经皮椎体成形和经皮椎体后凸成形治疗中的骨水泥渗漏

doi:10.3969/j.issn.2095-4344.2012.51.027

摘要/Abstract

摘要：

背景：经皮椎体成形和经皮椎体后凸成形是近年来微创脊柱外科常用的技术，随着其临床应用越来越多，主要并发症骨水泥渗漏也越来越多地见于临床报道。
目的：综述经皮椎体成形和经皮椎体后凸成形治疗中骨水泥渗漏的研究进展。
方法：由第一作者检索2000至2011年 PubMed数据及万方数据库有关经皮椎体后凸成形和经皮椎体成形治疗骨水泥渗漏的分类、相关危险因素、对机体的影响、防治等方面的文献。
结果与结论：经皮椎体后凸成形治疗的骨水泥渗漏率低于经皮椎体成形治疗。注射少量骨水泥即可恢复压缩椎体的刚度，一般腰椎注射4-6 mL，胸椎可适当加大剂量。术者需准确把握骨水泥的注射时机，注入调制后时间>10 min的骨水泥，骨水泥呈面团状，渗漏率低。椎体周壁破损时行两种治疗发生骨水泥渗漏的概率增大。两者骨水泥渗漏引起肺栓塞的概率较低，但一旦发生，后果严重，对心血管系统也有一定影响，因此，需严格掌握手术适应证，正确选择进针点和穿刺入路，严格把握骨水泥的注射时机和剂量，以精确的术中操作和优质的术中监测将骨水泥渗漏风险降至最低。

Abstract:

BACKGROUND: Percutaneous vertebroplasty and percutaneous kyphoplasty are commonly used in minimally invasive spine surgery in recent years. However, with the clinical development, bone cement leakage that is the main complication of percutaneous vertebroplasty and percutaneous kyphoplasty is also increasingly found in clinical reports.
OBJECTIVE: To review the research progress in bone cement leakage during percutaneous vertebroplasty and percutaneous kyphoplasty.
METHODS: The articles (2000/2011) about classification, related risk factors, the influence on the body, prevention and cure related to bone cement leakage during percutaneous vertebroplasty and percutaneous kyphoplasty were retrieved by the first author in the PubMed and Wanfang databases.
RESULTS AND CONCLUSION: Percutaneous kyphoplasty has a lower rate of bone cement leakage compared with percutaneous vertebroplasty. A small dosage of bone cement injection can restore the stiffness of the compressed vertebral. For the lumbar vertebra, 4 to 6 mL bone cement is enough. The injection dose can be increased for the thoracic vertebrae. Surgeons need to grasp the opportunity of bone cement injection. When we inject the bone cement over 10 minutes after modulation, the leakage rate of bone cement is low. When the vertebral wall is incomplete, the cement leakage rate is increased in the percutaneous vertebroplasty and percutaneous kyphoplasty. The chance of pulmonary embolism caused by bone cement leakage during percutaneous vertebroplasty and percutaneous kyphoplasty is low. But if it happens, it could lead to serious consequences, and also has certain effects on the cardiovascular system. Therefore, we must grasp the operation indication strictly, and choose the right entry point and the puncture path. We should control the dosage of bone cement and the injection timing correctly by precise operation and high-quality intraoperative monitoring to minimize the risk of bone cement leakage.

姚晓光，张文武，刘连涛，马树伟，申勇. 经皮椎体成形和经皮椎体后凸成形治疗中的骨水泥渗漏[J]. 中国组织工程研究, 2012, 16(51): 9645-9649.

Yao Xiao-guang, Zhang Wen-wu, Liu Lian-tao, Ma Shu-wei, Shen Yong. Bone cement leakage during percutaneous vertebroplasty and percutaneous kyphoplasty [J]. Chinese Journal of Tissue Engineering Research, 2012, 16(51): 9645-9649.

参考文献

引言

材料方法

讨论

文章快阅

延伸阅读

骨水泥渗漏是经皮椎体成形和经皮椎体后凸成形治疗难以逾越的难题，一直是临床医生的讨论热点，对于如何有效预防骨水泥渗漏，应该注意一下几点:经皮椎体成形和经皮椎体后凸成形治疗均属于微创技术，拥有一台透视影像清晰的C型X射线机以及选择能使骨水泥拥有满意X射线呈影能力的助影剂是非常必要的，高质量的影像学监视是防止渗漏的关键。如果术中发现骨水泥已经渗漏，应立即停止注射。如非椎体后方渗漏，可观察30 s，待先期注入的骨水泥进一步聚合固化并封堵渗漏口时再试行注射或就此终止手术。另外，影像导向系统应用于经皮椎体后凸成形治疗将被普及，以使操作更安全精确；术前借助CT和MRI明确伤椎周壁破坏情况以及骨折的新鲜程度，严格掌握手术适应证；正确选择进针点和穿刺入路，在经皮椎体成形和经皮椎体后凸成形治疗时采用椎弓根入路可以延长骨水泥到椎骨外的骨性通道，减少骨水泥渗漏的风险。在进针过程中尽量减少穿刺针的晃动以减小穿刺针与周围骨质间隙，同时反复进行正侧为透视，避免穿破椎弓根，防止骨水泥渗漏；严格把握骨水泥的注射时机和剂量，过稀的骨水泥注入会增加渗漏机会，过硬则不易注入。骨水泥的集合时相分为湿砂期、拉丝期、面团期和硬化期4个阶段，注射应在拉丝期甚至拉丝后期比较合适。在骨水泥的注射计量上，如果能达到较为满意的临床效果时不应过分强调将整个椎体填满在，以尽可能减少骨水泥渗漏；椎体前壁破损采用骨水泥分次灌注治疗，椎体后壁及侧壁破损采用全程动态C型臂X射线监视灌注过程能有效防止骨水泥渗漏；在完成椎体骨水泥灌注后不宜急于拔出工作套管，可适当旋转套管，在骨水泥完全固化后再把套管从椎弓根内拔出可有效避免骨水泥沿椎弓根穿刺针道渗漏；Bhatia 等研究发现术前向椎体静脉内注射明胶海绵；用生物材料制作的气囊可不必取出，避免渗漏，可以有效降低骨水泥静脉渗漏的风险。