2. 广州中医药大学第一附属医院脊柱外科, 广东 510405
2. Department of Spinal Surgery, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong, China
骨质疏松性椎体压缩性骨折(OVCF)是骨质疏松症的常见并发症,好发于绝经后妇女及老年人。经皮椎体成形术(PVP)通过向椎体内注入填充材料以稳定骨折、强化椎体,止痛效果确切、允许术后早期活动,是应用广泛的微创方法,但部分患者术后存在顽固性腰背痛、活动功能下降、继发椎体骨折等情况[1]。近年来,矢状面失衡对脊柱疾病症状的影响越来越受到关注[2-4]。本研究回顾分析了2011年6月—2013年6月在广州中医药大学第一附属医院接受PVP治疗的OVCF患者资料,探讨术后脊柱矢状面平衡状态与疗效的关系,报告如下。
1 资料与方法 1.1 一般资料病例纳入标准:①确诊OVCF并接受PVP治疗;②术前影像资料及各项问卷评分资料完整;③术后随访 > 12个月影像及问卷评分资料完整;④手术均由同一位高年资医师主刀;⑤术后常规抗骨质疏松治疗2年(钙剂+维生素D+双膦酸盐)。共68例患者符合上述纳入条件,进入本研究。
1.2 分组方法采用Barrey法[4],在术后即刻全脊柱侧位X线片上测量C7矢状面轴向垂线至骶骨后上角的水平距离(SVA)与股骨中点至骶骨后上角水平距离的比值,当SVA落在骶骨后上角后方计为负值,落于股骨头中心前方则计为正值且 > 1。定义该比值 < 0是平衡状态,0~0.5为代偿平衡, > 0.5为失平衡(图 1),将患者分为生理平衡组(A组)、代偿平衡组(B组)、失平衡组(C组)。
术前1 d及术后12个月分别采用疼痛视觉模拟量表(VAS)评分[5]评价腰背痛、Barthel日常活动(activity of daily life,ADL)评分[6]评价活动功能、Berg评分[7]评价机体平衡控制能力;记录因新发OVCF再次入院接受治疗及术后12个月随访时胸腰段畸形Cobb角增加 > 10°者,统计其发生率。
1.4 统计学处理使用SPSS 17.0软件进行数据分析。患者性别、骨折次数、伤椎分布等计数资料的比较采用χ2检验;符合正态分布且方差齐性的计量资料采用单因素方差分析进行比较,不符合正态分布的计量资料采用多样本秩和检验进行比较,3组间比较存在差异的则进一步应用LSD法进行两两比较。以P < 0.05为差异有统计学意义。
2 结果3组患者性别、年龄、伤椎节段分布、骨折发生次数、骨密度(BMD)、术前疼痛评分及活动功能等基线特征差异无统计学意义(P > 0.05,表 1)。
腰背痛VAS评分A组优于B组、C组,B组优于C组,差异均有统计学意义(P < 0.05,表 2)。活动功能ADL评分A组优于B组、C组,B组优于C组,差异均有统计学意义(P < 0.05,表 2)。机体维持平衡能力Berg评分A组、B组间差异无统计学意义,但A组、B组均优于C组且差异有统计学意义(P < 0.05,表 2)。再次OVCF发生率A组(12.5%,4/32)低于B组(44.0%,11/25)、C组(63.6%,7/11),差异均有统计学意义(P < 0.05),B组和C组间差异无统计学意义。胸腰段畸形Cobb角增大 > 10°的发生率A组(0)低于B组(40.0%,10/25)、C组(72.7%,8/11),差异有统计学意义(P < 0.05),B组和C组间差异无统计学意义。
PVP以微创手段治疗OVCF,能在短时间内迅速止痛并为伤椎提供坚强支撑,使患者能安全地进行术后的早期活动[1]。但也有部分患者术后疗效不佳,如重新出现腰背痛、胸腰段后凸畸形进展等,复查影像资料能观察到脊柱新发骨折、退变等[8-11]。与术后症状相关的可能因素包括严重骨质疏松、骨水泥状态(注入量、弥散情况、是否渗漏)、脊柱-骨盆矢状面失衡等[12-17]。矢状面失衡干扰脊柱载荷传递导致应力异常集中,会加速脊柱退变、诱发骨折,多项研究均推断其能引起脊柱相关症状[18-22],但有关矢状面失衡与PVP手术疗效之间关系的临床研究较少。
脊柱的矢状面平衡使人体能够以最小的能耗获得平衡及活动能力。失衡状态与椎间组织退变、腰椎滑脱、椎体骨折等脊柱病相互影响、互成因果。本研究发现PVP术后脊柱矢状面平衡正常的患者腰背痛改善、活动功能、机体平衡能力均优于失平衡和代偿平衡的患者;术后脊柱矢状面代偿平衡和失平衡的患者再次发生OVCF(伤椎再骨折、邻椎骨折、跳跃椎骨折)的概率要高于矢状面平衡正常的患者;脊柱矢状面代偿平衡和失平衡的患者更易出现胸腰段畸形的进展性恶化。
腰背痛改善情况、活动功能以及机体保持平衡的能力是相互影响的。机体维持平衡能力下降不仅制约日常活动,更与疼痛、再跌倒风险等密切相关[23-25]。通过对各组患者之间基线特征的对比分析排除患者年龄、性别、BMD等因素以后,影响手术疗效的最可能因素与术后矢状面失衡状态下脊柱载荷的异常传递有关。这与既往研究中载荷异常传递会导致脊柱生理弯曲交界区段的椎体应力过度集中,从而引起新发骨折、椎间病变和腰背肌群过度劳损的研究结论相吻合[25-26]。新发椎体骨折、椎间病变和腰背肌群过度劳损已被证实是影响PVP疗效的高度相关因素。①新发的椎体骨折在手术椎体、邻近椎体以及跳跃椎体均有可能发生,直接导致剧烈疼痛、活动受限等术后症状。本研究结果显示脊柱矢状面失衡的患者更易发生此现象,但也有部分研究报道新发椎体骨折与骨水泥注入量、骨水泥材料选择以及术后维生素D缺乏等因素有关[27-30]。②椎间组织退变可引起术后新发的神经症状,常被认为与骨水泥填充过多、弥散不佳、团块形状过于规则以及椎间渗漏等有关。但也有研究者有不同的观点,如Khosla等[31]基于2年随访的研究认为骨水泥椎间渗漏并不对PVP疗效(尤其是疼痛、活动功能)产生影响。但研究已证实矢状面失衡状态下的脊柱,椎间不稳和椎间盘退变的发生和进展均较平衡状态下的脊柱显著增快[32-33]。③矢状面失衡所致腰背肌群在异常姿势和负荷状态下出现的劳损性疼痛是PVP术后疗效不佳最常见的原因,这与Chen等[34]的研究结论相符,他们发现通过系统的腰背肌锻炼能够使PVP术后疗效持续改善达2年以上,显著降低术后下腰痛的发生率。
综上所述,PVP治疗OVCF,术后疗效与患者的脊柱矢状面平衡情况密切相关。矢状面失衡的患者术后更易出现新发腰背痛、机体平衡维持能力下降、活动功能低下、脊柱畸形进展或新发骨折等。因此对术后矢状面平衡状态异常的患者,可考虑适当延长卧床时间或给予佩戴支具、定期随诊,警惕疼痛、活动功能下降等“信号”症状,早期进行影像复查及对症处理。
[1] | Liu J, Li X, Tang D, et al. Comparing pain reduction following vertebroplasty and conservative treatment for osteoporotic vertebral compression fractures: a metaanalysis of randomized controlled trials[J]. Pain Physician, 2013, 16(5): 455–464. |
[2] | Chaléat-Valayer E, Mac-Thiong JM, Paquet J, et al. Sagittal spino-pelvic alignment in chronic low back pain[J]. Eur Spine J, 2011, 20 Suppl 5: 634–640. |
[3] | Glassman SD, Bridwell K, Dimar JR, et al. The impact of positive sagittal balance in adult spinal deformity[J]. Spine (Phila Pa 1976), 2005, 30(18): 2024–2029. DOI:10.1097/01.brs.0000179086.30449.96 |
[4] | Barrey C, Roussouly P, Perrin G, et al. Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms?[J]. Eur Spine J, 2011, 20 Suppl 5: 626–633. |
[5] | Huskisson EC. Measurement of pain[J]. Lancet, 1974, 2(7889): 1127–1131. |
[6] | Mahoney FI, Barthel DW. Functional evaluation: the Barthel index[J]. Md State Med J, 1965, 14: 61–65. |
[7] | Berg KO, Wood-Dauphinee SL, Williams JI, et al. Measuring balance in the elderly: validation of an instrument[J]. Can J Public Health, 1992, 83(Suppl 2): S7–11. |
[8] | Chen XM, Ma HS, Wang M, et al. Analysis of causes of pain after kyphoplasty for osteoporotic vertebral compression fractures[J]. Chin Med J (Engl), 2013, 126: 2192–2194. |
[9] | Kim MH, Lee AS, Min SH, et al. Risk factors of new compression fractures in adjacent vertebrae after percutaneous vertebroplasty[J]. Asian Spine J, 2011, 5(3): 180–187. DOI:10.4184/asj.2011.5.3.180 |
[10] | 郝定均, 刘鹏, 贺宝荣, 等. 陈旧性与新鲜性压缩骨折行椎体成形术的临床对比研究[J]. 脊柱外科杂志, 2012, 10(2): 83–86. |
[11] | 邢润麟, 张顺聪, 梁德, 等. 椎体成形术与椎体后凸成形术治疗骨质疏松性椎体压缩骨折术后伤椎再塌陷的对比研究[J]. 脊柱外科杂志, 2015, 13(4): 207–210. |
[12] | Zhang YZ, Kong LD, Cao JM, et al. Incidence of subsequent vertebral body fractures after vertebroplasty[J]. J Clin Neurosci, 2014, 21(8): 1292–1297. DOI:10.1016/j.jocn.2013.12.022 |
[13] | Zou J, Mei X, Zhu X, et al. The long-term incidence of subsequent vertebral body fracture after vertebral augmentation therapy: a systemic review and metaanalysis[J]. Pain Physician, 2012, 15(4): E515–522. |
[14] | Lee DG, Park CK, Park CJ, et al. Analysis of risk factors causing new symptomatic vertebral compression fractures after percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures: a 4-year follow-up[J]. J Spinal Disord Tech, 2015, 28(10): E578–583. DOI:10.1097/BSD.0000000000000043 |
[15] | Nieuwenhuijse MJ, Putter H, van Erkel AR, et al. New vertebral fractures after percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures: a clustered analysis and the relevance of intradiskal cement leakage[J]. Radiology, 2013, 266(3): 862–870. DOI:10.1148/radiol.12120751 |
[16] | Lin WC, Cheng TT, Lee YC, et al. New vertebral osteoporotic compression fractures after percutaneous vertebroplasty: retrospective analysis of risk factors[J]. J Vasc Interv Radiol, 2008, 19(2 Pt 1): 225–231. |
[17] | Kamano H, Hiwatashi A, Kobayashi N, et al. New vertebral compression fractures after prophylactic vertebroplasty in osteoporotic patients[J]. AJR Am J Roentgenol, 2011, 197(2): 451–456. DOI:10.2214/AJR.10.5937 |
[18] | 何飞平, 盖景颖, 李如求. 经皮椎体后凸成形术治疗老年重度骨质疏松性椎体压缩骨折[J]. 脊柱外科杂志, 2015, 13(6): 360–363. |
[19] | Korovessis P, Zacharatos S, Repantis T, et al. Evolution of bone mineral density after percutaneous kyphoplasty in fresh osteoporotic vertebral body fractures and adjacent vertebrae along with sagittal spine alignment[J]. J Spinal Disord Tech, 2008, 21(4): 293–298. DOI:10.1097/BSD.0b013e31812e6295 |
[20] | Barrey C, Roussouly P, Le Huec JC, et al. Compensatory mechanisms contributing to keep the sagittal balance of the spine[J]. Eur Spine J, 2013, 22 Suppl 6: S834–841. |
[21] | Papanastassiou ID, Filis AK, Gerochristou MA, et al. Controversial issues in kyphoplasty and vertebroplasty in malignant vertebral fractures[J]. Cancer Control, 2014, 21(2): 151–157. |
[22] | Lee JS, Lee HS, Shin JK, et al. Prediction of sagittal balance in patients with osteoporosis using spinopelvic parameters[J]. Eur Spine J, 2013, 22(5): 1053–1058. DOI:10.1007/s00586-013-2672-1 |
[23] | Wang HJ, Giambini H, Zhang WJ, et al. A modified sagittal spine postural classification and its relationship to deformities and spinal mobility in a Chinese osteoporotic population[J]. PLoS One, 2012, 7(6): e38560. DOI:10.1371/journal.pone.0038560 |
[24] | Imagama S, Ito Z, Wakao N, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males[J]. Eur Spine J, 2013, 22(6): 1346–1353. DOI:10.1007/s00586-013-2721-9 |
[25] | Lazennec JY, Brusson A, Rousseau MA. Hip-spine relations and sagittal balance clinical consequences[J]. Eur Spine J, 2011, 20 Suppl 5: 686–698. |
[26] | Lamartina C, Berjano P. Classification of sagittal imbalance based on spinal alignment and compensatory mechanisms[J]. Eur Spine J, 2014, 23(6): 1177–1189. DOI:10.1007/s00586-014-3227-9 |
[27] | Balkarli H, Demirtas H, Kilic M, et al. Treatment of osteoporotic vertebral compression fractures with percutaneous vertebroplasty under local anesthesia: clinical and radiological results[J]. Int J Clin Exp Med, 2015, 8(9): 16287–16293. |
[28] | Zou D, Zhang K, Ren Y. Therapeutic effects of PKP on chronic painful osteoporotic vertebral compression fractures with or without intravertebral cleft[J]. Int J Clin Exp Med, 2015, 8(9): 15780–15786. |
[29] | Heo DH, Chin DK, Yoon YS, et al. Recollapse of previous vertebral compression fracture after percutaneous vertebroplasty[J]. Osteoporos Int, 2009, 20(3): 473–480. DOI:10.1007/s00198-008-0682-3 |
[30] | Summa A, Crisi G, Cerasti D, et al. Refractures in cemented vertebrae after percutaneous vertebroplasty and pain relief after a second procedure: a retrospective analysis[J]. Neuroradiol J, 2009, 22(2): 239–243. DOI:10.1177/197140090902200216 |
[31] | Khosla A, Diehn FE, Rad AE, et al. Neither subendplate cement deposition nor cement leakage into the disk space during vertebroplasty significantly affects patient outcomes[J]. Radiology, 2012, 264(1): 180–186. DOI:10.1148/radiol.12112215 |
[32] | Kim YB, Kim YJ, Ahn YJ, et al. A comparative analysis of sagittal spinopelvic alignment between young and old men without localized disc degeneration[J]. Eur Spine J, 2014, 23(7): 1400–1406. DOI:10.1007/s00586-014-3236-8 |
[33] | 徐宝山, 闫广辉, 夏群, 等. 经皮椎体后凸成形术治疗椎体骨质疏松性骨折的复位效果观察[J]. 脊柱外科杂志, 2013, 11(3): 133–136. |
[34] | Chen BL, Zhong Y, Huang YL, et al. Systematic back muscle exercise after percutaneous vertebroplasty for spinal osteoporotic compression fracture patients: a randomized controlled trial[J]. Clin Rehabil, 2012, 26(6): 483–492. DOI:10.1177/0269215511423557 |