急性症状性骨质疏松性胸腰椎骨折分型及其可信度检验和临床应用效果评价

目的建立急性症状性骨质疏松性胸腰椎骨折(ASOTLF)分型系统,并进行可信度检验及临床应用效果评价。方法采用回顾性病例系列研究分析2016年1月至2018年12月西安交通大学附属红会医院收治的1293例骨质疏松性胸腰椎骨折(OTLF)患者临床资料,其中男514例,女779例;年龄57~90岁[(71.4±6.3)岁]。骨密度T值为-5.0~-2.5 SD[(-3.1±-0.4)SD]。根据临床症状和骨折影像学特征,将ASOTLF分为4型:Ⅰ型(隐匿型)、Ⅱ型(压缩型)、Ⅲ型(爆裂型)和Ⅳ型(不稳定型),其中Ⅱ型分为ⅡA型、ⅡB型、ⅡC型3个亚型,Ⅲ型分为ⅢA型、ⅢB型2个亚型。其中Ⅰ型75例(5.8%),ⅡA型500例(38.7%),ⅡB型134例(10.4%),ⅡC型97例(7.5%),ⅢA型442例(34.2%),ⅢB型27例(2.1%),Ⅳ型18例(1.4%)。首先,对3名观察者共计3000次评估分型的可信度进行检测;其次,根据分型采用不同的治疗方法:Ⅰ型采用后路经皮椎体成形术(PVP)治疗,Ⅱ型采用体位复位+PVP治疗,ⅢA型、ⅢB型分别采用经皮椎体后凸成形术(PKP)和后路切开复位减压植骨融合钉道强化内固定术治疗,Ⅳ型采用后路(减压)复位植骨融合钉道强化内固定术治疗。比较总体患者及各型患者术前、术后1个月及末次随访时观察视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、局部Cobb角及椎体后凸角(椎体角),并记录Framkel分级情况和并发症。结果患者均获随访24~43个月[(29.9±5.1)个月]。观察者间可信度平均总体κ值为0.83,观察者内可信度平均总体κ值为0.88。总体患者术前VAS、ODI分别为(5.8±0.7)分、72.5±6.6,术后1个月分别为(1.8±0.6)分和25.0±6.3,末次随访时分别为(1.5±0.6)分和19.5±6.2(P均<0.05)。总体患者术前Cobb角及椎体角分别为13(7,20)°和7(5,10)°,术后1个月分别为8(4,11)°和4(3,6)°,末次随访时分别为9(5,12)°和5(4,8)°(P均<0.05)。各分型末次随访时VAS、ODI、Cobb角及椎体角均较术前明显改善(P均<0.05)。1例Ⅳ型、5例ⅢB型患者出现脊髓压迫症状,术前Frankel分级为C级1例,D级5例,末次随访时均恢复为E级(P<0.05)。3例Ⅳ型、22例ⅢB型患者出现下肢放射痛、麻木等症状,给予椎管减压、椎体强化内固定术治疗后,末次随访时仅有3例患者存在浅感觉减退,其余患者均完全恢复。结论本研究提出了ASOTLF分型,其可信度较高。根据分型采用相应治疗方法均取得较为满意的临床疗效,说明该分型对于临床治疗方法选择具有一定的指导意义。

Foundation of acute symptomatic osteoporotic thoracolumbar fracture classification system and its validity examination and clinical application evaluation

Objective To establish the acute symptomatic osteoporotie thoracolumbar fracture(ASOTLF)lassifcation system,and to examine the reliability and evaluate the efect of clinical application.Methods A retrospective case series study was conducted to analyze the clinical data of 1293 patients with osteoporotic thoracolumbar fracture(OTLF)adnmitted to Honghui Hospital from January 2016 to December 2018.There were 514 males and 779 females,aged 57-90 years[(71.4±6.3)years].The T value of bone mass density was-5.0--2.5SD[(-3.1±-0.4)SD].According to the clinical symptoms a and fracture morphology,OTLF was divided into 4 types,namely type I(I occult fracture),type Ⅱ(compressed fracture),type Ⅲ(burst fracture)and type IV(unstable fracture).The type Ⅱwas subdivided into three subtypes(type IIA,IB,IIC),and the Type Ⅱ into two subtypes(type IIA,IIB).of all patients,75 patients(5.8%)were with type I,500(38.7%)with typell A,134(10.4%)with type IB,97(7.5%)with type IIC,442(34.2%)with type IIA,27(2.1%)with type IB and 18(1.4%)with type IV.After testing the validity of the lassification,diferent treatment methods were utilized according to the classification,including percutaneous vertebroplasty(PVP)for Type I,PVP after postural reduction for Type Ⅱ,percutaneous kyphoplasty(PKP)for Type IIA,posterior reduction and decompression,bone graft fusion and bone cement-augmented screw fixation for Type IB,and posterior reduction,bone graft fusion and bone cement-augmented screw fixation for Type IV.The visual analog score(VAS),Oswestry disability index(ODI),Frankel grade of spinal cord injury,local Cobb Angle,and vetebral body angle(vertebral body angle)were recorded in all patients and in each type of patients before surgery,at 1 month after surgery and at the last fll-up.The neurological function recowery and complications were also reoded.Results The patients were fllowed up for 2443 months[(29.9±5.1)months].A total of 3000 ssessments in two rounds were conducted by three observers.The overall K value of inter-observer credibility was 0.83,and the overall K value of intra-observer credibility was 0.88.The VAS and ODI of all patients were(5.8±0.7)points and 72.5±6.6 before surgery,(1.8±0.6)points and 25.0±6.3 at 1 month after sugery,and(1.5±0.6)points and 19.5±6.2 at the last fllow-up,respectively(all P<0.05).The Cobb angle and vertebral body angle of all patients were(13.0±9.1)°and(8.0±4.6)°before surgery,(7.9±5.2)°and(4.6±2.9)°at 1 month after surgery,and(9.1±6.0)°and(5.8±3.0)°at the last fllowu,respectively(all P<0.05).At the last fllow-up,VAS,ODI,Cobb Angle and VBA of each type of patients were significanly improved compared with those before surgery(allP<0.05).The spinal cord compression symploms were found 1 patient with type Ⅳ and 5 patients with type Ⅲ preoperatively.At the last follow-up,neurological function improved from grade C to grade E in 1 patient and from grade D to grade E in5 patients(P<0.05).The lower limb radiation pain or numbness 3 patients with type Ⅳ and 22 patients with type Ⅱ preoperatively were fully recovered after surgical treatment at the last fllw-up except for three patients.Concdusions The ASOTLF lassfcation is established and has high consistency and reliability.The classification-oriented treatment strategy has achieved a relatively satisfactory ffeet,indicating that the cassification has a certain guiding significance for treatment of OTLF.