Chinese Journal of Tissue Engineering Research ›› 2022, Vol. 26 ›› Issue (22): 3598-3601.doi: 10.12307/2022.291
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Yang Liu1, Du Jianwei2
Received:
2021-03-03
Revised:
2021-04-10
Accepted:
2021-06-12
Online:
2022-08-08
Published:
2022-01-13
Contact:
Du Jianwei, MD, Master’s supervisor, Associate chief physician, Affiliated Hospital of Yangzhou University, Yangzhou 225000, Jiangsu Province, China
About author:
Yang Liu, Master candidate, Dalian Medical University, Dalian 116041, Liaoning Province, China
CLC Number:
Yang Liu, Du Jianwei. Measures to reduce the leakage rate of bone cement during vertebral augmentation[J]. Chinese Journal of Tissue Engineering Research, 2022, 26(22): 3598-3601.
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2.1 骨质疏松性椎体压缩骨折与椎体增强手术 骨质疏松性椎体压缩骨折是目前脊柱外科的一种常见病,有保守治疗与手术治疗可以选择。保守治疗的方法包括物理制动、卧床休息、服用非类固醇类抗炎镇痛药及阿片类药物对症止痛,但效果不是很理想,甚至会加重患者病情[3]。例如保守治疗时,患者卧床时间长,其骨质疏松的情况会更加严重,长期卧床限制了患者的生活起居,会加重疼痛,还易引起卧床并发症如肺炎、静脉血栓等,长期的卧床导致运动量的减少,进一步导致骨量丢失、骨强度下降,造成再骨折反复发生,从而陷入恶性循环[4]。采取手术的方式尽管有相当的危害,但是这种方式可以显著缓解患者因疾病造成的痛苦,目前治疗这一疾病方法包括经皮椎体成形术和后凸成形,椎体后凸成形是以经皮椎体后成形的发展为基石演变而来的。自从20世纪80年代经皮椎体成形被首次提出以来,一直被广泛用于骨质疏松性椎体压缩骨折的手术治疗[5]。椎体增强手术是一项脊柱微创技术,对于患者术后功能的恢复有很大益处,然而随着这一技术的普遍应用,一些问题也变得越发明显,最典型的就是骨水泥渗漏的问题。虽然大部分骨水泥渗漏都没有很明显的临床表现,但是在进行椎体成形注射骨水泥时还是需要小心,因为一旦骨水泥渗漏入椎管里,那么后果将是不可估量的,可能会产生一系列神经脊髓受压的临床表现[6],例如感觉运动等功能的丧失。相对于保守治疗和开放手术,选择微创的椎体增强手术患者预后情况要更好,但是不同的椎体增强手术之间差异巨大,骨水泥渗漏率是比较不同椎体增强手术的一个焦点。 2.2 不同术式对骨水泥渗漏的影响 传统椎体增强手术包括经皮椎体成形与经皮椎体后凸成形,是目前治疗骨质疏松性椎体压缩骨折的常用方法,它能立即缓解患者疼痛的症状,并且远期效果优异[7-9]。经皮椎体成形是通过椎弓根直接向患椎体注入骨水泥,具有手术时间短、患者症状改善快、费用低等优势,但是对于恢复椎体高度方面效果不明显。而椎体后凸成形则是通过患者背部皮肤,经椎弓根与椎体建立通道,通过该通道向球囊内注入对比剂致球囊扩张使椎体恢复解剖形态,再注入骨水泥使椎体稳定,可以恢复脊柱的生理弧度和椎体高度,增加椎体强度[10-11],患椎愈合效果好,但是费用较高、手术时间长。对于两者的比较也一直存在,术后骨水泥渗漏情况是比较它们的重点。2006年TAYLOR等[12]的研究中表明,经皮椎体成形术中的骨水泥漏出率大约为40%,而椎体后凸球囊扩张成形术中的骨水泥漏出率仅为8%,椎体后凸球囊扩张成形的骨水泥漏出率要比经皮椎体成形要低,这一结论与LAREDO等[13]得出的结果相似。SEMAAN 等[14]针对这一研究差异做了一项回顾性分析,通过纳入316例患有椎体压缩性骨折患者的411例椎体,分析了采用经皮椎体成形与椎体后凸成形治疗患者的骨水泥渗漏情况和术后临床结果,可以得出与TAYLOR等相同的结论;但是二者术后的临床结果反馈并无明显差异,经皮椎体成形与经皮椎体后凸成形在原理上没有明显差异,但是现在临床上用的比较多的还是经皮椎体后凸成形,这也与其术后骨水泥渗漏率低、能恢复压缩椎体高度的原因有关。甚至还有研究学者认为椎体后凸成形可以作为经皮椎体成形手术失败的补救手术[15]。除了上述椎体后凸成形的一些优点外,它还存在一些缺陷。KIM 等[16]进行的生物力学研究发现,因为椎体后凸成形要用球囊撑开椎体,而撑开的球囊会破坏椎体内部分松质骨,影响骨水泥向椎体四周弥散,骨水泥不能与上下终板接触,会形成一段空隙,这也会使椎体发生二次压缩骨折,影响临床预后。相比之下,当选择椎体成形治疗时骨水泥更容易通过骨小梁间隙弥散到非骨折区域和上下终板,这将使骨折椎体获得更大范围的支撑,界面强度也明显提高,这也是经皮椎体成形手术骨水泥容易发生渗漏的原因。但是由于这两种传统术式骨水泥渗漏情况严重,使骨水泥渗漏成为了椎体增强手术的讨论焦点[17-18]。研究人员提出了一种新的手术方式,即囊袋椎体成形,这种技术具有良好降低骨水泥渗漏率的作用,其可以凭借网袋的约束作用限制骨水泥的流动,减少骨水泥渗漏[19-20]。以此可以看出最新的囊袋椎体成形能有效降低骨水泥渗漏率,但是由于手术成本与技术原因无法全面开展,因此从骨水泥自身因素上做文章也是一条可行的途径。 2.3 骨水泥自身因素对骨水泥渗漏的影响 除了手术方法的选择会对骨水泥渗漏产生影响,骨水泥自身因素也会对其渗漏产生影响,自身因素可能包括骨水泥的黏度、注射速度、注入剂量及骨水泥类型等。黏度是液体流动能力的最具指示性的参数,是聚甲基丙烯酸甲酯骨水泥的主要特征参数之 一[21]。此外,黏度还会影响骨水泥在椎体中的空间分布,当黏度不足时可能会改变椎体之间压力的传递模式,从而诱发相邻椎体骨折[22]。CHEN等[23]对840例患有骨质疏松性胸腰椎压缩性骨折患者进行回顾性分析,最后得出高黏度骨水泥相对于低黏度骨水泥在椎体成形术后的渗漏率更低,临床效果和预后更好。骨水泥注射剂量与速度对于术后骨水泥渗漏也有一定的影响。姚海燕等[24]临床试验得出,成人腰椎压缩性骨折术中注入骨水泥的有用剂量为1.5-5 mL,过少的骨水泥手术效果不好,过多的骨水泥渗漏风险显著增加。骨水泥的类型很多,目前临床上应用的有聚甲基丙烯酸甲酯、磷酸钙和复合骨水泥,但是使用最多的还是聚甲基丙烯酸甲酯[25],因为它具有性能好、有效时间长、成本低的优点。骨水泥自身因素对骨水泥渗漏的影响十分大,选择合适的骨水泥材料是基础,应用相应的填充技术也同样重要,降低骨水泥渗漏率需要双管齐下,从而达到满意的临床效果。 2.4 椎体压缩骨折术中骨水泥渗漏的类型 椎体成形术后临床医生最担心的事情,除了感染就是骨水泥渗漏了。SARACEN等[26]通过研究616例患者1 100个压缩性骨折椎体来分析术后骨水泥漏的类型与特点,结果表明骨质疏松骨折患者术后骨水泥漏的发生率最高,为50.2%,而这些骨水泥渗漏又分为4种类型,分别是椎旁静脉漏、椎旁软组织漏、椎管漏和椎间盘漏,其中椎旁软组织漏的发生率最高,为25.7%,发生椎管内骨水泥漏出的结果最严重,会压迫脊髓而产生一系列神经系症状。当然除了这些相对常见的渗漏类型,还有一些比较少见的病例,MICHAEL等[27]就发现了一种少见的椎体压缩性骨折术后骨水泥渗漏病例类型,即硬膜内骨水泥渗漏。硬膜内骨水泥渗漏很少,文献中很少有硬膜内骨水泥渗漏的报道,急诊手术报道不到1%[28]。据报道,38%-72.5%的病理性骨折和30%-65%的骨质疏松性骨折患者,在接受椎体增强手术医治后会出现骨水泥肺栓塞的情况[28-29]。下腔静脉骨水泥栓塞的情况也被报道过[16]。骨水泥渗漏到不同部位可能会引起不同的临床表现,例如骨水泥漏入大血管或椎管内引起脊髓压迫、神经损伤、血管热损伤和肺栓塞等严重并发症[30]。对于大多数骨水泥渗漏来说,产生不适的临床表现的比例很低,对于漏入椎旁软组织或者椎旁静脉的骨水泥漏,一般不会引起临床症状[31]。还有学者将骨水泥渗漏分为两种类型,即皮质型和静脉型,TANG等[32]通过1 090例患者来研究这两种类型骨水泥漏的危险因素,最后得出高龄、创伤是皮质型骨水泥渗漏的最高危险因素,女性则是静脉型骨水泥渗漏的最高危险因素。 2.5 目前应对骨水泥渗漏的一些措施 对于预防术后骨水泥渗漏可以早期干预,通过在骨水泥自身因素上做文章来减少骨水泥渗漏率。有研究发现,通过提高骨水泥固-液质量比可以明显提高骨水泥抗压强度和减少骨水泥凝固时间[33]。近年来有学者提出了经皮弯角椎体成形的概念并予以实施手术,最后结果证明对于降低骨水泥渗漏有较好的效果[34],这一手术方式的优点是利用弯角套管单侧穿刺使骨水泥能双侧均匀分布,相对于传统双侧穿刺的手术具有手术时间短、骨水泥渗漏率低、手术创口小等优点[35]。同济大学附属同济医院采用了聚醚醚酮骨水泥输送导管和记忆合金内芯相结合的装置,仅通过行单侧椎弓根穿刺就能够在椎体的穿刺侧、椎体中央和对侧进行多点骨水泥注射,改善骨水泥分布,从而实现双侧穿刺的手术效果[36],这一方法能够有效降低骨水泥渗漏率。钟远鸣等[37]经过Meta分析得出和单侧椎弓根入路椎体成形相比,弯角椎体成形具有骨水泥渗漏率低、止痛效果明显、骨水泥于椎体中心总分布率高等优势。还有研究发现,骨水泥在椎体内散布的形态也会对骨水泥渗漏产生影响,“H”型散布相较于“O”型分布来说骨水泥渗漏率会降低,术后邻近椎体骨折的发生率也会降低[38-39]。骨水泥注入剂量对于骨水泥渗漏也有影响,注入骨水泥剂量过多会增加骨水泥渗漏风险。孙海波等[40]研究发现,在经皮椎体成形术中注入低剂量骨水泥也可以缓解疼痛,有比较好的临床预后,还可以显著减少手术时间、降低骨水泥渗漏的风险。还有学者提出,使用骨折的内复位方法联合骨水泥强化可以使塌陷的椎体高度得到有效恢复的固定,这对减少骨水泥渗漏能起到有效作用。VERLAAN 等[41]对20例胸腰椎骨折患者在椎弓根钉的基础上应用球囊扩张技术辅助复位塌陷椎体,随后注入骨水泥强化椎体,从术后6年的随访中得出球囊辅助复位联合骨水泥强化可以更好地治疗椎体压缩骨折,并且患者满意度较高。针对这一结论,DE GENDT等[42]进行了长达13年的随访研究,得出椎弓根螺钉球囊辅助终板复位加骨水泥强化是一种安全、可行、有效的方法。"
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