PVP聯(lián)合高粘度骨水泥治療重度骨質(zhì)疏松性椎體壓縮骨折的臨床應(yīng)用
發(fā)布時(shí)間：2019-07-05 11:54
【摘要】：研究背景和目的:骨質(zhì)疏松癥是骨量減少、骨組織微細(xì)結(jié)構(gòu)被破壞,從而導(dǎo)致骨脆性的增加,骨折風(fēng)險(xiǎn)增高的全身性骨骼疾病。流行病學(xué)調(diào)查發(fā)現(xiàn),在女性的一生中,其患骨質(zhì)疏松性骨折的危險(xiǎn)性高達(dá)40%,大于女性常見三大惡性腫瘤(子宮內(nèi)膜癌、乳腺癌、卵巢癌)的總和。骨質(zhì)疏松性骨折通常發(fā)生于包括椎體、髖部、手腕和腳踝骨折。椎體的骨折發(fā)生的頻率隨年齡的增加而增加。近年來,微創(chuàng)外科等到了迅猛的發(fā)展,隨著外科技術(shù)的不斷進(jìn)步,現(xiàn)代高科技設(shè)備的高速發(fā)展,各國專家開始探索更新的技術(shù)和方法。對于微創(chuàng)脊柱外科領(lǐng)域而言,椎體成形術(shù)(Vertebroplasty,VP)作為一種最新的技術(shù)受到了學(xué)者們的廣泛關(guān)注。1984年,法國學(xué)者Galibert等第一次對椎體侵襲性海綿狀血管瘤使用經(jīng)皮穿刺椎體術(shù),取得了良好的手術(shù)效果,他借助外科手術(shù)進(jìn)行填塞骨水泥的經(jīng)驗(yàn),從而奠定了椎體成形術(shù)的基礎(chǔ)。美國于1997年第一次因?qū)琴|(zhì)疏松性椎體壓縮性骨折保守治療無效,而采用經(jīng)皮椎體成形術(shù)(Pereutaneous Vertebroplasty,PVP),病人癥狀緩解明顯。2000年中國也將椎體成形術(shù)用于治療骨質(zhì)疏松性椎體壓縮性骨折同時(shí)伴后凸畸形,同樣獲得良好的效果。在臨床上椎體成形術(shù)作為治療骨質(zhì)疏松性椎體壓縮性骨折微創(chuàng)的一種手術(shù)方式得以逐漸推廣,因?yàn)樵撌侄慰捎行Ь徑夤钦垡鸬奶弁?對于廣大骨質(zhì)疏松性椎體壓縮性骨折患者群體是巨大的福音。PVP在治療老年OVCF引起的疼痛時(shí)具有手術(shù)創(chuàng)傷小、安全性高、操作簡單、見效快等特點(diǎn),在臨床的應(yīng)用得以快速使用,特別在治療脊柱轉(zhuǎn)移腫瘤、血管瘤、骨質(zhì)疏松壓縮性骨折引起的局部疼痛,取得了良好的療效[1]。但對于重度OVCF(椎體高度嚴(yán)重塌陷,椎體高度不到原高度的1/3)的治療,因操作難度大,骨水泥滲漏風(fēng)險(xiǎn)高,目前尚存爭議,許多學(xué)者將其視為PVP治療的相對禁忌證[2]。臨床有關(guān)PVP治療重度OVCF的文獻(xiàn)報(bào)道相對少見。在本研究中,我們通過改變傳統(tǒng)穿刺模式,于正位透視確立穿刺針內(nèi)外位置、側(cè)位確立穿刺針上下位置,將穿刺套筒精確放置于重度骨質(zhì)疏松椎體壓縮性骨折正中,同時(shí)運(yùn)用高粘度骨水泥采取先慢后快的注入方式,最大限度減少骨水泥滲漏的發(fā)生。研究方法:收集2013年1月-2015年1月收治的應(yīng)用PVP治療的重度胸腰椎OVCF患者176例,其中男61例,女115例,年齡58~78歲;平均67.7歲。跌傷94例,扭傷31例,無明顯誘因51例。共累及204個(gè)椎體,其中T10 23椎,T11 22椎,T12 49椎,L1 43椎,L2 29椎,椎體后壁破壞38椎,椎體高度壓縮均大于2/3。比較手術(shù)前后受傷椎體高度、后凸Cobb角、視覺模擬評分(Visual Analogue Scale,VAS)和Oswestry功能障礙指數(shù)(Oswestry disability index,ODI)變化情況,觀察骨水泥灌注、滲漏及其他并發(fā)癥。納入標(biāo)準(zhǔn):(1)所有患者M(jìn)RI提示為新鮮骨折,骨密度測定T值≤-2.5 SD,確診為原發(fā)性或者繼發(fā)性骨質(zhì)疏松癥;(2)入院前患者均出現(xiàn)明顯腰背疼痛感并伴有活動(dòng)受限;(3)術(shù)前X線片顯示受傷椎體壓縮程度2/3,診斷為重度OVCF。排除標(biāo)準(zhǔn):MRI檢查提示患者椎管狹窄或椎管內(nèi)占位,合并神經(jīng)損傷。研究結(jié)果:共納入PVP治療重度胸腰椎壓縮性骨折患者176例,其中男61例,女115例;年齡58~78歲,平均67.7歲。致傷原因:跌傷94例,扭傷31例,無明顯誘因51例。共累及204個(gè)椎體,其中T10 23椎,T11 22椎,T12 49椎,L1 43椎,L2 29椎,椎體后壁破壞38椎。64例患者出現(xiàn)骨水泥滲漏情況,滲漏率36.4%,其中椎旁靜脈滲漏7例,椎間隙滲漏38例,椎前軟組織滲漏19例。5例患者腰背部疼痛部分緩解,4例患者注入骨水泥后5分鐘出現(xiàn)下肢燒灼感,10分鐘后緩解,所有患者均未出現(xiàn)明顯的不良反應(yīng),包括脊髓神經(jīng)壓迫或受損癥狀及體征、硬膜外血腫、肺部感染、肺栓塞、褥瘡等,無心腦血管意外發(fā)生�；颊咝g(shù)后ODI[(31.73±7.98)分]及VAS[(2.33±0.91)分]均優(yōu)于術(shù)前[(75.40±8.17)分、(7.23±0.88)分](p0.05)。術(shù)后(術(shù)后3 d及術(shù)后1年)的椎體前緣高度、椎體中線高度、后凸Cobb角、VAS評分及ODI與術(shù)前相比,差異均有統(tǒng)計(jì)學(xué)意義(p0.05)。但術(shù)后1年與術(shù)后3 d的椎體前緣高度、椎體中線高度、后凸Cobb角、VAS疼痛評分、ODI脊柱評分差異無統(tǒng)計(jì)學(xué)意義(p0.05)。研究結(jié)論:PVP使用高粘度骨水泥治療重度OVCF,能顯著緩解疼痛、改善運(yùn)動(dòng)功能,且發(fā)生骨水泥滲漏的幾率較傳統(tǒng)骨水泥低,具有良好的安全性和有效性,因此,該新技術(shù)方法在臨床上具有廣泛的應(yīng)用前景,可為廣大骨質(zhì)疏松患者帶來福音。
文內(nèi)圖片：
圖片說明：椎體成形后凸器械（注釋：a：壓力泵的加壓手柄要逆時(shí)針旋轉(zhuǎn)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.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R687.3;R580
本文編號：2510502
文內(nèi)圖片：
圖片說明：椎體成形后凸器械（注釋：a：壓力泵的加壓手柄要逆時(shí)針旋轉(zhuǎn)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.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R687.3;R580
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