单侧椎弓根旁入路PKP治疗腰椎OVCF的临床疗效观察

doi:10.3877/cma.j.issn.2096-0263.2021.03.003

目的

对比单侧椎弓根旁入路与双侧椎弓根入路经皮椎体成形术治疗骨质疏松性腰椎压缩骨折的临床效果。

方法

回顾性分析2017年7月至2019年1月徐州医科大学附属医院经皮椎体成形术治疗的68例（共73节椎体）骨质疏松性腰椎压缩骨折病例，根据手术入路方式分为经单侧椎弓根旁入路组（单侧组）为32例35椎，其中男性7例、女性25例，年龄（61~79）岁，平均（69.7±5.3）岁；经双侧椎弓根入路（双侧组）为36例38椎，其中男9例、女27例，年龄（62~81）岁，平均（71.5±6.8）岁，比较两组手术指标、影像学指标以及功能障碍指标。

结果

两组患者均完成3~6个月，平均（5.0±0.9）个月的随访观察，两组患者术后1 d、3个月的腰腿痛视觉模拟评分（VAS）评分、Oswestry功能障碍指数（ODI）均较术前明显减低（P<0.05）；单侧组手术时间为（37±6）min、术中出血量为（15±3）ml、透视次数为（17±4）次、骨水泥注入量为（4.8±1.1）ml，均少于双侧组[手术时间：（51±8）min，术中出血量：（23±5）ml，透视次数：（26±5）次，骨水泥注入量：（5.7±1.4）ml]（t=7.967，t=7.636，t=7.72，t=3.035，P<0.001）。单侧组伤椎术后1 d和3个月的后凸Cobb角值分别为（9±3）°和（10±3）°、同时间点的椎体前缘压缩程度分别为：（15±6）%和（15±6）%，双侧组伤椎术后1 d和3个月的后凸Cobb角值分别为（10±3）°和（10±3）°。同时间点的椎体前缘压缩程度分别为：（17±5）%和（16±6）%，两组伤椎的术后后凸Cobb角及椎体前缘压缩程度均较术前改善（P<0.05），但两组间的骨水泥弥散理想程度、术后1 d与3个月的后凸Cobb角及椎体高度恢复率之间，差异均无统计学意义；单侧入路组骨水泥无症状渗漏率为9.38%（3/32），双侧入路组为11.11%（4/36），差异无统计学意义。

结论

单侧椎旁入路和双侧椎弓根入路经皮椎体成形术均能快速、有效地治疗腰椎骨质疏松性椎体骨折，且单侧入路经皮椎体成形手术可以相对减少手术时间和透视次数、骨水泥用量、出血量。

关键词: 腰椎, 骨质疏松性骨折, 单侧, 椎弓根旁路, 经皮椎体成形术

Objective

To compare the clinical effect of unilateral parapedicle approach and bilateral pedicle approach in the treatment of osteoporotic lumbar vertebral compression fractures.

Methods

From July 2017 to January 2019, 68 patients (73 vertebrae) with osteoporotic lumbar compression fractures treated by percutaneous vertebroplasty in our hospital were retrospectively analyzed. According to the surgical approach, they were divided into unilateral parapedicle approach group (unilateral group) with 32 cases (35 vertebrae) , including 7 males and 25 females, aged 61-79 years (average, 69.7±5.3) years, and the bilateral pedicle approach (bilateral group) had 36 patients (38 vertebrae), including 9 males and 27 females, aged 62-81 years, with an average of (71.5±6.8) years. The operation index, imaging index and dysfunction index of the two groups were compared.

Results

All patients in the two groups were followed up for 3-6 months. Patients in the two groups had significantly lower visual analogue scale (VAS) scores for lumbocrural pain and Oswestry Disability Index (ODI) before operation and 1 d and 3 months after operation (P<0.05). The operation time, intraoperative bleeding volume, fluoroscopic times, and bone cement injection volume in the unilateral group were (37±6) min, (15±3) mL, and (17±4) ml, respectively, which were less than those in the bilateral group [operation time: (51±8) min, intraoperative bleeding volume: (23±5) mL, and fluoroscopic times: (5.7±1.4) ml] (t=7.967, t=7.636, t=7.72, t=3.035, P<0.05). In the unilateral group, the Cobb angles of kyphosis were (9±3) and (10±3) one day and three months after surgery, (15±6)% and (15±6)% at the same time point, respectively. In the bilateral group, the Cobb angles of kyphosis were (10±3) and (10±3) one day and three months after surgery, respectively. The leading edge compression at the same time point was: (17±5)% and (16±6)%, respectively. The kyphoscolic Cobb angle and the compression of the leading edge of the vertebral body in the two groups were both improved after operation (P<0.05), but there were no significant differences in the ideal degree of cement dispersion, kyphoscolic Cobb angle 1 d and 3 months after operation and the recovery rate of vertebral body height between the two groups. The asymptomatic leakage rate of bone cement was 9.38%(3/32) in the unilateral approach group and 11.11%(4/36) in the bilateral approach group.

Conclusion

Both unilateral paravertebral approach and bilateral pedicle access percutaneous vertebroplasty can treat lumbar osteoporotic vertebral fractures quickly and effectively, and unilateral percutaneous vertebroplasty can relatively reduce the operation time and fluoroscopy times, bone cement consumption and bleeding volume.

Key words: Lumbar spine, Osteoporosis fractures, Unilateral, Lateral pedicle approach, Percutaneous vertebroplasty

表1 两组腰椎OVCF患者一般资料对比

组别	例数	男/女（例）	年龄（岁，±s）	BMI（kg/m²，±s）	骨密度T值（mg/cm³，±s）	骨折椎体分布情况（例）
组别	例数	男/女（例）	年龄（岁，±s）	BMI（kg/m²，±s）	骨密度T值（mg/cm³，±s）	L₁	L₂	L₃	L₄	L₅
单侧组	32	7/25	70±5	19.5±2.1	2.9±0.4	12	7	9	7	0
双侧组	36	9/27	72±7	20.2±1.8	3.0±0.5	15	8	6	6	3
统计值		χ²=0.299	t=1.267	t=0.169	t=0.743	χ²=0.585
P值		0.979	0.210	0.528	0.460	0.561

表1 两组腰椎OVCF患者一般资料对比

组别	例数	男/女（例）	年龄（岁，±s）	BMI（kg/m²，±s）	骨密度T值（mg/cm³，±s）	骨折椎体分布情况（例）
组别	例数	男/女（例）	年龄（岁，±s）	BMI（kg/m²，±s）	骨密度T值（mg/cm³，±s）	L₁	L₂	L₃	L₄	L₅
单侧组	32	7/25	70±5	19.5±2.1	2.9±0.4	12	7	9	7	0
双侧组	36	9/27	72±7	20.2±1.8	3.0±0.5	15	8	6	6	3
统计值		χ²=0.299	t=1.267	t=0.169	t=0.743	χ²=0.585
P值		0.979	0.210	0.528	0.460	0.561

图1~4 女性，67岁，L₂椎体新鲜压缩性骨折。图1术前腰椎MRI（T₁WI）显示L₂椎体内信号减低，提示L₂椎体新鲜骨折；图2术前腰椎X线显示L₂椎体楔型改变，a-c为L₂椎体上终板线和b-d为下终板线，两者延线夹角为上下终板夹角，该伤椎后凸Cobb角测量=上下终板夹角-自身生理角度，即30.2°-（-10.0°）=40.2°；a-b为L₂椎体前缘高度，c-d为L₂椎体后缘高度，该伤椎的前缘压缩程度=[（c-d线）-（a-b线）]/伤椎后缘高度（c-d）,即=（33.7-21.9）/33.7=35.01%；图3术前根据伤椎CT图像设计的穿刺通路，a-b：椎体正中矢状线；c-d：经椎弓根穿刺途径线；e-f：经椎弓根最大内倾角穿刺途径线；g-h：经椎弓根旁通路穿刺途径线，可见其途径椎体中部，h点已超过伤椎对侧1/3矢状线位；图4术中C型臂下正位透视显示：采用单侧椎弓根旁穿刺途径，套筒进入L₂伤椎，注入骨水泥已超过对侧椎体1/3处，弥散至伤椎对侧

表2 两组骨质疏松性椎体压缩骨折患者手术情况比较（±s）

组别	例数	手术时间（min）	术中透视数（次）	术中出血量（ml）	骨水泥注射量（ml）	住院天数（d）
单侧组	32	37±6	17±4	15±3	4.8±1.1	4.0±1.1
双侧组	36	51±8	26±5	23±5	5.7±1.4	4.8±1.2
t值		7.967	7.72	7.636	3.035	2.548
P值		<0.001	<0.001	<0.001	0.003	0.132

表2 两组骨质疏松性椎体压缩骨折患者手术情况比较（±s）

组别	例数	手术时间（min）	术中透视数（次）	术中出血量（ml）	骨水泥注射量（ml）	住院天数（d）
单侧组	32	37±6	17±4	15±3	4.8±1.1	4.0±1.1
双侧组	36	51±8	26±5	23±5	5.7±1.4	4.8±1.2
t值		7.967	7.72	7.636	3.035	2.548
P值		<0.001	<0.001	<0.001	0.003	0.132

图5~6 女性，67岁，L₂椎体压缩性骨折行单侧椎弓根旁路入路PKP治疗术后1 d的X线片检查。图5患者术后腰椎X线正位片，显示L₂椎体高密度信号影表现。骨水泥已超过对侧椎体中部a线，弥散至伤椎对侧；图6患者术后腰椎X线侧位片，显示L₂椎体前缘高度恢复明显，a-c线和b-d线夹角为上下终板夹角，该伤椎后凸Cobb角测量=3.3°-（-10.0°）=13.3°；该伤椎的前缘压缩程度=[（c-d线）-（a-b线）]/（c-d线），即=（33.7-28.6）/33.7=15.13%

表3 两组骨质疏松性椎体压缩骨折患者伤椎手术前后影像学指标比较

组别	例数	后凸cob角（°，±s）			椎体前缘压缩程度（%，±s）			骨水泥理想分布率[例（%）]	骨水泥无症状渗漏率[例（%）]
组别	例数	术前	术后1 d	术后3个月	术前	术后1 d	术后3个月	骨水泥理想分布率[例（%）]	骨水泥无症状渗漏率[例（%）]
单侧组	32	37±5	9±3^*	10±3^*	37±9	15±6^*	15±6^*	27（84.38）	3（9.38）
双侧组	36	39±7	10±3^*	10±3^*	37±11	17±5^*	16±6^*	31（86.11）	4（11.11）
统计值		t=1.101	t=0.706	t=0.903	t=0.235	t=1.305	t=0.334	χ²=0.019	χ²=0.055
P值		0.275	0.481	0.369	0.815	0.196	0.735	0.887	0.814

表3 两组骨质疏松性椎体压缩骨折患者伤椎手术前后影像学指标比较

组别	例数	后凸cob角（°，±s）			椎体前缘压缩程度（%，±s）			骨水泥理想分布率[例（%）]	骨水泥无症状渗漏率[例（%）]
组别	例数	术前	术后1 d	术后3个月	术前	术后1 d	术后3个月	骨水泥理想分布率[例（%）]	骨水泥无症状渗漏率[例（%）]
单侧组	32	37±5	9±3^*	10±3^*	37±9	15±6^*	15±6^*	27（84.38）	3（9.38）
双侧组	36	39±7	10±3^*	10±3^*	37±11	17±5^*	16±6^*	31（86.11）	4（11.11）
统计值		t=1.101	t=0.706	t=0.903	t=0.235	t=1.305	t=0.334	χ²=0.019	χ²=0.055
P值		0.275	0.481	0.369	0.815	0.196	0.735	0.887	0.814

表4 两组骨质疏松性椎体压缩骨折患者手术前后腰腿VAS评分及ODI比较（分，±s）

组别	例数	疼痛评分VAS			ODI
组别	例数	术前	术后1 d	术后3个月	术前	术后1 d	术后3个月
单侧组	32	7.9±0.8	1.8±0.9^*	1.1±0.5^*	38.2±5.8	9.8±2.7^*	7.9±2.4^*
双侧组	36	8.1±1.0	1.5±0.8^*	1.3±0.7^*	39.2±5.1	8.7±2.5^*	7.7±2.1^*
t值		0.765	1.24	0.806	0.733	1.744	0.534
P值		0.447	0.21	0.423	0.466	0.858	0.595

表4 两组骨质疏松性椎体压缩骨折患者手术前后腰腿VAS评分及ODI比较（分，±s）

组别	例数	疼痛评分VAS			ODI
组别	例数	术前	术后1 d	术后3个月	术前	术后1 d	术后3个月
单侧组	32	7.9±0.8	1.8±0.9^*	1.1±0.5^*	38.2±5.8	9.8±2.7^*	7.9±2.4^*
双侧组	36	8.1±1.0	1.5±0.8^*	1.3±0.7^*	39.2±5.1	8.7±2.5^*	7.7±2.1^*
t值		0.765	1.24	0.806	0.733	1.744	0.534
P值		0.447	0.21	0.423	0.466	0.858	0.595

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Clinical observation of unilateral-beside approach PKP in treatment of lumbar OVCF

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Clinical observation of unilateral-beside approach PKP in treatment of lumbar OVCF