单侧弯角椎体成形术治疗2种特殊类型的骨质疏松性椎体压缩性骨折的疗效分析

Analysis of the Therapeutic Effect of Unilateral Pedicle Approach Vertebroplasty in the Treatment of Two Special Types of Osteoporotic Vertebral Compression Fractures

摘要: 目的：探讨单侧弯角椎体成形术(Percutaneous curved vertebroplasty, PCVP)和双侧椎体成形术(Percutaneous vertebroplasty, PVP)治疗椎弓根内倾不足与椎弓根细小的骨质疏松性椎体压缩性骨折(Osteoporotic vertebral compression fracture, OVCF)的疗效比较。方法：采用回顾性病例对照研究分析2016年3月~2018年6月嘉兴市第二医院骨科收治的62例骨质疏松性椎体压缩性骨折患者的临床资料，其中男21例，女41例；年龄65~86 [(75.10 ± 5.56)岁]。骨折节段：T₁₀ 4椎，T₁₁ 8椎，T₁₂ 10椎，L₁ 10椎，L₂ 9椎，L₃ 9椎，L₄ 7椎，L₅ 5椎。先根据椎弓根形态分为椎弓根内倾不足(26例，共26个椎体)、椎弓根细小(36例，共36个椎体)两种特殊类型，再根据手术方式不同分为PCVP组(PCVP组中其中10例为椎弓根内倾不足病例。12例为椎弓根细小病例)和PVP组(PVP组中其中16例椎弓根内倾不足病例，24例椎弓根细小病例)，分别比较两组手术时间、骨水泥注入量、术中出血量、骨水泥渗漏等相关并发症、术前和术后1周及术后1年视觉模拟评分(Visual analogue scale, VAS)、手术前和术后1周及术后1年Oswestry功能残障指数(Oswestry disability index, ODI)。术后两组椎体应用CT平扫评估骨水泥在伤椎椎体内部分布情况。结果：患者均获随访12~48个月[(18.55 ± 6.70)个月]。椎弓根内倾不足：PCVP组手术时间(26.70 ± 2.26) min、PVP组手术时间(36.81 ± 2.66) min (P < 0.01)，PCVP组术中出血量为(9.50 ± 1.43) ml、PVP组术中出血量为(18.63 ± 2.36) ml (P < 0.01)，PCVP组骨水泥注射量为(3.85 ± 0.21) ml、PVP组骨水泥注射量为(3.83 ± 0.35) ml (P > 0.05)；椎弓根细小：PCVP组手术时间(25.83 ± 2.17) min、PVP组手术时间(38.04 ± 5.02) min (P < 0.01)，PCVP组术中出血量为(11.58 ± 2.84) ml、PVP组术中出血量为(17.17 ± 2.87) ml (P < 0.01)，PCVP组骨水泥注射量为(3.62 ± 0.38) ml、PVP组骨水泥注射量为(3.83 ± 0.45) ml (P > 0.05)。PCVP组术前、术后1周及术后1年的VAS分别为(6.82 ± 0.91)分、(2.32 ± 0.57)分、(1.59 ± 0.67)分；PVP组术前、术后1周及术后1年的VAS分别为(7.10 ± 0.98)分、(2.40 ± 0.74)分、(1.65 ± 0.74)分。两组术后VAS均较术前明显降低(P < 0.01)，术后两组间比较，差异均无统计学意义(P > 0.05)。PCVP组术前、术后1周及术后1年ODI分别为70.27 ± 7.43、22.00 ± 4.83、19.59 ± 2.63，PVP组手术前、术后1周及术后1年ODI分别为70.78 ± 4.88、20.78 ± 3.30、19.28 ± 4.56，两组术后1年ODI均较术前明显降低(P < 0.01)，术后两组间比较，差异均无统计学意义(P > 0.05)。PCVP组术后复查CT发现骨水泥分布均超过椎体中线，骨水泥渗漏率为4.55%。PVP组术后复查CT发现骨水泥有3例弥散超过椎体中线，其余均分布椎体两侧，骨水泥渗漏率为30.00%。两组骨水泥渗漏率，差异有统计学意义(P < 0.05)；两组发生渗漏患者均无明显不适。PVP组穿刺并发症出现2例穿刺入椎管和3例穿刺致椎弓根外壁破裂(P < 0.05)，但患者均无明显不适。结论：PCVP治疗OVCF具有手术时间短、出血量少、渗漏率低、更优的骨水泥分布等优点，且对椎弓根内倾不足、椎弓根细小两种特殊类型的患者具有更好的适应症，值得一定程度地选择应用和推广。

Abstract: Objective: To compare the efficacy of unilateral Percutaneous Curved Vertebroplasty (PCVP) and bilateral Percutaneous Vertebroplasty (PVP) in treating Osteoporotic Vertebral Compression Fractures (OVCF) with insufficient pedicle inclination or narrow pedicles. Methods: A retrospective case-control study was conducted on 62 OVCF patients admitted to the Department of Orthopedics, Jiaxing Second Hospital from March 2016 to June 2018, including 21 males and 41 females, aged 65-86 years (mean 75.10 ± 5.56). Fractured vertebrae: T10 (4), T11 (8), T12 (10), L1 (10), L2 (9), L3 (9), L4 (7), L5 (5). Patients were first categorized based on pedicle morphology into two special types: insufficient pedicle inclination (26 patients, 26 vertebrae) and narrow pedicles (36 patients, 36 vertebrae). They were then divided into the PCVP group (In the PCVP group, 10 cases had insufficient pedicle inclination, and 12 cases had narrow pedicles.) and the PVP group (Among the PVP group, there were 16 cases of insufficient pedicle inclination and 24 cases of small pedicles.) according to the surgical procedure. Operative time, bone cement volume, intraoperative blood loss, bone cement leakage and other related complications, Visual Analogue Scale (VAS) scores preoperatively, at 1 week postoperatively, and at 1 year postoperatively, and Oswestry Disability Index (ODI) scores preoperatively, at 1 week postoperatively, and at 1 year postoperatively were compared between the two groups. Postoperative CT scans were used to assess the distribution of bone cement within the fractured vertebrae. Results: All patients were followed up for 12-48 months (mean 18.55 ± 6.70 months). Insufficient Pedicle Inclination subgroup: Operative time was significantly shorter in the PCVP group (26.70 ± 2.26 min) than in the PVP group (36.81 ± 2.66 min) (P < 0.01). Intraoperative blood loss was significantly less in the PCVP group (9.50 ± 1.43 ml) than in the PVP group (18.63 ± 2.36 ml) (P < 0.01). Bone cement volume showed no significant difference between the PCVP group (3.85 ± 0.21 ml) and the PVP group (3.83 ± 0.35 ml) (P > 0.05). Narrow Pedicles subgroup: Operative time was significantly shorter in the PCVP group (25.83 ± 2.17 min) than in the PVP group (38.04 ± 5.02 min) (P < 0.01). Intraoperative blood loss was significantly less in the PCVP group (11.58 ± 2.84 ml) than in the PVP group (17.17 ± 2.87 ml) (P < 0.01). Bone cement volume showed no significant difference between the PCVP group (3.62 ± 0.38 ml) and the PVP group (3.83 ± 0.45 ml) (P > 0.05). VAS scores in the PCVP group were 6.82 ± 0.91 preoperatively, 2.32 ± 0.57 at 1 week postoperatively, and 1.59 ± 0.67 at 1 year postoperatively. VAS scores in the PVP group were 7.10 ± 0.98 preoperatively, 2.40 ± 0.74 at 1 week postoperatively, and 1.65 ± 0.74 at 1 year postoperatively. VAS scores decreased significantly postoperatively in both groups (P < 0.01), but no significant differences were found between the two groups at any postoperative time point (P > 0.05). ODI scores in the PCVP group were 70.27 ± 7.43 preoperatively, 22.00 ± 4.83 at 1 week postoperatively, and 19.59 ± 2.63 at 1 year postoperatively. ODI scores in the PVP group were 70.78 ± 4.88 preoperatively, 20.78 ± 3.30 at 1 week postoperatively, and 19.28 ± 4.56 at 1 year postoperatively. ODI scores at 1 year postoperatively decreased significantly compared to preoperatively in both groups (P < 0.01), but no significant differences were found between the two groups at any postoperative time point (P > 0.05). Postoperative CT in the PCVP group showed bone cement distribution exceeding the vertebral midline in all cases, with a cement leakage rate of 4.55%. In the PVP group, postoperative CT showed bone cement distribution exceeding the midline in only 3 cases, with the rest distributed bilaterally; the cement leakage rate was 30.00%. The difference in cement leakage rates between the two groups was statistically significant (P < 0.05). None of the patients with cement leakage experienced significant symptoms. The PVP group had 2 cases of needle misplacement into the spinal canal and 3 cases of pedicle wall breach during puncture (P < 0.05), but none of these patients experienced significant symptoms. Conclusion: PCVP for OVCF offers advantages including shorter operative time, less blood loss, lower cement leakage rate, and superior bone cement distribution. It demonstrates better applicability for the two special types of patients with insufficient pedicle inclination or narrow pedicles, and is worthy of selective application and promotion to a certain extent.