单侧椎弓根旁与经椎弓根入路行椎体成形术治疗胸腰段骨质疏松性椎体压缩骨折的疗效比较

Comparison of therapeutic effects between percutaneous vertebroplasty via unilateral para-pedicle approach and unilateral pedicle approach for the treatment of osteoporotic vertebral compression fractures

摘要:

目的 探讨经单侧椎弓根旁入路穿刺至对侧旁正中线行椎体成形术（UPA-PVP）与传统经单侧椎弓根入路行经皮椎体成形术（TUA-PVP）治疗胸腰段骨质疏松性椎体压缩骨折（OVCF）的疗效。方法 回顾性分析2018年3月—2023年10月在岳阳市人民住院并行经皮穿刺椎体成形术治疗的254例胸腰椎OVCF患者，按不同治疗方法分为UPA-PVP组（143例）和TUA-PVP组（111例）。均为胸腰椎（T₈～L₂）单个椎体骨折。UPA-PVP组根据术前胸腰椎正侧位X射线片、CT及MRI评估伤椎内靶向穿刺点，即穿刺椎体对侧旁正中线与椎体前中1/3交界处，根据靶向穿刺点逆向设计穿刺路径及确定体表定位点；TUA-PVP组采用传统经椎弓根投影10点或2点方法穿刺，参考术后胸腰椎正侧位X射线片、三维CT判断骨水泥在手术椎体内的弥散分布情况。比较两组患者术前、术后4 h、术后2 d及术后6个月患者的腰背部疼痛视觉模拟评分（VAS）及全身恢复情况Oswestry功能障碍指数（ODI），比较两组患者骨水泥渗漏，伤椎再骨折等相关并发症。结果 两组患者单个椎体手术时间、术中失血量比较，差异均无统计学意义（P >0.05）。UPA-PVP组单个椎体骨水泥注入量大于TUA-PVP组（P <0.05）。两组患者术前、术后4 h、术后2 d及术后6个月的腰背部疼痛VAS评分和ODI指数比较，结果 ①两组患者不同时间点腰背部疼痛VAS评分和ODI指数比较，差异均有统计学意义（P <0.05）；②两组患者腰背部疼痛VAS评分和ODI指数比较，差异均有统计学意义（P <0.05）；③两组患者腰背部疼痛VAS评分和ODI指数变化趋势比较，差异均有统计学意义（P <0.05）。UPA-PVP组、TUA-PVP组患者左、右侧入路骨水泥渗漏率比较，差异无统计学意义（P >0.05）。两组患者骨水泥总渗漏率比较，差异有统计学意义（P <0.05）。随访3～24个月，所有患者达到骨性愈合。UPA-PVP组无手术椎体对侧再骨折情况，17例患者出现其他椎体压缩性骨折，再次行椎体成形术；TUA-PVP组5例患者手术椎体对侧再次出现骨折，12例患者出现其他椎体压缩性骨折，均再次行椎体成形术。UPA-PVP组手术椎体再骨折率低于TUA-PVP组（P <0.05）。UPA-PVP组与TUA-PVP组其他椎体骨折率比较，差异无统计学意义（P >0.05）。结论 UPA-PVP与TUA-PVP两种手术方法均能有效缓解OVCF患者腰背部疼痛。UPA-PVP方法治疗OVCF，以穿刺靶点为目标，逆向设计穿刺路径，简单易行，较TUA-PVP方法能达到更好的骨水泥椎体内分布，降低椎体再骨折率，有效缓解椎体骨折后腰背痛，提高患者生活质量，疗效满意。

Abstract:

Objective To evaluate therapeutic effects on osteoporotic vertebral compression fracture (OVCF) in the thoracolumbar region between the approach of unilateral para-pedicle puncture to the contralateral midline for percutaneous vertebroplasty (UPA-PVP) and the traditional approach of unilateral pedicle for percutaneous vertebroplasty (TUA-PVP).Method A retrospective analysis was conducted on 254 patients with OVCF and treated with percutaneous vertebroplasty (PVP) in Yueyang People's Hospital from March 2018 to October 2023. They were divided into UPA-PVP group (143 cases) and TUA-PVP group (111 cases) according to different treatment methods. All are single vertebral fractures of the thoracolumbar spine (T₈ to L₂). The UPA-PVP group defined the targeted puncture point within the injured vertebra based on preoperative thoracolumbar X-rays, CT and MRI, and based on the targeted puncture point reversely designed the puncture path and determined the body surface positioning point. The TUA-PVP group used the traditional transpedicular projection 10 or 2 o'clock point method for puncture, and referred to postoperative thoracolumbar X-rays and The three-dimensional CT was used to evaluate the diffusion distribution of bone cement in the surgical vertebra, The visual analogue scale (VAS) of lower back pain and Oswestry disability index (ODI) were recorded in the preoperative and postoperative 4 hours and 2 days and 6 months after surgery, along with related complications such as bone cement leakage and recurrent vertebral fractures.Result All patients successfully completed PVP surgery. The amount of vertebral bone cement filling in the UPA-PVP group was higher than that in the TUA-PVP group, and the difference was statistically significant (P <0.05). The VAS score and ODI index improved with patients at 4 hours, 2 days, and 6 months after surgery that compared to the preoperative, and gradually improved over time. Moreover, the UPA-PVP group showed better improvement than the TUA-PVP group at 4 hours and 2 days after surgery, with statistical significance (P <0.05). Postoperative follow-up X-ray and CT showed that in the UPA-PVP group, all surgical vertebrae had a uniform distribution of bone cement, with a 100% excellent rate. A total of 12 vertebral bodies experienced leakage of bone cement into the paravertebral soft tissue or paravertebral veins, with a total leakage rate of 8.39%. TUA-PVP group: with an excellent rate of 40.54%. A total of 19 vertebral bodies experienced leakage into the paravertebral soft tissue and paravertebral veins, with a total leakage rate of 17.12%. The difference in the total leakage rate of bone cement between the two groups was statistically significant (P <0.05). Follow up for 3 to 24 months (8.53 ± 3.37) showed that all patients achieved final bone healing during the follow-up process. During the follow-up, there were no cases of contralateral vertebral fractures in the UPA-PVP group (0/143), In the TUA-PVP group, there were 5 cases (5/111) of contralateral vertebral fractures in the surgical vertebral body, The difference in vertebral body refractured rate between the two groups was statistically significant (P <0.05).Conclusion Both UPA-PVP and TUA-PVP surgical methods can effectively alleviate lower back pain in OVCF patients. The UPA-PVP method is to treat OVCF with the puncture target as the target and the reversely design of the puncture path. It is simple and feasible, and can achieve better distribution of bone cement in the vertebral body compared to the TUA-PVP method, reduce the rate of vertebral refractured, effectively alleviate lower back pain after vertebral fracture, improve the patient's quality of life, and achieve satisfactory treatment results.