本文選題：椎體內(nèi)真空裂隙 + 骨質(zhì)疏松性椎體壓縮骨折　； 參考：《廣州中醫(yī)藥大學(xué)》2017年博士論文

【摘要】：研究一在骨質(zhì)疏松性椎體壓縮骨折中的椎體內(nèi)真空裂隙對(duì)治療效果影響背景:先前的研究發(fā)現(xiàn),經(jīng)皮椎體強(qiáng)化術(shù)治療伴椎體內(nèi)真空裂隙的骨質(zhì)疏松性椎體壓縮骨折在中長(zhǎng)期隨訪過(guò)程中強(qiáng)化椎有較高的再塌陷率,因此椎體內(nèi)真空裂隙被推測(cè)可能是強(qiáng)化椎再塌陷的一個(gè)重要誘發(fā)因素,但到目前為止仍不能找到椎體內(nèi)真空裂隙與再塌陷之間的顯著聯(lián)系。目的:分析椎體內(nèi)真空裂隙的發(fā)病機(jī)制及其特點(diǎn),探討椎體內(nèi)真空裂隙對(duì)經(jīng)皮椎體強(qiáng)化術(shù)治療骨質(zhì)疏松性椎體壓縮骨折的療效影響。方法:回顧分析廣州中醫(yī)藥大學(xué)第一附屬醫(yī)院脊柱骨科于2010年1月-2014年12月連續(xù)收治因單節(jié)段的骨質(zhì)疏松性椎體壓縮骨折而接受經(jīng)皮椎體強(qiáng)化術(shù)治療符合納入標(biāo)準(zhǔn)的患者148例,其中伴椎體內(nèi)真空裂隙患者52例(IVC組),不伴椎體內(nèi)真空裂隙患者96例(無(wú)IVC組)。兩組隨訪時(shí)間均超過(guò)2年。分別比較兩種患者術(shù)前基值包括性別、年齡、骨礦物密度的T值,傷椎分布節(jié)段、術(shù)前傷椎壓縮率、局部后凸角及術(shù)前后背部VAS評(píng)分。比較兩組患者在即時(shí)術(shù)后、術(shù)后1年及2年內(nèi)傷椎高度和局部后凸角相關(guān)放射學(xué)參數(shù)以及VAS評(píng)分變化的差異。另外,分別比較兩組患者在骨水泥滲漏及鄰椎繼發(fā)骨折率的差異。結(jié)果:椎體內(nèi)真空裂隙在骨質(zhì)疏松性椎體壓縮骨折的發(fā)病率主要與更高的年齡和更嚴(yán)重的骨質(zhì)去礦物化密切相關(guān),兩組患者在術(shù)前其他基值比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后兩組患者傷椎高度及局部后凸角較術(shù)前顯著矯正(P0.05),兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后2年隨訪,IVC組患者較術(shù)后發(fā)生顯著的再塌陷,在術(shù)后2年強(qiáng)化椎垂直壓縮率、局部后凸角、強(qiáng)化椎高度進(jìn)展性丟失率、進(jìn)展性增加的后凸角及VAS評(píng)分IVC組明顯高于無(wú)IVC組(P0.05)。兩組患者在骨水泥滲漏率及鄰椎繼發(fā)骨折率方面比較無(wú)統(tǒng)計(jì)學(xué)差異(P0.05)。結(jié)論:經(jīng)皮椎體強(qiáng)化術(shù)治療伴椎體內(nèi)真空裂隙的骨質(zhì)疏松性椎體壓縮骨折患者在早期階段是有效的;但在長(zhǎng)期隨訪過(guò)程中強(qiáng)化椎容易出現(xiàn)再塌陷及后凸畸形,因此對(duì)此類患者我們推薦嚴(yán)密的觀察和延長(zhǎng)隨訪時(shí)間,必要時(shí)佩戴支具或內(nèi)固定。研究二經(jīng)皮椎體強(qiáng)化術(shù)治療伴椎體內(nèi)真空裂隙的骨質(zhì)疏松性椎體壓縮骨折術(shù)后強(qiáng)化椎再塌陷的風(fēng)險(xiǎn)因素背景:結(jié)合文獻(xiàn)報(bào)道和我們的臨床研究觀察,發(fā)現(xiàn)經(jīng)皮椎體強(qiáng)化術(shù)治療伴椎體內(nèi)真空裂隙的骨質(zhì)疏松椎體壓縮骨折在術(shù)后中長(zhǎng)期的隨訪中強(qiáng)化椎有較高的塌陷率,但是到目前為止尚未見(jiàn)到對(duì)其再塌陷的風(fēng)險(xiǎn)因素進(jìn)行研究報(bào)道。目的:探討經(jīng)皮椎體強(qiáng)化術(shù)治療伴椎體內(nèi)真空裂隙的骨質(zhì)疏松性椎體壓縮骨折術(shù)后強(qiáng)化椎再塌陷的風(fēng)險(xiǎn)因素。方法:收集伴椎體內(nèi)真空裂隙的骨質(zhì)疏松性椎體壓縮骨折患者52例。將術(shù)后2年與即時(shí)術(shù)后相比強(qiáng)化椎高度丟失≥15%或局部后凸角進(jìn)展性增加≥10 °作為再塌陷的標(biāo)準(zhǔn),我們采用單因素和多因素logistic回歸分析識(shí)別包括性別、年齡、骨礦物密度T值、傷椎分布節(jié)段、術(shù)前傷椎壓縮程度、裂隙在傷椎內(nèi)的分布位置、骨水泥在裂隙內(nèi)填充樣式、傷椎復(fù)位率和局部復(fù)位角等相關(guān)的風(fēng)險(xiǎn)因素。結(jié)果:若以術(shù)后2年與即時(shí)術(shù)后強(qiáng)化椎高度丟失≥15%為再塌陷的判定標(biāo)準(zhǔn),僅骨水泥的裂隙填充樣式作為唯一的風(fēng)險(xiǎn)因素(OR=21.58,P=0.001);若以術(shù)后2年與即時(shí)術(shù)后強(qiáng)化椎局部后凸角進(jìn)展性增加≥10 °為再塌陷的判定標(biāo)準(zhǔn),骨水泥的裂隙填充樣式(OR=57.06,P=0.002)和局部后凸角矯正過(guò)大(0R=0.67,P=0.005)為兩個(gè)顯著重要的風(fēng)險(xiǎn)因素,而在其他臨床和放射學(xué)參數(shù)方面未見(jiàn)顯著性差異。結(jié)論:骨水泥的裂隙填充樣式和局部后凸角矯正過(guò)大是經(jīng)皮椎體強(qiáng)化術(shù)治療伴椎體內(nèi)真空裂隙的骨質(zhì)疏松性椎體壓縮骨折術(shù)后強(qiáng)化椎再塌陷的兩個(gè)重要風(fēng)險(xiǎn)因素。因此,我們推薦對(duì)這類病人更應(yīng)該嚴(yán)密的觀察和延長(zhǎng)隨訪。研究三骨水泥在不同位置的裂隙區(qū)域中的不同填充樣式對(duì)強(qiáng)化椎的生物力學(xué)特性影響背景:充分牢固的固定及足夠的穩(wěn)定性是骨傷科療效的保證。結(jié)合既往的微觀辯證研究發(fā)現(xiàn),椎體內(nèi)裂隙在傷椎內(nèi)的位置、骨水泥在裂隙區(qū)域的填充樣式可能是經(jīng)皮椎體強(qiáng)化術(shù)治療伴椎體內(nèi)真空裂隙的骨質(zhì)疏松性椎體壓縮骨折再塌陷的兩個(gè)重要誘因。然而到目前為止,這兩種風(fēng)險(xiǎn)因素對(duì)強(qiáng)化椎生物力學(xué)穩(wěn)定性影響尚未見(jiàn)到相應(yīng)的國(guó)內(nèi)外文獻(xiàn)進(jìn)行報(bào)道。目的:借助于中醫(yī)提出的"微觀辯證"治療理念和現(xiàn)代的診療技術(shù),同時(shí)借助于先進(jìn)的三維有限元技術(shù)來(lái)全面分析術(shù)后骨水泥在不同位置的裂隙區(qū)域中的不同的填充方式之間的生物力學(xué)性能差異,從微觀辯證角度闡明經(jīng)皮椎體強(qiáng)化術(shù)治療伴椎體內(nèi)裂隙的骨質(zhì)疏松性椎體壓縮骨折術(shù)后再塌陷提供生物力學(xué)實(shí)驗(yàn)依據(jù)。方法:建立胸11-腰1正常有限元模型,以胸12為傷椎并在此基礎(chǔ)上建立伴椎體內(nèi)裂裂隙的骨質(zhì)疏松性椎體壓縮骨折的有限元模型,在此基礎(chǔ)上建立不同骨水泥填充樣式的有限元模型,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。分別比較四種不同模型在皮質(zhì)骨骨折區(qū)域、皮質(zhì)骨未骨折區(qū)域、松質(zhì)骨、鄰椎終板的最大Von Mises應(yīng)力之間的差異。結(jié)果:對(duì)于四種不同模型而言,強(qiáng)化椎皮質(zhì)骨骨折區(qū)域最大應(yīng)力主要分布在骨折區(qū)域后方,而皮質(zhì)骨未骨折區(qū)域最大應(yīng)力主要分布在鄰近相應(yīng)終板周邊的區(qū)域。相對(duì)于裂隙填充樣式而言,骨水泥的嵌插填充樣式不僅可明顯降低所有模型傷椎皮質(zhì)骨骨折區(qū)域的最大應(yīng)力,而且可降低骨水泥團(tuán)塊周邊松質(zhì)骨的最大應(yīng)力。當(dāng)椎體內(nèi)裂隙偏上時(shí),骨水泥嵌插填充樣式亦可明顯降低傷椎皮質(zhì)骨未骨折區(qū)域的最大應(yīng)力,但是當(dāng)裂隙位置偏下時(shí),骨水泥嵌插填充樣式反而會(huì)增加傷椎皮質(zhì)骨未骨折區(qū)域的最大應(yīng)力。另外,椎體內(nèi)裂隙的位置及骨水泥的填充樣式對(duì)鄰椎終板的最大應(yīng)力無(wú)顯著性的影響。結(jié)論:與裂隙填充樣式相比,骨水泥的嵌插填充樣式可明顯提高強(qiáng)化椎生物力學(xué)穩(wěn)定性。但當(dāng)裂隙位置偏下時(shí),嵌插填充樣式雖可進(jìn)一步降低傷椎皮質(zhì)骨骨折區(qū)域和周邊松質(zhì)骨應(yīng)力值,但有可能會(huì)進(jìn)一步增加傷椎皮質(zhì)骨未骨折區(qū)域的應(yīng)力值,因此對(duì)此類應(yīng)該慎重選擇相應(yīng)骨水泥的填充樣式。
[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.
【學(xué)位授予單位】：廣州中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

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