骨质疏松性椎体骨折患者PKP术后邻近椎体骨折和骨水泥松动的因素.pdf

收稿日期:2022-08-24;修订日期:2022-10-21作者简介:刘旭东(1982-),男,吉林籍,主管技师研究方向:放射医学技术通信作者:万江花电子邮箱:临床研究骨质疏松性椎体骨折患者 PKP 术后邻近椎体骨折和骨水泥松动的因素刘旭东,万江花,张业雨,林娟,钟贞浩(海南医学院第一附属医院放射科,海南海口 570100)摘要:目的 探讨骨质疏松性椎体压缩性骨折(osteoporotic vertebral compression fractures,OVCF)患者 PKP 术后邻近椎体骨折(adjacent vertebral fractures,AVF)和骨水泥松动(cement loosening,CL)的影像学因素。方法 选择 2018 年 1 月 2020 年 12月在本院接受 PKP 治疗的 OVCF 患者 193 例,收集患者临床资料和影像学资料冠状位 Cobb 角、矢状垂直轴(sagittal verticalaxis,SVA)、骨盆入射角(pelvic incidence,PI)、骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)、伤椎楔形角、局部后凸角、楔形角矫正度、局部后凸角矫正度,观察影响 AVF 和 CL 的独立风险因素。结果PKP 术后 AVF 发生 41 例(21.24%)。AVF 组患者伴退行性脊柱侧凸的占比、SVA、PT、局部后凸角、局部后凸角矫正度、楔形角矫正度均高于非 AVF 患者,SS 低于非AVF 患者,差异均有统计学意义(P0.05)。AVF 组患者年龄、骨水泥用量高于非 AVF 患者,骨密度低于非 AVF 患者,差异均有统计学意义(P0.05)。PKP 术后 CL 发生率为9.84%。CL 组患者退行性脊柱侧凸的占比、SVA、PT、局部后凸角、楔形角、局部后凸角矫正度、楔形角矫正度、棘突骨折的占比均高于非 CL 组患者,SS 低于非 CL 组患者(P0.05)。多因素分析显示,年龄75 岁、退行性脊柱侧凸、局部后凸角是 PKP 术后 AVF 的风险因素(P0.05);年龄、棘突骨折是 PKP 术后 CL 的风险因素(P0.05)。结论 退行性脊柱侧凸、局部后凸角等影像学特征是 PKP 术后 AVF 的风险因素,棘突骨折是 CL 的风险因素。关键词:骨质疏松性压缩性椎体骨折;球囊后凸成形术;邻近椎体骨折;骨水泥松动中图分类号:R619,R687.3 文献标识码:A 文章编号:1005-7234(2023)04-0582-04DOI:10.3969/j.issn.1005-7234.2023.04.021Imaging factors of adjacent vertebral fractures and loosening of bone cement after balloon kyphoplasty in patients withosteoporotic vertebral fracturesLIU Xu-dong,WAN Jiang-hua,ZHANG Ye-yu,LIN Juan,ZHONG Zhen-hao(Department of Radiology,the First Affiliated Hospital of Hainan Medical College,Haikou 570100,China)Abstract:Objective To study the imaging factors of adjacent vertebral fractures(AVF)and cement loosening(CL)after balloonkyphoplasty(PKP)in patients with osteoporotic vertebral compression fractures(OVCF).Methods A total of 193 patients with OVCFwho received PKP treatment in our hospital from January 2018 to December 2020 were selected as the research objects,and the clinicaland imaging data coronal Cobb angle,sagittal vertical axis(SVA),pelvic incidence angle(PI),pelvic tilt angle(PT),sacral slopeangle(SS),wedge angle,local kyphosis angle,wedge angle correction,local kyphosis angle correction were collected.Independentrisk factors affecting AVF and CL were observed.ResultsAVF occurred in 41 cases(21.24%)after PKP.In the AVF group,thedegenerative scoliosis,SVA,PT,local kyphosis angle,local kyphosis angle change,local kyphosis angle correction and wedge anglecorrection were all higher than those in the non AVF group,and SS was lower than that in the non AVF group(P0.05).The age andbone cement dosage of patients in AVF group were higher than those in non AVF patients,and the bone mineral density andbisphosphonate dosage were lower than those in non AVF patients(P0.05).The incidence of CL was 9.84%.The degenerativescoliosis,SVA,PT,local kyphosis angle,wedge angle,position local kyphosis angle change,position wedge angle change,localkyphosis angle correction,wedge angle correction and spinous process fracture in CL group were higher than those in non CL group,andSS was lower than that in non CL group(P0.05).Multivariate analysis showed that age75 years,degenerative scoliosis and localkyphosis angle were risk factors for AVF(P0.05),and age and spinous process fracture were risk factors for CL(P10定义为存在退行性脊柱侧凸。1.3 统计学方法采用 SPSS 23.0 统计学软件包进行数据分析,图 1 术前和术后测量伤椎楔形角和局部后凸角示意图(图中 A示术前局部后凸角,A示术后局部后凸角,B 示术前楔形角,B示术后楔形角,局部后凸角矫正度=A-A,楔形角矫正度=B-B)计量资料表示为“均数标准差”,组间比较采用 t 检验;计数资料采用“例(%)”表示,组间比较采用卡方检验;多因素分析采用 Logistic 回归模型进行处理,P0.05 为差异有统计学意义。2 结果2.1 AVF 发生率及临床资料比较193 例中,有41 例术后1 年内发生 AVF,发生率为21.24%。其中30 例发生于术后2 个月内,9 例发生于术后 2 6 个月,2 例发生于术后 6 个月以上。AVF 组患者退行性脊柱侧凸和棘突骨折的占比、SVA、PT、局部后凸角、局部后凸角矫正度、楔形角矫正度均高于非 AVF 患者,SS 低于非 AVF 患者,差异均有统计学意义(P0.05);见表 1。AVF 组患者年龄、骨水泥用量高于非 AVF 患者,骨密度低于非AVF 患者,差异均有统计学意义(P0.05);见表 2。2.2 CL 发生率及术前临床资料比较193 例中,19 例出现 CL,发生率为 9.84%。CL组患者退行性脊柱侧凸、SVA、PT、局部后凸角、楔形角、术后楔形角、局部后凸角矫正度、楔形角矫正度、棘突骨折的占比等数据均高于非 CL 组患者,SS 低于非 CL 组患者,差异均有统计学意义(P0.05);见表 3。CL 和非 CL 组患者性别的差异有统计学意义(P0.05),且 CL 组年龄、骨水泥用量显著高于非CL 组患者(P0.05),骨密度 T 值显著低于非 CL 组患者(P0.05);见表 4。2.3 影响 AVF 和 CL 的多因素分析以 AVF(非 AVF=0,AVF=1)为应变量,对单因素分析有意义的自变量赋值并采用多因素 Logistic回归分析,结果显示,年龄75 岁、退行性脊柱侧凸、局部后凸角是 AVF 的风险因素(P0.05);年龄75岁、棘突骨折是 CL 的风险因素(P0.05)。见表 5。385颈腰痛杂志 2023 年第 44 卷第 4 期 The Journal of Cervicodynia and Lumbodynia 2023,Vol.44 No.4表 1 AVF 患者和非 AVF 患者影像学资料比较临床资料AVF(n=41)非 AVF(n=152)t/x2P退行性脊柱侧凸例(%)13(31.71)10(6.58)19.4230.001SVA(mm)65.3831.4751.0825.462.4220.019PI()51.0313.4749.4514.960.6100.545PT()30.547.8123.498.652.1870.033SS()20.379.7723.288.172.0610.044局部后凸角()19.677.6515.756.312.3360.023楔形角()23.486.1419.456.082.4320.018术后局部后凸角()11.455.0710.675.300.9400.351术后楔形角()10.856.439.477.020.4320.668局部后凸角矫正度()8.434.124.823.452.5110.015楔形角矫正度()12.755.359.854.462.6860.010棘突骨折例(%)9(21.95)10(6.58)8.5970.003表 2 AVF 和非 AVF 患者临床资料比较临床资料AVF(n=41)非 AVF(n=152)t/2P性别(男/女,例)15/2646/1060.5970.440年龄(岁)75.305.3370.247.142.4460.018BMI(kg/m2)23.883.4623.152.970.3300.743骨密度(T 值)-3.450.61-3.170.482.6130.012责任椎体(T11/T12/L1/L2,例)3/17/16/511/63/61/170.0390.998术前抗骨质疏松治疗(例)15(36.59)61(40.13)0.1700.680骨水泥用量(mL)4.381.083.820.832.7420.008手术医师(A/B/C,例)13/19/951/70/310.0070.997表 3 CL 发生率及术前影像学资料比较临床资料CL(n=19)非 CL(n=174)t/2P退行性脊柱侧凸例(%)8(42.11)15(8.62)18.2970.001SVA(mm)67.0430.3353.8021.972.9370.005PI()50.9714.8849.6315.090.4730.638PT()31.868.4925.168.432.2270.030SS()19.528.3623.8210.462.5600.013局部后凸角()20.186.1915.837.382.7400.008楔形角()24.586.4119.608.152.8120.007术后局部后凸角()11.595.1810.944.300.2710.787术后楔形角()10.485.899.876.712.5590.013局部后凸角矫正度()10.125.135.313.462.7010.009楔形角矫正度()13.916.4310.035.972.2080.032棘突骨折例(%)6(31.58)13(7.47)11.2170.001表 4 CL 和非 CL 患者临床资料比较临床资料CL(n=19)非 CL(n=174)t/2P性别(男/女,例)4/1557/11710.2500.001年龄(岁)75.884.3270.116.852.8830.006BMI(kg/m2)23.633.1723.282.970.6020.550骨密度(T 值)-3.730.58-3.260.472.5830.013责任椎体(T11/T12/L1/L2,例)2/8/6/214/70/72/180.5240.914术前抗骨质疏松治疗(例)11653.4340.064骨水泥用量(mL)4.380.763.760.692.4460.018手术医师(A/B/C,例)6/9/458/80/360.0240.988表 5 影响 AVF 和 CL 的多因素分析应变量自变量SEWaldPOR95%CI下限上限AVF年龄75 岁1.0120.3637.7720.0053.4071.2808.229退行性脊柱侧凸0.8240.3545.4180.0202.0161.1076.150局部后凸角0.2030.0914.9760.0261.3071.1141.656CL年龄75 岁0.8760.3326.9620.0082.5481.4199.134棘突骨折1.3450.42110.2070.0017.4161.72518.366485颈腰痛杂志 2023 年第 44 卷第 4 期 The Journal of Cervicodynia and Lumbodynia 2023,Vol.44 No.43 讨论PKP 是治疗 OVCF 的常用微创手术,可快速缓解 OVCF 患者疼痛并提高生活质量4。AVF 是 PKP的主要并发症,可导致复发性背痛和预后不良,是导致再次手术的风险因素5。荟萃分析显示,PKP 术后 AVF 受抗骨质疏松药物、年龄、OVCF 椎体压缩程度等多种因素影响6。Fribourg 等7研究显示,与自然发生未经治疗的 OVCF 患者比较,PKP 治疗术后的再发骨折发生率更高,多数是在术后 2 个月内发生。Su 等8一项队列研究显示,PKP 治疗 OVCF 术后再骨折率为 27.8%,本研究有 21.24%的患者发生 AVF,低于上述文献报道,这可能是因为不同研究中纳入的患者基线状态不同。本研究结果显示,年龄75 岁是 AVF 的风险因素,与既往研究6-7一致。这可能是因为随着年龄增加,患者骨质量呈降低趋势所致。本研究重点观察了 PKP 术后 AVF 和 CL 患者的术前影像学特征。结果显示,退行性脊柱侧凸、局部后凸角、楔形角、棘突骨折等影像学特征与 AVF 风险增高明显相关。局部后凸角是 AVF 的风险因素,但楔形角未表现出与AVF 的独立相关性,结果提示,局部后凸角较单纯楔形角更能预测 PKP 术后 AVF 风险,这可能与局部后凸角既涉及到骨折水平,又涉及到楔形角相关。此外,局部后凸角较楔形角更容易测量,是 PKP 术后AVF 的理想预测指标。本研究显示,合并退行性脊柱侧凸是 PKP 术后 AVF 的独立风险因素。既往研究显示,脊柱侧凸、脊柱后凸等力线异常改变了椎体的应力和承重状态8,本研究选择的胸腰段 OVCF患者,其应力集中区也是退行性腰椎侧凸的集中分布区,合并退行性腰椎侧凸可影响了 PKP 术后的椎体应力,导致 AVF 发生率增加。本研究有 9.84%的患者出现 CL,低于既往文献报道的 25.1%9。有研究显示,椎体爆裂性骨折是PKP 术后翻修手术的风险因素10。本研究未包括爆裂性椎体骨折的患者。本研究显示,年龄75 岁、棘突骨折是 CL 的风险因素,这些因素同样也是 AVF的风险因素。在 AOspine 胸腰椎损伤分类系统中,伴随棘突骨折的 OVCF 可归类为 B2 型,可能需要手术器械干预11。结果提示,对存在棘突骨折的的患者,应谨慎选择 PKP 作为干预措施。综上所述,本研究显示,退行性脊柱侧凸、局部后凸角和棘突骨折等影像学特征是 PKP 术后 AVF的风险因素,棘突骨折是 CL 的风险因素,可用于术前的手术规划。参考文献:1 邓硕,万权,曾振华,等.二维 CT 与 C 型臂 X 线引导椎体成形术治疗骨质疏松性椎体压缩性骨折的疗效比较J.中华疼痛学杂志,2021,17(05):496-502.2 田永刚,韩立强,王铜浩,等.靶点穿刺 PKP 手术治疗骨质疏松性椎体压缩性骨折疗效分析J.天津医药,2021,49(10):1067-1071.3 方艳志,郭亮,毕松超,等.单侧 PKP 治疗骨质疏松性胸腰椎压缩性骨折疗效分析J.医学理论与实践,2021,34(18):3193-3194.4 乔小万,邓强,李中锋,等.骨质疏松椎体压缩性骨折 PKP 术后骨水泥渗漏研究进展 J.医学综述,2021,27(16):3226-3231.5 冯明星.椎体成形术后邻近节段再骨折椎体成形治疗效果观察J.深圳中西医结合杂志,2017,27(19):74-75.6 Papanastassiou ID,Phillips FM,Van Meirhaeghe J,et al.Compa-ring effects of kyphoplasty,vertebroplasty,and non-surgical man-agement in a systematic review of randomized and non-randomizedcontrolled studiesJ.Eur Spine J,2012,21(9):1826-1843.7 Fribourg D,Tang C,Sra P,et al.Incidence of subsequent verte-bral fracture after kyphoplastyJ.Spine(Phila Pa 1976),2004,29(20):2270-6;discussion 2277.8 Su CH,Tu PH,Yang TC,et al.Comparison of the therapeuticeffect of teriparatide with that of combined vertebroplasty with an-tiresorptive agents for the treatment of new-onset adjacent vertebralcompression fracture after percutaneous vertebroplastyJ.SpinalDisord Tech,2013,26(4):200-206.9 Shin HK,Park JH,Lee IG,et al.A study on the relationship be-tween the rate of vertebral body height loss before balloon ky-phoplasty and early adjacent vertebral fractureJ.J Back Muscu-loskelet Rehabil,2021,34(4):649-656.10 Matsumoto K,Hoshino M,Omori K,et al.Preoperative scoringsystem for predicting early adjacent vertebral fractures afterBalloon KyphoplastyJ.J Orthop Sci,2021,26(4):538-542.11 陈孜,赵国辉,金丹杰,等.后路短节段内固定结合伤椎强化技术治疗骨质疏松性胸腰椎爆裂性骨折J.中国微创外科杂志,2019,19(12):1088-1091.585颈腰痛杂志 2023 年第 44 卷第 4 期 The Journal of Cervicodynia and Lumbodynia 2023,Vol.44 No.4