Abstract
目的
比较短节段钉棒固定联合伤椎椎体成形（short segmental pedicle screw fixation combined with vertebroplasty，SSF+VP）以及短节段钉棒固定联合伤椎植骨（short segmental pedicle screw fixation combined with bone graft，SSF+BG）治疗不稳定型 Kümmell 病的疗效，为临床选择治疗方法提供参考。
方法
将 2013 年 3 月—2015 年 2 月收治并符合选择标准的 48 例不稳定型 Kümmell 病患者纳入研究。其中 25 例采用 SSF+VP 治疗（SSF+VP 组），23 例采用 SSF+BG 治疗（SSF+BG组）。两组患者性别、年龄、病程、骨密度、骨折节段以及术前疼痛视觉模拟评分（VAS）、功能障碍指数（ODI）以及后凸 Cobb 角比较，差异均无统计学意义（P>0.05），具有可比性。记录两组手术时间以及手术相关并发症发生情况；采用 VAS、ODI 评分以及后凸Cobb角评价手术疗效。
结果
SSF+VP组手术时间为（107.7±18.8）min，SSF+BG组为（113.7±22.4）min，两组比较差异无统计学意义（t=–1.045，P=0.302）。术中SSF+VP组 6 例出现骨水泥渗漏，术后 SSF+BG 组 1 例切口延迟愈合。X 线片复查示，两组植骨均融合，SSF+VP组植骨融合时间为（15.1±1.3）周，SSF+BG组为（15.7±1.8）周，比较差异无统计学意义（t=–1.361，P=0.180）。两组术后即刻及末次随访时 VAS、ODI 评分以及 Cobb 角均显著低于术前（P<0.05）。SSF+VP 组术后即刻及末次随访时以上指标比较，差异均无统计学意义（P>0.05）；而 SSF+BG 组末次随访时 VAS 评分显著低于术后即刻（P<0.05）；Cobb 角、ODI 评分与术后即刻比较，差异无统计学意义（P>0.05）。术后即刻 SSF+VP 组 VAS 评分优于 SSF+BG 组（P<0.05），但末次随访时 SSF+BG 组明显优于 SSF+VP 组（P<0.05）；术后即刻及末次随访时两组间 Cobb 角、ODI 评分比较，差异均无统计学意义（P>0.05）。
结论
与 SSF+VP 相比，SSF+BG 治疗不稳定型 Kümmell 病术后骨折椎体可达骨性愈合，疼痛改善明显，并发症较少，疗效更满意。
Keywords: Kümmell病, 短节段固定, 椎体成形术, 植骨
Abstract
Objective
To compare the effectiveness between short segmental fixation combined with vertebroplasty (SSF+VP) and short segmental pedicle screw fixation combined with bone graft (SSF+BG) in the treatment of unstable type Kümmell’s disease so as to provide a reference for the selection of the surgical method.
Methods
Between March 2013 and February 2015, 48 patients with unstable type Kümmell’s disease who were in accordance with the inclusive criteria were included in the study. SSF+VP were used in 25 cases (SSF+VP group) and SSF+BG in 23 cases (SSF+BG group). There was no significant difference in gender, age, disease duration, bone mineral density, fracture segment, and preoperative visual analogue scale (VAS), Oswestry disability index (ODI), and kyphotic Cobb angle between 2 groups (P>0.05). The operation time and complications related to operation were recorded; the effectiveness was evaluated by VAS, ODI, and kyphotic Cobb angle.
Results
The operation time was (107.7±18.8) minutes in SSF+VP group and was (113.7±22.4) minutes in SSF+BG group, showing no significant difference between 2 groups (t=–1.045,P=0.302). Bone cement leakage occurred in 6 cases of SSF+VP group, and incision delayed healing occurred in 1 case of SSF+BG group. All patients achieved bone graft fusion on X-ray films. The bone graft fusion time was (15.1±1.3) weeks in SSF+VP group and (15.7±1.8) weeks in SSF+BG group, showing no significant difference between 2 groups (t=–1.361,P=0.180). The VAS, ODI, and kyphotic Cobb angle at immediate after operation and at last follow-up were significantly lower than preoperative ones (P<0.05). The VAS, ODI, and kyphotic Cobb angle had no significant difference between at immediate and at last follow-up in SSF+VP group (P>0.05). In SSF+BG group, VAS at last follow-up was significantly lower than that at immediate after operation (P<0.05), but no significant difference was found in kyphotic Cobb angle and ODI (P>0.05). SSF+VP group was significantly better than SSF+BG group in VAS at immediate after operation (P<0.05), but SSF+BG group was significantly better than SSF+VP group at last follow-up (P<0.05). There was no significant difference in kyphotic Cobb angle and ODI between 2 groups at immediate after operation and at last follow-up (P>0.05).
Conclusion
SSF+BG can achieve satisfactory effectiveness in the treatment of unstable type Kümmell’s disease, and it has the advantages of good bony healing, obvious improvement of pain, and low complication incidence when compared with SSF+VP.
Keywords: Kümmell’s disease, short segmental fixation, vertebroplasty, bone graft
Kümmell 病是骨质疏松椎体压缩性骨折的常见并发症之一，患者多于轻微外伤后出现腰背部疼痛，数周或数月后疼痛消失，但数月或数年后疼痛再次发作且加重，并伴有脊柱后凸畸形等临床表现。根据病理和临床特点，Kümmell 病又被称为延迟性椎体塌陷、椎体骨折骨不愈合、椎体骨坏死以及椎体假关节等[1-3]。目前，短节段钉棒固定联合伤椎椎体成形（short segmental pedicle screw fixation combined with vertebroplasty，SSF+VP）、短节段钉棒固定联合伤椎植骨（short segmental pedicle screw fixation combined with bone graft，SSF+BG）均可用于治疗不稳定型Kümmell病[4-7]，但有关两种治疗方法疗效差异以及使用范围的比较研究较少。为此，我们回顾分析 2013 年 3 月—2015 年 2 月采用上述两种方法治疗的患者临床资料，比较两种方法疗效，以期为临床选择治疗方法提供参考。报告如下。
1. 临床资料
1.1. 患者选择标准
纳入标准：① 术前经 X 线片确诊为不稳定型 Kümmell 病患者。② 患者均有轻微外伤后腰背部疼痛史，疼痛缓解 3 个月以上再次出现并加重。③ 骨密度检查 T 值≤–2.5；④ 胸腰椎正侧位 X 线片可见骨折椎体内裂隙影像，过伸过屈位显示椎体不稳定；CT 可见骨折椎体内低信号影。排除标准：① 患有严重内科疾病、不能耐受手术者；② 确诊为肿瘤或感染者；③ 随访期间发生其他创伤致伤椎再骨折或相邻节段椎体骨折者；④ 临床资料不完整者；⑤ 随访期间死亡者。
2013 年 3 月—2015 年 2 月，共 48 例患者符合选择标准纳入研究。其中 25 例采用 SSF+VP 治疗（SSF+VP组），23 例采用 SSF+BG 治疗（SSF+BG 组）。
1.2. 一般资料
SSF+VP 组：男 5 例，女 20 例；年龄 60～84 岁，平均 71.4 岁。病程 14～51 周，平均 19.6 周。腰椎骨密度 T 值为–2.9 ± 0.2。骨折节段：T10 1 例，T11 3 例，T12 11例，L1 8例，L3 2 例。
SSF+BG 组：男 3 例，女 20 例；年龄57～79岁，平均 68.2岁。病程 15～63 周，平均 21.5 周。腰椎骨密度 T 值–2.8±0.3。骨折节段：T11 2 例，T12 9 例，L1 9例，L2 3 例。
两组患者性别、年龄、病程、骨密度、骨折节段以及术前疼痛视觉模拟评分（VAS）、功能障碍指数（ODI）以及后凸 Cobb 角比较，差异均无统计学意义（P>0.05），具有可比性。见表 1-3。
1.3. 手术方法
两组患者手术均由同一组医师完成。
SSF+VP 组：全麻下，患者取俯卧位，胸下及骨盆处各放置一靠垫使腹部悬空，降低腹腔压力，减少术中出血和促进骨折过伸椎体复位。取后侧正中切口，暴露伤椎相邻上、下各 1 个椎体，并于伤椎相邻上、下椎体采用专用通道经椎弓根注入骨水泥后植入 4 枚螺钉，选取合适长度连接棒预弯后撑开，达伤椎满意复位后拧紧螺母。穿刺针经伤椎双侧椎弓根穿刺，依次放入穿刺针及工作通道，C 臂 X 线机透视下注入骨水泥，直至骨水泥钉道强化及填充满意。取同种异体骨（湖北联结生物材料有限公司）进行后外侧融合。
SSF+BG 组：患者麻醉、体位、手术入路以及骨折复位方法与 SSF+VP 组一致。伤椎复位满意后，于伤椎相邻上、下椎体椎弓根植入 4 枚螺钉，然后使用不同型号锥子建立伤椎椎弓根通道，使用长柄磨钻磨除硬化带以及刮匙刮除硬化骨坏死组织，使骨面新鲜化。然后取一侧髂骨联合同种异体骨（湖北联结生物材料有限公司）植入伤椎椎体并打压，使植入骨与骨折面紧密接触。C 臂 X 线机透视满意后，于伤椎经椎弓根植入螺钉。使用自体髂骨联合同种异体骨（来源同前）进行后外侧融合。
1.4. 术后处理
术后 2～4 d 患者在腰背部支具保护下下床活动，术后 1 个月开始床上腰背部肌肉锻炼，术后 3 个月去除腰背部支具。术后长期行抗骨质疏松治疗。
1.5. 疗效评价指标
记录两组手术时间，观察术中及术后手术相关并发症发生情况。采用 VAS 评分评价疼痛改善情况，ODI 评价功能改善情况[8]；摄侧位 X 线片测量后凸 Cobb 角评价脊椎后凸程度，Cobb 角为上一椎体下软骨终板与伤椎下软骨终板夹角。
1.6. 统计学方法
采用 SPSS17.0 统计软件进行分析。计量资料以均数±标准差表示，组间比较采用独立样本 t 检验；组内各时间点间比较采用重复测量方差分析，两两比较采用配对 t 检验；计数资料组间比较采用χ2检验；检验水准 α=0.05。
2. 结果
两组患者均顺利完成手术。SSF+VP 组手术时间为（107.7±18.8）min，SSF+BG 组为（113.7±22.4）min，比较差异无统计学意义（t=–1.045，P=0.302）。
术中 SSF+VP 组 6 例出现骨水泥渗漏，其中骨水泥相邻椎间盘渗漏 3 例，椎旁渗漏 2 例，椎体前方渗漏 1 例，但术后患者均无明显不适症状；随访期间患者均未出现骨水泥碎裂及移位。术后 SSF+BG 组 1 例切口延迟愈合，渗出物细菌培养未见感染，经定期换药后愈合。其余患者切口均Ⅰ期愈合。X 线片复查示，两组植骨均融合，SSF+VP 组植骨融合时间为（15.1±1.3）周，SSF+BG 组为（15.7±1.8）周，比较差异无统计学意义（t=–1.361，P=0.180）。见图 1、2。
图 1.
A 77-year-old female patient with Kümmell’s disease at L1 in SSF+VP group a. Lateral X-ray film before operation; b. Sagittal CT before operation; c. MRI before operation; d. Lateral X-ray film at immediate after operation; e. Lateral X-ray film at 18 months after operation; f. Sagittal CT at 18 months after operation
SSF+VP 组患者，女，77 岁，L1 椎体 Kümmell 病 a. 术前侧位 X 线片； b. 术前矢状位 CT； c. 术前 MRI； d. 术后即刻侧位 X 线片； e. 术后 18 个月侧位 X 线片； f. 术后 18 个月矢状位 CT
图 2.
A 64-year-old male patient with Kümmell’s disease at T12 in SSF+BG group a. Lateral X-ray film before operation; b. Sagittal CT before operation; c. MRI before operation; d. Lateral X-ray film at immediate after operation; e. Lateral X-ray film at 24 months after operation; f. Sagittal CT at 24 months after operation
SSF+BG 组患者，男，64 岁，T12 椎体 Kümmell 病 a. 术前侧位 X 线片； b. 术前矢状位 CT； c. 术前 MRI； d. 术后即刻侧位 X 线片； e. 术后 24 个月侧位 X 线片； f. 术后 24 个月矢状位 CT
两组患者术后疼痛、功能及脊椎后凸程度均改善明显，术后即刻及末次随访时 VAS 评分、ODI 评分、Cobb 角均显著低于术前，比较差异有统计学意义（P<0.05）。SSF+VP 组术后即刻及末次随访时以上指标比较，差异均无统计学意义（P>0.05）。而 SSF+BG 组末次随访时VAS评分显著低于术后即刻，差异有统计学意义（P<0.05）；末次随访时 Cobb角、ODI评分与术后即刻比较，差异无统计学意义（P>0.05）。术后即刻 SSF+VP 组 VAS 评分优于 SSF+BG 组（P<0.05），但末次随访时SSF+BG组明显优于SSF+VP组（P<0.05）；术后即刻及末次随访时两组间 Cobb 角、ODI 评分比较，差异均无统计学意义（P>0.05）。见表 1～3。
表 1.
Comparison of the VAS between 2 groups at pre- and post-operation （
）
手术前后两组VAS评分比较（
）
| 组别
Group |
例数
n |
术前
Preoperative |
术后即刻
Immediately after operation |
末次随访
Last follow-up |
统计值
Statistic |
|
*与术前比较P<0.05，#与术后即刻比较，P<0.05
* Compared with preoperative value, P<0.05;# compared with the value at immediate postoperatively, P<0.05 | |||||
| SSF+VP | 25 | 7.8±1.3# | 2.4±0.8* | 3.1±1.3* | F=952.945，P=0.000 |
| SSF+BG | 23 | 8.4±1.4# | 4.1±1.2* | 1.8±0.9*# | F=709.944，P=0.000 |
| 统计值
Statistic |
t=–1.747
P= 0.087 |
t=–5.701
P= 0.000 |
t=4.008
P=0.000 |
||
表 3.
Comparison of the kyphotic Cobb angle between 2 groups at pre- and post-operation（°，
）
手术前后两组后凸Cobb角比较（°，
）
| 组别
Group |
例数
n |
术前
Preoperative |
术后即刻
Immediately after operation |
末次随访
Last follow-up |
统计值
Statistic |
|
*与术前比较P<0.05，#与术后即刻比较，P<0.05
* Compared with preoperative value, P<0.05;# compared with the value at immediate postoperatively, P<0.05 | |||||
| SSF+VP | 25 | 30.7±8.8# | 10.4±4.6* | 12.3±3.4* | F=351.260，P=0.000 |
| SSF+BG | 23 | 27.8±6.9# | 9.7±4.3* | 11.2±3.7* | F=361.288，P=0.000 |
| 统计值
Statistic |
t=1.265
P=0.212 |
t=0.579
P=0.565 |
t=1.075
P=0.288 |
||
表 2.
Comparison of the ODI between 2 groups at pre- and post-operation（
）
手术前后两组ODI评分比较（
）
| 组别
Group |
例数
n |
术前
Preoperative |
术后即刻
Immediately after operation |
末次随访
Last follow-up |
统计值
Statistic |
|
*与术前比较 P<0.05，#与术后即刻比较 P<0.05
* Compared with preoperative value, P<0.05;# compared with the value at immediate postoperatively, P<0.05 | |||||
| SSF+VP | 25 | 85.2±6.9# | 32.4±4.7* | 33.8±4.8* | F=4675.036，P=0.000 |
| SSF+BG | 23 | 87.5±5.9# | 34.3±5.1* | 32.6±4.6* | F=3893.317，P=0.000 |
| 统计值
Statistic |
t=–1.252
P= 0.217 |
t=–1.363
P= 0.186 |
t=0.852
P=0.400 |
||
3. 讨论
Kümmell 病是以伤椎内裂隙征为特征，CT 可见伤椎内低信号空腔裂隙[9]，裂隙内可为气体或液体。伤椎在过伸过屈位X线片上可看作假关节，因椎体不稳导致患者腰背部疼痛[10-11]。1978 年 Maldague 等[12]通过对 10 例 Kümmell 病患者病灶组织进行组织学检查，发现裂隙内大多为无血管的骨质、纤维组织和脂肪组织，并首次提出了骨折椎体内裂隙与局部骨组织缺血有关。Kim等[13]及Malghem等[14]研究表明，Kümmell 病患者受轻微外伤后致椎体内微血管损伤及生物力学破坏，从而出现伤椎不稳，影响骨质修复和愈合，进而导致缺血性骨坏死。
Kümmell 病的治疗旨在稳定脊柱、减轻患者疼痛[15-18]，该病保守治疗无效，需要手术治疗。不稳定型 Kümmell 病相当于 Li 等[4]提出的Ⅱ期，即椎体高度丢失＞20%，伴邻近椎间盘退变，骨折不稳定，伴或不伴神经症状的腰痛。对于不稳定型 Kümmell 病的治疗一直存在争议。既往多采用单纯后路椎体成形术，术后易出现后凸角丢失及腰背部疼痛症状加重等表现[19-20]。本研究结果显示，针对不稳定型患者，SSF+VP 和 SSF+BG 经后路固定均可达到稳定椎体、缓解疼痛的目的，两组术后即刻 VAS 评分、ODI、后凸 Cobb 角均较术前明显改善（P<0.05）。术后即刻及末次随访时，两组 Cobb 角、ODI 比较差异无统计学意义（P>0.05）。术后即刻 SSF+BG 组患者腰背部疼痛改善程度低于 SSF+VP 组，分析原因为 SSF+VP 术中植入的骨水泥可消除椎间微动，在短期内即可有效缓解疼痛。但骨水泥不具有生物活性，本身不能被新生骨组织取代，不能达到骨性愈合；此外骨水泥存在放热和毒效应两大缺点，植入后可直接对周围骨性结构和周围神经造成损害。因此，SSF+VP 术后远期存在后凸 Cobb 角进一步增大，患者生活质量下降风险，但本研究随访时间较短，该结果尚有待进一步观察。末次随访时 SSF+BG 组 VAS 评分优于SSF+VP组，差异有统计学意义（P<0.05），提示 SSF+BG 治疗后远期疼痛缓解程度更理想。
SSF+BG 术中通过磨除伤椎硬化带、刮除硬化骨坏死组织，使骨面新鲜化，将自体髂骨和同种异体骨混合植入新鲜化椎体内，促进了骨折愈合。术后 SSF+BG 组患者骨折椎体均达骨性融合，随访期间无伤椎再塌陷发生。虽然术中取自体骨植骨及对伤椎硬化灶进行清理，手术时间可能会延长，但本研究中两组手术时间比较差异无统计学意义（P>0.05）。并发症方面，SSF+VP 组术中 6 例发生骨水泥渗漏，而 SSF+BG 组仅 1 例出现切口延迟愈合，提示 SSF+BG 组手术并发症较少，且有效避免了骨水泥渗漏风险。综上述，我们认为 SSF+BG 是治疗不稳定型 Kümmell 病的首选术式。
References
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