lays the foundation for vertebroplasty. In the first time in 1997, the conservative treatment of the osteoporotic vertebral compression fracture was not effective, and the patient's symptoms were relieved by percutaneous vertebroplasty (PVP). In 2000, the vertebroplasty was also used to treat osteoporotic vertebral compression fractures with kyphosis, A good effect is also obtained. In the treatment of osteoporotic vertebral compression fractures, a minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures has been gradually promoted, since the means can effectively relieve the pain caused by the fracture, and is a great gospel for patients with a wide range of osteoporotic vertebral compression fractures. The PVP has the characteristics of small operation wound, high safety, simple operation, quick effect and the like in the treatment of the pain caused by the old OVCF, and can be used for rapid use in the clinical application, in particular to the local pain caused by the treatment of the spinal metastatic tumor, the hemangioma, the osteoporosis and the compression fracture, Good results[1] were obtained. However, for severe OVCF (the height of the vertebral body is severely collapsed, the height of the vertebral body is less than 1/3 of the original height), because the operation is difficult, the risk of bone cement leakage is high, there is still a dispute, and many scholars regard it as the relative contraindication of the treatment of PVP[2]. The literature on the treatment of severe OVCF with PVP is relatively rare. in the present study, by changing the traditional puncture pattern, the internal and external positions of the puncture needle are established in the normal position, the upper and lower positions of the puncture needle are established at the side positions, the puncture sleeve is accurately placed in the middle of the compression fracture of the severe osteoporosis vertebral body, At the same time, high-viscosity bone cement is used to take a slow and fast injection mode to minimize the occurrence of bone cement leakage. Methods:176 patients with severe thoracic and lumbar OVCF treated with PVP from January 2013 to January 2015 were collected, including 61 males and 115 females, aged from 58 to 78 years, with an average of 67.7 years. There were 94 cases of traumatic injury,31 cases of sprain, and 51 cases with no obvious inducement. 204 vertebral bodies were involved, of which T10 23 vertebra, T11 22 vertebra, T12 49 vertebra, L1 43 vertebra, L2 29 vertebra, the vertebral body posterior wall damaged 38 vertebra, the vertebral body height compression is more than 2/3. The changes of the height of the injured vertebral body, the post-convex Cobb angle, the visual analogue scale (VAS) and the Oswestry disability index (ODI) were compared before and after the operation, and the cement perfusion, leakage and other complications were observed. Inclusion criteria: (1) All patients with MRI showed fresh fracture, and the bone mineral density was measured with T-value of 1-2.5 SD, and the diagnosis was primary or secondary osteoporosis; (2) the patient had obvious back-and-back pain and limited activity before admission; (3) The preoperative X-ray showed that the degree of compression of injured vertebral body was 2/3 and the diagnosis was severe OVCF. Exclusion criteria: MRI examination revealed spinal stenosis or intravertebral space occupying, and combined nerve injury. Results: A total of 176 patients with severe thoracolumbar compression fractures were treated with PVP, including 61 males and 115 females. The age was 58 to 78 years, with an average of 67.7 years. The cause of injury:94 cases of traumatic injury,31 cases of sprain, and 51 cases with no obvious inducement. A total of 204 vertebral bodies were involved, including T10 23, T11 22, T12 49, L1 43, L2 29, and posterior wall of the vertebral body in 38 cases. The leakage of bone cement in 64 patients was 36.4%, including 7 cases of paravertebral venous leakage and 38 cases of disc space leakage. There were 19 cases of soft tissue leakage in the front of the disc. The pain in the back and back of 5 patients was relieved, and the burning sensation of the lower limbs was observed in 4 patients after injection of the bone cement for 5 minutes. After 10 minutes, no obvious adverse reaction was observed in all patients, including spinal cord compression or impaired symptoms and signs, and epidural hematoma. Pulmonary infection, pulmonary embolism, bedsore, etc., no cardiovascular and cerebrovascular accident. The postoperative ODI[(31.73-7.98) scores] and VAS[(2.33-0.91) scores] were superior to the preoperative[(75.40-8.17) scores] (7.23-0.88) scores] (p0.05). The height of the anterior edge of the vertebral body, the height of the midline of the vertebral body, the Cobb angle of the posterior convex Cobb, the VAS score and the ODI of the post-operative (3-d and 1-year post-operative) were statistically significant (p0.05). However, there was no significant difference in the height of the anterior edge of the vertebral body, the midline of the vertebral body, the post-convex Cobb angle, the VAS pain score and the ODI spinal score in one year and the third day after the operation (p0.05). Conclusion: The use of high-viscosity bone cement in the treatment of severe OVCF can significantly relieve the pain, improve the function of exercise, and the rate of bone cement leakage is lower than that of the conventional cement, and it has good safety and effectiveness. And can bring the gospel to a large number of patients with osteoporosis.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R687.3;R580
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