本文選題：回顧性研究 + 骨質(zhì)疏松癥��； 參考：《南方醫(yī)科大學(xué)》2017年博士論文

【摘要】：研究背景骨質(zhì)疏松性椎體壓縮骨折是骨質(zhì)疏松癥患者常見(jiàn)的骨折類(lèi)型,椎體成形術(shù)(PVP)因其良好的止痛效果而廣泛用于治療骨質(zhì)疏松性椎體壓縮骨折。目前PVP采用單側(cè)還是雙側(cè)椎弓根入路還有爭(zhēng)議,主要原因是單側(cè)椎弓根入路PVP的臨床療效及安全性受到質(zhì)疑。隨著PVP的臨床使用,術(shù)后其他椎體再發(fā)骨折的報(bào)道逐漸增加,尤其是鄰近椎體骨折;但也有報(bào)道術(shù)后鄰近椎體骨折發(fā)生率并不高。目前PVP術(shù)后再發(fā)椎體骨折的相關(guān)風(fēng)險(xiǎn)因素、生物力學(xué)機(jī)制尚無(wú)明確結(jié)論。研究方法:1、單側(cè)與雙側(cè)經(jīng)椎弓根入路PVP治療骨質(zhì)疏松性椎體壓縮骨折臨床療效比較:回顧分析南方醫(yī)院收治的單節(jié)段骨質(zhì)疏松性椎體壓縮骨折患者,根據(jù)手術(shù)入路不同分為單側(cè)椎弓根入路組和雙側(cè)椎弓根入路組,比較兩組患者的臨床療效、手術(shù)時(shí)間、骨水泥灌注量、骨水泥滲漏率、骨折椎體高度恢復(fù)程度及后凸矯正度數(shù)等。2、椎體成形術(shù)治療Kummell's病的臨床研究:回顧南方醫(yī)院收治并經(jīng)椎體成形術(shù)治療的Kummell's病患者,比較患者的臨床療效、手術(shù)時(shí)間、骨水泥灌注量、骨水泥滲漏率、骨折椎體高度恢復(fù)程度及后凸矯正度數(shù)等。3、椎體成形術(shù)后再發(fā)椎體骨折相關(guān)危險(xiǎn)因素分析:回顧分析南方醫(yī)院收治的經(jīng)椎體成形術(shù)治療的骨質(zhì)疏松椎體壓縮骨折患者相關(guān)臨床資料,探討PVP術(shù)后再發(fā)椎體骨折的相關(guān)危險(xiǎn)因素。4、椎體成形術(shù)后鄰近椎體生物力學(xué)研究:取人體防腐胸腰段標(biāo)本,包埋、固定。于腰1椎體建立骨折模型,在不同狀態(tài)下測(cè)定整體剛度、鄰近椎體及椎間盤(pán)的應(yīng)變。實(shí)驗(yàn)結(jié)果:1、單側(cè)與雙側(cè)經(jīng)椎弓根入路PVP治療骨質(zhì)疏松性椎體壓縮骨折臨床療效比較:單側(cè)組患者手術(shù)時(shí)間(36.4±6.0min)少于雙側(cè)組(52.9±6.8min),骨水泥注入量(3.7± 1.1ml)較雙側(cè)組(4.3± 1.1ml)少,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。兩組患者術(shù)后椎體前緣壓縮改善程度、椎體中央壓縮改善程度及后凸cobb角矯正度數(shù)比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。兩組患者術(shù)后24 h、3個(gè)月及12個(gè)月VAS評(píng)分均明顯低于術(shù)前,差異有統(tǒng)計(jì)學(xué)意義(P0.05),但兩組患者之間術(shù)后24h、3個(gè)月及12個(gè)月VAS評(píng)分比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。雖然單側(cè)組患者骨水泥滲漏率(28.9%)較雙側(cè)組(46.4%)低,但二者比較無(wú)差異(P0.05)。2、椎體成形術(shù)治療Kummell's病的臨床研究:單側(cè)組患者手術(shù)時(shí)間明顯短于雙側(cè)組(P0.05),兩組間骨水泥注入量、滲漏率、術(shù)后椎體前緣壓縮改善程度、椎體中央壓縮改善程度及后凸矯正度數(shù)、隨訪VAS評(píng)分差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。兩組術(shù)后24 h、術(shù)后3個(gè)月及末次隨訪時(shí)VAS評(píng)分均明顯低于術(shù)前,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。3、椎體成形術(shù)后再發(fā)椎體骨折相關(guān)危險(xiǎn)因素分析:共182患者符合納入標(biāo)準(zhǔn),其中男性27人、女性155人,平均年齡69.7歲;隨訪時(shí)間24～50個(gè)月(平均26.4個(gè)月),共21名患者出現(xiàn)再發(fā)椎體骨折,發(fā)生率為11.5%。單因素及多因素回歸分析發(fā)現(xiàn):患者性別,年齡,骨密度,骨水泥注入量,椎間隙骨水泥滲漏,術(shù)前骨折椎體后凸角度,術(shù)前骨折椎體前緣、中央壓縮程度,術(shù)后骨折椎體前緣、中央的恢復(fù)程度,術(shù)后骨折椎體后凸矯正度數(shù)等因素與術(shù)后再發(fā)骨折無(wú)顯著相關(guān)性(P0.05);僅體重指數(shù)、骨折椎體數(shù)目與術(shù)后再發(fā)骨折有顯著相關(guān)性(P0.05)。4、生理載荷下椎體成形術(shù)后鄰近椎體生物力學(xué)研究:腰1椎體平均注入骨水泥量為4.4ml(3.8～5.0ml)。注射骨水泥后剛度(201±65N/mm)較骨折后明顯提高(96±24N/mm,P0.05),但仍低于骨折前的剛度(242±67 N/mm,P0.05)。注射骨水泥后鄰近上位椎體的應(yīng)變較骨折前相比無(wú)明顯差異(P0.05),而鄰近下位椎體的應(yīng)變較骨折前明顯增加(P0.05)。結(jié)論:1、單側(cè)與雙側(cè)椎弓根入路穿刺椎體成形術(shù)(PVP)均可取得相當(dāng)?shù)呐R床效果。2、椎體成形術(shù)治療Kummell's病時(shí),單側(cè)穿刺可取得與雙側(cè)穿刺類(lèi)似的臨床效果。3、骨折椎體數(shù)目、體重指數(shù)是PVP術(shù)后出現(xiàn)再發(fā)骨折的危險(xiǎn)因素。4、PVP不能將節(jié)段剛度恢復(fù)至正常水平,但改變了下位椎體的載荷分享。
[Abstract]:Background osteoporotic vertebral compression fracture is a common fracture type of osteoporotic patients. Vertebroplasty (PVP) is widely used for the treatment of osteoporotic vertebral compression fractures because of its good analgesic effect. Currently, unilateral or bilateral pedicle pedicle approach is still disputed with PVP, the main reason is the unilateral pedicle approach of PVP. The effect and safety of the bed are questioned. With the clinical use of PVP, reports of other vertebral fractures are increasing, especially adjacent vertebral fractures, but there are also reports that the incidence of adjacent vertebral fractures is not high. There is no clear conclusion of the related risk factors for the recurrence of vertebral fractures after PVP. Method: 1, comparison of the clinical efficacy of unilateral and bilateral transpedicular approach PVP in the treatment of osteoporotic vertebral compression fractures: retrospective analysis of single segment osteoporotic vertebral compression fractures treated in southern hospitals, and the surgical approaches were divided into unilateral pedicle approach group and bilateral pedicle pedicle approach group, and compared the clinical efficacy of the two groups. Operation time, bone cement perfusion, bone cement leakage, degree of vertebral height recovery and kyphosis correction degree, etc..2, vertebroplasty for the treatment of Kummell's's disease: a retrospective study of patients with Kummell's disease treated in the southern hospital and treated with vertebroplasty, compared with the patient's clinical efficacy, operation time, cement perfusion, bone cement .3, analysis of risk factors for vertebral fracture after vertebroplasty: retrospective analysis of related clinical data of patients with osteoporotic vertebral compression fractures treated by vertebroplasty in the southern hospital, and to explore the risk factors associated with recurrent vertebral fractures after PVP,.4 Biomechanical study of adjacent vertebral body after vertebroplasty: take the body anticorrosive thoracolumbar specimens, embedded and fixed. Establish the fracture model in the lumbar 1 vertebral body, determine the overall stiffness, adjacent vertebra and intervertebral discs under different conditions. Experimental results: 1, unilateral and bilateral vertebral arch root approach PVP treatment of osteoporotic vertebral compression fracture clinical treatment Comparison: the operation time of the unilateral group (36.4 + 6.0min) was less than that of the bilateral group (52.9 6.8min), the amount of bone cement injection (3.7 + 1.1ml) was less than that of the bilateral group (4.3 + 1.1ml), and the difference was statistically significant (P0.05). The improvement degree of the anterior compression of the vertebral body in the two groups, the improvement degree of the central compression of the vertebral body and the correction degree of the kyphosis Cobb angle were all different There was no statistical significance (P0.05). The score of 24 h, 3 months and 12 months after operation in the two groups was significantly lower than that before the operation, the difference was statistically significant (P0.05), but there was no statistical difference between the two groups after 24h, 3 months and 12 months (P0.05). Although the rate of bone cement leakage (28.9%) in the unilateral group was lower than that of the bilateral group (46.4%). But there was no difference (P0.05).2, the clinical study of vertebroplasty in the treatment of Kummell's disease: the operation time of the unilateral group was significantly shorter than that of the bilateral group (P0.05), the amount of bone cement injection, the leakage rate, the improvement degree of the compression of the vertebral anterior margin after the operation, the degree of central compression modification and the kyphotic correction of the vertebral body, and the difference of the follow-up of VAS scores were not statistically significant. Study significance (P0.05). The two group 24 h after operation, 3 months and the last follow-up, the VAS scores were significantly lower than before the operation, the difference was statistically significant (P0.05).3, after vertebroplasty, the risk factors of re vertebral fracture: a total of 182 patients were in accordance with the inclusion criteria, including 27 men, 155 women, average age of 69.7 years, and 24~50 follow-up time. The incidence of recurrent vertebral fractures was found in 21 patients (average 26.4 months). The incidence was 11.5%. single factor and multiple factor regression analysis. The patients' sex, age, bone mineral density, bone cement injection, intervertebral bone cement leakage, anterior vertebral vertebral kyphosis angle, preoperation bone fracture front edge, central compression degree, fracture vertebral anterior margin after operation, center of vertebral fracture, Central There was no significant correlation between the degree of recovery and the degree of correction of posterior vertebral kyphosis after the operation (P0.05). Only body mass index, the number of fractured vertebral bodies had a significant correlation with the postoperative recurrent fracture (P0.05).4. Under physiological load, the biomechanical study of the adjacent vertebral body after vertebroplasty: the average amount of bone cement injected in the lumbar 1 vertebral body was 4.4ml (3) .8 ~ 5.0ml). The stiffness (201 + 65N/mm) after the injection of bone cement was significantly higher than that of the fracture (96 + 24N/mm, P0.05), but still lower than that before the fracture (242 + 67 N/mm, P0.05). The strain adjacent to the upper vertebral body after injection of bone cement had no significant difference compared with that before the fracture (P0.05), and the strain of adjacent lower vertebral body was significantly higher than that before the fracture (P0.05). Conclusion: 1 One side and bilateral pedicle pedicle puncture vertebroplasty (PVP) can achieve a considerable clinical effect of.2. When vertebroplasty is used to treat Kummell's disease, unilateral puncture can achieve a similar clinical effect to bilateral puncture.3, the number of fractured vertebrae, body mass index (BMI) is a risk factor for recurrent fractures after PVP, and PVP can not restore segmental stiffness. To normal level, but the load sharing of the lower vertebrae was changed.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R687.3

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