發(fā)布時間：2018-05-10 13:56

  本文選題：骨質(zhì)疏松性胸腰椎壓縮骨折 + 經(jīng)皮球囊擴(kuò)張椎體后凸成形術(shù)　； 參考：《湖北中醫(yī)藥大學(xué)》2013年碩士論文

【摘要】：目的：骨質(zhì)疏松癥(Osteoporosis)是指骨礦物質(zhì)成分和骨質(zhì)等比例地不斷減低，臨床上以骨皮質(zhì)變薄、骨小梁數(shù)量減少為病理特點(diǎn)，骨質(zhì)脆性增加而容易并發(fā)骨折的一種全身骨代謝障礙性疾病。腰背部疼痛是其最常見的臨床癥狀，，疼痛部位多在脊柱或脊柱兩側(cè)，臥床休息疼痛癥狀可以有所緩解，但是當(dāng)腰部承受負(fù)重時，疼痛加重。骨折是骨質(zhì)疏松癥最為常見也是最嚴(yán)重的并發(fā)癥，尤其以胸腰椎壓縮性骨折（OVCF）為多見，骨折發(fā)生后，常出現(xiàn)脊柱和（或）脊柱兩側(cè)的彌漫性疼痛，脊柱的后凸畸形及功能障礙，嚴(yán)重影響著患者的健康狀況及生活質(zhì)量[1，2]。伴隨著醫(yī)療技術(shù)的不斷發(fā)展，經(jīng)皮穿刺球囊擴(kuò)張椎體后凸成形術(shù)（PKP）已逐漸成為目前治療OVCF的首選方法，其微創(chuàng)的手術(shù)方法及顯著的止痛效果被患者廣泛接受，并使其在臨床上迅速開展。許多專家學(xué)者就單、雙側(cè)入路的選擇方面，以及不同的穿刺方式，對患者的疼痛緩解，脊柱功能和椎體后凸畸形的恢復(fù)，以及骨水泥用量，手術(shù)時間，骨水泥滲漏等方面，各有各的看法，未形成比較統(tǒng)一的認(rèn)識，筆者通過對單側(cè)與雙側(cè)入路PKP治療OVCF的臨床觀察,分析兩種手術(shù)操作方法的差異。 資料與方法:回顧性分析筆者在湖北省中醫(yī)院骨科實(shí)習(xí)期間(2010.10-2012.12)收治的采取PKP技術(shù)治療的OVCF患者55例(女性35例,男性20例),年齡在56-92歲,平均年齡76.4歲，按手術(shù)方式的不同,隨機(jī)分為單側(cè)入路PKP組和雙側(cè)入路PKP組.其中單側(cè)入路PKP組25例,共33個椎體；雙側(cè)入路PKP組30例,共30個椎體,比較兩組在疼痛模擬癥狀VAS評分、椎體后凸角度（cobb角）、脊柱功能障礙指數(shù)（ODI）、手術(shù)時間、術(shù)中骨水泥用量、骨水泥滲漏等方面的差異。 結(jié)果: 1.疼痛模擬癥狀VAS評分 單側(cè)入路PKP組:術(shù)前24小時VAS評分為(7.73±1.35)分，術(shù)后24小時VAS評分為(3.12±1.49)分，術(shù)后1月VAS評分為(3.03±1.48)分;手術(shù)前后比較VAS評分有統(tǒng)計學(xué)意義（p0.01），術(shù)后24小時與術(shù)后1月VAS評分比較無統(tǒng)計學(xué)意義（p0.05）。雙側(cè)入路PKP組:術(shù)前24小時為(7.63±1.43)分，術(shù)后24小時為(2.33±0.99)分,術(shù)后1月為(2.10±0.19)分,手術(shù)前后比較有統(tǒng)計學(xué)意義（p0.01），術(shù)后24小時與術(shù)后一月比較無統(tǒng)計學(xué)意義（p0.05）。 2.脊柱功能障礙評分 單側(cè)入路PKP組術(shù)后Oswestry評分為(11.52±1.49)。雙側(cè)入路PKP組術(shù)后Oswestry評分為(11.27±1.98)。兩組功能障礙指數(shù)比較無統(tǒng)計學(xué)意義（t=0.567，p0.05）。 3.手術(shù)時間長短 單側(cè)入路PKP組手術(shù)時間為(50.82±6.17)分鐘。雙側(cè)入路PKP組手術(shù)時間為(60.93±5.65)分鐘。兩組手術(shù)操作時間比較有統(tǒng)計學(xué)意義（t=6.762，p0.01）。 4.術(shù)中骨水泥用量 單側(cè)入路PKP組術(shù)中骨水泥用量為(2.96±0.92)毫升。雙側(cè)入路PKP組術(shù)中骨水泥用量為(3.79±0.98)毫升。兩組術(shù)中骨水泥用量比較有統(tǒng)計學(xué)意義（t=3.490，p0.01）。 5.椎體后凸角度 單側(cè)入路PKP組術(shù)前為(16.36±4.05)°，術(shù)后24小時為(13.52±2.75)°，術(shù)后1月為(13.57±2.71)°。手術(shù)前后比較有統(tǒng)計學(xué)意義（p0.01），術(shù)后24小時與術(shù)后1月比較無統(tǒng)計學(xué)意義（p0.05）。雙側(cè)入路PKP組術(shù)前為(15.89±3.72)°，術(shù)后24小時為(13.63±2.73)°，術(shù)后1月為(13.65±2.72)°。手術(shù)前后比較有統(tǒng)計學(xué)意義（p0.05），術(shù)后24小時與術(shù)后1月比較無統(tǒng)計學(xué)意義（p0.05）。兩組間手術(shù)前后比較無統(tǒng)計學(xué)意義（p0.05）。 6.骨水泥滲漏 單側(cè)入路PKP組33例中，發(fā)生滲漏3例，發(fā)生率為9.09%。雙側(cè)入路PKP組30例中，發(fā)生滲漏1例，發(fā)生率為3.33%。兩組灌注劑滲漏情況比較有統(tǒng)計學(xué)意義（X2=0.88，p0.05）。 結(jié)論:行單側(cè)或雙側(cè)入路PKP手術(shù)都能有效緩解OVCF引起的疼痛癥狀，一定程度地恢復(fù)脊柱的后凸畸形，可有效改善患者的脊柱的功能，以及明顯緩解骨折帶來的疼痛癥狀，但單側(cè)入路PKP組可以明顯縮短手術(shù)時間、減少骨水泥用量；雙側(cè)入路PKP組骨水泥滲漏率稍偏低;兩組各有各的優(yōu)缺點(diǎn)，所以臨床上需要仔細(xì)斟酌，根據(jù)不同的患者選擇合理的穿刺方式。
[Abstract]:Objective: Osteoporosis (Osteoporosis) is a kind of systemic bone metabolic disorder, which is the most common clinical symptom, the pain site of the back is the most common bone mineral composition and bone and so on, with the thinner cortical bone, the reduction of the bone trabecular number as the pathological characteristic, the bone brittleness increases and the fracture is easy to be complicated. The rest of the spine and spine can be relieved on both sides of the spine, but the pain can be relieved in bed rest, but the pain increases when the waist is weighed. Fracture is the most common and most serious complication of osteoporosis, especially in the thoracic and lumbar compression fracture (OVCF), and the diffuse pain on the sides of the spine and / or spine often occurs after the fracture. The kyphosis and dysfunction of the spine seriously affect the health of the patients and the quality of life ([1,2].) with the continuous development of medical technology. Percutaneous balloon kyphoplasty (PKP) has gradually become the first choice for the treatment of OVCF, and its minimally invasive hand method and significant analgesic effect are widely accepted by the patient. Many experts and scholars have different views on the choice of the unilateral approach, the choice of bilateral approach, the relief of the pain of the patients, the recovery of spinal function and kyphosis, the dosage of bone cement, the time of operation, the leakage of bone cement and so on. Through the clinical observation of unilateral and bilateral PKP in the treatment of OVCF, the difference of the two operative methods was analyzed.
Materials and methods: a retrospective analysis of 55 cases of OVCF patients (35 women, 20 males) treated by PKP in the Department of orthopedics of Hubei Provincial Traditional Chinese Medical Hospital (2010.10-2012.12), aged 56-92 years old, with an average age of 76.4 years, were divided into unilateral approach PKP group and bilateral approach PKP group according to the different surgical methods. There were 25 cases in group PKP, with 33 vertebral bodies, 30 cases in group PKP with bilateral approach, and 30 vertebral bodies. The difference between the two groups in the pain simulated symptom VAS score, the kyphosis angle (Cobb angle), the spine dysfunction index (ODI), the operation time, the amount of bone cement during the operation and the leakage of bone cement were compared.
Result:
1. pain analogue symptom VAS score
Unilateral approach PKP group: 24 hours before operation VAS score (7.73 + 1.35), 24 hours VAS score (3.12 + 1.49), and January VAS score (3.03 + 1.48); before and after operation, VAS scores were statistically significant (P0.01), 24 hours after operation and postoperative VAS score after operation (P0.05). Bilateral approach PKP group: 24 hours preoperative (24 hours before operation) The score of 7.63 + 1.43), 24 hours after operation (2.33 + 0.99), (2.10 + 0.19) after operation, was statistically significant (P0.01) before and after operation (P0.05), and there was no statistical significance (P0.05) compared with the postoperative month after operation.
2. spinal dysfunction score
The Oswestry score of PKP group after unilateral approach was (11.52 + 1.49). The Oswestry score in group PKP after bilateral approach was (11.27 + 1.98). The two group dysfunction index was not statistically significant (t=0.567, P0.05).
3. the length of operation time
The operation time of the unilateral approach in group PKP was (50.82 + 6.17) minutes. The operation time of PKP group on bilateral approach was (60.93 + 5.65) minutes. The operation time of the two groups was statistically significant (t=6.762, P0.01).
The dosage of bone cement during the 4. operation
The amount of bone cement in the unilateral PKP group was (2.96 + 0.92) ml. The dosage of bone cement in group PKP was (3.79 + 0.98) milliliters in the bilateral approach. The two groups of bone cement in the two groups were statistically significant (t=3.490, P0.01).
5. vertebral kyphosis angle
The unilateral approach was (16.36 + 4.05) before operation (16.36 + 4.05), 24 hours after operation (13.52 + 2.75) degrees and (13.57 + 2.71) degrees in January. There was statistical significance before and after operation (P0.01). There was no statistical significance (P0.05) for 24 hours after operation (15.89 + 3.72) before operation in group PKP, and (13.63 + 2.73) degrees (13.63 + 2.73) after operation, and (1) after surgery in January. 3.65 + 2.72). There were statistical significance before and after operation (P0.05). There was no significant difference between the 24 hours after operation and January after operation (P0.05). There was no statistical significance before and after operation between the two groups (P0.05).
6. bone cement leakage
Among 33 cases of unilateral approach PKP group, 3 cases had leaking, the incidence of which was 30 cases in group PKP of 9.09%. bilateral approach, 1 cases had leakage, and the rate of occurrence rate of 3.33%. two group was statistically significant (X2=0.88, P0.05).
Conclusion: PKP operation with unilateral or bilateral approach can effectively relieve the symptoms of pain caused by OVCF and restore the kyphosis of the spine to a certain extent. It can effectively improve the function of the spinal column and obviously relieve the pain symptoms caused by the fracture, but the unilateral approach PKP group can obviously shorten the operation time and reduce the amount of bone cement; bilateral entry can be used. The leakage rate of bone cement in group PKP was slightly lower. The two groups had their own advantages and disadvantages, so they need careful consideration in clinical practice and choose reasonable puncture methods according to different patients.

【學(xué)位授予單位】：湖北中醫(yī)藥大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R687.3

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