PKP治疗骨质疏松性胸腰椎骨折：症状突出侧与非突出侧入路的临床疗效对比

PKP for the Treatment of Osteoporotic Thoracolumbar Fractures: Comparison of Clinical Effect of Symptom Dominating Side and Symptom Non-Dominating Side Approaches

摘要: 目的：受试对象腰背部疼痛症状并非均匀对称分布于伤椎两侧，而表现为一侧疼痛较明显，对侧疼痛不如该侧明显。探讨采用单侧经皮椎体后凸成形术(percutaneous kyphoplasty, PKP)治疗IIa型急性症状性骨质疏松性胸腰椎骨折(acute symptomatic osteoporotic thoracolumbar fracture, ASOTLF)症状突出侧入路与非突出侧入路临床疗效对比。方法：前瞻性研究西安交通大学医学部附属红会医院2020年6月至2021年1月诊治的OTLICS评分 ≥ 5分、ASOTLF分型IIa型、急性症状性骨质疏松性胸腰椎单椎体骨折患者。采用随机数字法将患者分为两组：A组采用单侧PKP于疼痛症状突出侧操作；B组采用单侧PKP于非突出侧操作。手术均有同一医师完成，统计所有患者临床基本信息(包括年龄、性别、体重指数、骨密度、受伤椎体节段等)，比较术前、术后1 d、1 w、2、12个月疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、伤椎前缘高度(AH)、伤椎后凸角(KA)的变化及并发症。根据术后1 d正位X线片计算骨水泥对侧分布率。结果：共纳入107例患者，其中男41例，女66例，年龄(71.85 ± 5.54)岁(范围：60~83岁)，随访(13.7 ± 4.5)个月(范围：12~18个月)。两组患者术前一般资料比较差异无统计学意义(P > 0.05)。两组患者手术时间、术中透视次数、住院时间均无统计学差异(P > 0.05)。两组患者术中、术后均无骨水泥不良反应及心、脑血管意外发生，无穿刺针误入椎管损伤神经等情况发生。A、B组分别有5例和7例骨水泥渗漏，均为无症状性椎旁或椎间隙渗漏，无椎管内渗漏发生；两组骨水泥填充量、骨水泥渗漏率、骨水泥对侧分布率差异无统计学意义(P > 0.05)。两组术后1 d、1 w、2、12个月时VAS、ODI、AH、KA均较术前改善(P < 0.05)，但A组术后1 d、1 w、2个月VAS及ODI评分较B组改善明显(P < 0.05)，两组末次随访时VAS及ODI评分无明显差异(P > 0.05)。结论：应用单侧PKP治疗IIa型急性症状性骨质疏松性胸腰椎单节段骨折过程中，虽然症状突出侧入路与非突出侧入路在中远期疗效方面未见明显差异，但是我们发现突出侧入路较非突出侧入路在术后早期提升止痛效果及生活质量方面存在一定优势。

Abstract: Objective: The pain symptoms of the subjects’ back were not evenly and symmetrically distributed on both sides of the injured vertebrae, but the pain was more obvious on one side and less obvious on the contralateral side. To compare the clinical effect of unilateral percutaneous kyphoplasty (PKP) in the treatment of type IIa acute symptomatic osteoporotic thoracolumbar fracture (ASOTLF) with asymptomatic side operation. Methods: A prospective case-control study was conducted on patients with ASOTLF type IIa, OTLICS score ≥ 5, and acute symptomatic osteoporotic thoracolum vertebral fractures admitted to the Honghui Hospital Affiliated to Xi’an Jiaotong University from June 2020 to January 2021. Patients were divided into two groups by random number method: In group A, patients received unilateral PKP on the symptom dominating side. In group B, patients treated with unilateral PKP on the symptom non-dominating side. All surgeries were performed by the same physician, and the basic clinical information of all patients (including age, gender, body mass index, bone mineral density, injured level, etc.) was collected. The changes of visual analogue scale (VAS), Oswestry disability index (ODI), anterior height (AH), kyphotic angle (KA) and complications were compared before and after surgery at 1 d, 1 w, 2 and 12 months. The contra-lateral distribution rate of bone cement was calculated by orthographic X-ray at 1 day after opera-tion. Results: A total of 107 patients were enrolled, including 41 males and 66 females, aged (71.85 ± 5.54) years (range: 60~83 years), followed up for (13.7 ± 4.5) months (range: 12~18 months). There was no significant difference in preoperative general data between the two groups (P > 0.05). There were no significant differences in operation time, intra-operative fluoroscopy times and hospital stay between the two groups (P > 0.05). There were no bone cement adverse reactions, cardiac and cerebrovascular adverse events, and no complications such as accidental puncture needle into spinal canal and nerve injury in two groups during and after operation. There were 5 cases and 7 cases of bone cement leakage in group A and B respectively, which was asymptomatic paravertebral or intervertebral leakage without intraspinal leakage. There were no significant differences in bone cement injection amount, bone cement leakage rate and bone cement contralateral distribution rate between the two groups (P > 0.05). VAS, ODI, AH and KA at 1 d, 1 w, 2 and 12 months after operation were all improved in both groups (P > 0.05), but VAS and ODI scores of group A were significantly improved compared with group B at 1 d, 1 w and 2 months postoperatively (P < 0.05), there were no significant differences in VAS and ODI scores between the two groups at the last follow-up (P > 0.05). Conclusions: In unilateral percutaneous kyphoplasty for the treatment of type IIa acute symptomatic osteoporotic thoracolumbral fractures, although there was no significant difference between symptom dominating side and symptom non- dominating sideoperations in the medium and long term outcomes, however, we found that the symptom dominating side operation has a certain advantage over the symptom non-dominating side operation in terms of pain relief in the early stage.