过伸复位联合经皮椎体后凸成形术治疗椎体后壁破裂的骨质疏松性椎体压缩骨折

目的:比较过伸复位联合经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)与单纯PKP治疗椎体后壁破裂的骨质疏松性椎体压缩骨折(osteoporotic vertebral compression fracture,OVCF)的临床疗效及安全性。方法:回顾性分析70例椎体后壁破裂的OVCF患者的病例资料,其中采用过伸复位联合PKP治疗38例(联合组),采用PKP治疗32例(PKP组)。男38例,女32例。年龄40~80岁,中位数60岁。均为单节段骨折,其中T 11 28例、T 12 22例、L 111例、L 29例。骨质疏松症病程6个月至7年,中位数3年。骨折至就诊时间1~21 d,中位数11 d。比较2组患者的手术时间、术中出血量、术后住院时间,术后12 h、24 h、48 h的胸腰背部疼痛视觉模拟量表(visual analogue scale,VAS)评分,复位前、复位后即刻、术后即刻、术后3个月、术后6个月的伤椎后凸Cobb角及伤椎前缘高度,术前、术后6个月的Oswestry功能障碍指数(Oswestry disability index,ODI)及日常生活活动能力量表(activity of daily living scale,ADL)评分。随访观察并发症发生情况。结果:①一般情况。2组患者的手术时间、术中出血量、术后住院时间比较,组间差异均无统计学意义[(52.7±5.8)min,(53.1±4.9)min, t=0.308,P =0.759;(7.4±1.0)mL,(7.2±1.1)mL, t=0.796,P =0.429;(9.7±1.3)d,(9.5±1.2)d, t=0.664,P =0.509]。②胸腰背部疼痛VAS评分。时间因素和分组因素存在交互效应( F=78.973,P =0.000);2组患者胸腰背部疼痛VAS评分总体比较,组间差异有统计学意义,即存在分组效应( F=5.945, P =0.000 );术后不同时间点胸腰背部疼痛VAS评分的差异有统计学意义,即存在时间效应( F=61.974,P =0.000);2组患者胸腰背部疼痛VAS评分随时间变化均呈下降趋势,但2组的下降趋势不完全一致[(6.8±1.0)分,(5.1±0.9)分,(4.2±0.7)分, F=56.134 ,P =0.000;(7.5±1.2)分,(6.7±1.0)分,(5.9±0.8)分, F=13.878,P =0.000];术后12 h、24 h、48 h,联合组的胸腰背部疼痛VAS评分均低于PKP组( t=2.777,P=0.007;t=7.016,P=0.000;t=9.060,P =0.000)。③伤椎后凸Cobb角。时间因素和分组因素存在交互效应( F=56.075,P =0.000);2组患者伤椎后凸Cobb角总体比较,组间差异有统计学意义,即存在分组效应( F=11.289,P =0.000);手术前后不同时间点伤椎后凸Cobb角的差异有统计学意义,即存在时间效应( F=45.201,P = 0.000 );2组患者伤椎后凸Cobb角随时间变化均呈减小趋势,但2组的减小趋势不完全一致(18.7°±2.4°,6.3°±1.2°,6.1°± 1.3°,6.2°±1.3°,6.4°±1.2°, F=22.397,P =0.000;18.6°±2.2°,7.9°±1.3°,7.8°±1.2°,7.9°±1.3°,7.8°±1.3°, F=15.986,P= 0.000);复位前,2组患者伤椎后凸Cobb角的组间差异无统计学意义( t=0.180,P =0.857);复位后即刻、术后即刻、术后3个月、术后6个月,联合组的伤椎后凸Cobb角均小于PKP组( t=5.350,P=0.000;t=5.644,P=0.000;t=5.450,P=0.000;t= 4.681 ,P =0.000)。④伤椎前缘高度。时间因素和分组因素存在交互效应( F=36.975,P= 0.000);2组患者伤椎前缘高度总体比较,组间差异有统计学意义,即存在分组效应( F=15.302,P =0.000);手术前后不同时间点伤椎前缘高度的差异有统计学意义,即存在时间效应( F=22.041,P= 0.000);2组患者伤椎前缘高度随时间变化均呈增高趋势,但2组的增高趋势不完全一致[(12.3±2.0)mm,(20.6±2.2)mm,(20.4±2.1)mm,(20.5±2.1)mm,(20.7±2.0)mm, F=18.957,P= 0.000;(12.5± 2.2)mm ,(18.7±2.0)mm,(18.9±2.2)mm,(18.8±2.1)mm,(18.9±2.0)mm, F=16.093,P =0.000];复位前,2组患者伤椎前缘高度的组间差异无统计学意义( t=0.398,P= 0.692);复位后即刻、术后即刻、术后3个月、术后6个月,联合组的伤椎前缘高度均高于PKP组( t=3.751,P=0.000;t=2.913,P=0.005;t=3.374,P=0.001;t=3.751,P =0.000)。⑤ODI。术前2组患者的ODI比较,差异无统计学意义( t=0.178,P =0.860);术后6个月,2组患者的ODI均较术前降低[(64.3±4.6)%,(19.7± 2.3)%, t=53.458,P= 0.000;(64.1±4.8)%,(23.6±2.9)%, t=40.853,P =0.000],联合组的ODI低于PKP组( t=6.274,P =0.000)。⑥ADL评分。术前2组患者的ADL评分比较,差异无统计学意义( t=0.235,P =0.815);术后6个月,2组患者的ADL评分均较术前增高[(41.6±3.5)分,(71.8±5.0)分, t=30.503,P =0.000;(41.4±3.6)分,(66.2±5.2)分, t=22.182,P = 0.000 ],联合组的ADL评分高于PKP组( t=4.584,P= 0.000)。⑦安全性。联合组1例出现骨水泥渗漏,PKP组1例出现骨水泥渗漏、1例出现骨折畸形愈合。2组患者并发症发生率比较,差异无统计学意义(χ^ 2=0.023,P =0.879)。结论:过伸复位联合PKP与单纯PKP治疗椎体后壁破裂的OVCF,二者在手术时间、术中出血量、术后住院时间及安全性方面无明显差异,但前者的临床疗效优于后者。

Hyperextension reduction combined with percutaneous kyphoplasty for treatment of osteoporotic vertebral compression fracture with cracked posterior vertebral body wall

Objective: To compare the clinical curative effects and safety of combination therapy of hyperextension reduction and percutaneous kyphoplasty(PKP)versus monotherapy of PKP for treatment of osteoporotic vertebral compression fracture(OVCF)with cracked posterior vertebral body wall(PVBW). Methods: The medical records of 70 OVCF patients with cracked PVBW were analyzed retrospectively.Thirty-eight patients were treated with hyperextension reduction combined with PKP(combination group),and the other patients were treated with monotherapy of PKP(PKP group).The patients consisted of 38 males and 32 females,and ranged in age from 40 to 80 years(Median=60 yrs)and in disease course of osteoporosis from 6 months to 7 years(Median=3 yrs).All of the fractures belonged to single- segment fracture,which located at T 11 (28),T 12 (22),L 1(11)and L 2(9).The duration from fracture to visit ranged from 1 to 21 days(Median= 11 days).The operative time,intraoperative blood loss,postoperative hospital stay,thoracolumbar pain visual analogue scale(VAS)scores measured at 12,24 and 48 hours after the surgery,kyphotic Cobb’s angle and anterior border height of injured vertebrae measured before reduction,immediately after reduction,immediately after surgery and at 3 and 6 months after the surgery,Oswestry disability index(ODI)before surgery and at 6 months after the surgery and activity of daily living scale(ADL)scores were compared between the 2 groups.The complications were also observed. Results: There was no statistical difference in operative time,intraoperative blood loss and postoperative hospital stay between the 2 groups(52.7+/-5.8 vs 53.1+/-4.9 minutes, t=0.308,P =0.759;7.4+/-1.0 vs 7.2+/-1.1 mL, t=0.796,P =0.429;9.7+/-1.3 vs 9.5+/-1.2 days, t=0.664,P =0.509).There was interaction between time factor and group factor in thoracolumbar pain VAS scores( F=78.973,P =0.000).There was statistical difference in thoracolumbar pain VAS scores between the 2 groups in general,in other words,there was group effect( F=5.945,P =0.000).There was statistical difference in thoracolumbar pain VAS scores between different timepoints after the surgery,in other words,there was time effect( F=61.974,P =0.000).The thoracolumbar pain VAS scores presented a time-dependent decreasing trend in both of the 2 groups,while the 2 groups were inconsistent with each other in the decreasing tendency(6.8+/-1.0,5.1+/-0.9,4.2+/-0.7 points, F=56.134,P =0.000;7.5+/-1.2,6.7+/-1.0,5.9+/-0.8 points, F=13.878 ,P =0.000).The thoracolumbar pain VAS scores were lower in combination group compared to PKP group at 12,24 and 48 hours after the surgery( t=2.777,P=0.007;t=7.016,P=0.000;t=9.060,P= 0.000).There was interaction between time factor and group factor in kyphotic Cobb’s angle of injured vertebrae( F=56.075,P =0.000).There was statistical difference in kyphotic Cobb’s angle of injured vertebrae between the 2 groups in general,in other words,there was group effect( F=11.289,P= 0.000).There was statistical difference in kyphotic Cobb’s angle of injured vertebrae between different timepoints before and after the surgery,in other words,there was time effect( F=45.201,P =0.000).The kyphotic Cobb’s angle of injured vertebrae presented a time-dependent decreasing trend in both of the 2 groups,while the 2 groups were inconsistent with each other in the decreasing tendency(18.7+/-2.4,6.3+/-1.2,6.1+/-1.3,6.2+/-1.3,6.4+/-1.2 degrees, F=22.397,P= 0.000;18.6+/-2.2,7.9+/-1.3,7.8+/-1.2,7.9+/-1.3,7.8+/-1.3 degrees, F=15.986,P =0.000).There was no statistical difference in kyphotic Cobb’s angle of injured vertebrae between the 2 groups before reduction( t=0.180,P =0.857).The kyphotic Cobb’s angles of injured vertebrae were smaller in combination group compared to PKP group immediately after reduction,immediately after surgery and at 3 and 6 months after the surgery( t=5.350,P=0.000;t=5.644,P=0.000;t=5.450,P=0.000;t=4.681,P =0.000).There was interaction between time factor and group factor in injured vertebrae anterior border height( F=36.975,P =0.000).There was statistical difference in injured vertebrae anterior border height between the 2 groups in general,in other words,there was group effect( F=15.302,P =0.000).There was statistical difference in injured vertebrae anterior border height between different timepoints before and after the surgery,in other words,there was time effect( F=22.041,P =0.000).The injured vertebrae anterior border height presented a time-dependent increasing trend in both of the 2 groups,while the 2 groups were inconsistent with each other in the increasing tendency(12.3+/-2.0,20.6+/-2.2,20.4+/-2.1,20.5+/-2.1,20.7+/-2.0 mm, F= 18.957 ,P =0.000;12.5+/-2.2,18.7+/-2.0,18.9+/-2.2,18.8+/-2.1,18.9+/-2.0 mm, F=16.093,P =0.000).There was no statistical difference in injured vertebrae anterior border height between the 2 groups before reduction( t=0.398,P =0.692).The injured vertebrae anterior border heights were higher in combination group compared to PKP group immediately after reduction,immediately after surgery and at 3 and 6 months after the surgery( t=3.751,P=0.000;t=2.913,P=0.005;t=3.374,P=0.001;t=3.751,P =0.000).There was no statistical difference in ODI between the 2 groups before the surgery( t=0.178,P =0.860).The ODI decreased in both of the 2 groups at 6 months after the surgery compared to pre-surgery(64.3+/-4.6 vs 19.7+/-2.3%, t=53.458,P =0.000;64.1+/-4.8 vs 23.6+/-2.9%, t=40.853,P =0.000),and was lower in combination group compared to PKP group( t=6.274,P =0.000).There was no statistical difference in ADL scores between the 2 groups before surgery( t=0.235,P =0.815).The ADL scores increased in both of the 2 groups at 6 months after the surgery compared to pre-surgery(41.6+/-3.5 vs 71.8+/-5.0 points, t=30.503,P =0.000;41.4+/- 3.6 vs 66.2+/-5.2 points, t=22.182,P =0.000),and were higher in combination group compared to PKP group( t=4.584,P = 0.000 ).The bone cement leakage was found in 1 patient in combination group and 1 patient in PKP group,and the fracture malunion was found in 1 patient in PKP group.There was no statistical difference in complication incidences between the 2 groups(χ^ 2=0.023,P = 0.879 ). Conclusion: There is no significant difference in operative time,intraoperative blood loss,postoperative hospital stay and safety between combination therapy of hyperextension reduction and PKP and monotherapy of PKP for treatment of OVCF with cracked PVBW,however,the former surpasses the latter in clinical curative effects.