骨质疏松性椎体压缩骨折经皮椎体强化术后并发残余腰背痛的危险因素.pdf

J Clin Pathol Res2023,43(7)http:/ 临床与病理杂志骨质疏松性椎体压缩骨折经皮椎体强化术后并发残余腰背痛的危险因素苏晓慧，芮晶晶，陈文月，秦晓冬（南京大学医学院附属鼓楼医院骨科，南京 210000）摘要 目的：探讨骨质疏松性椎体压缩骨折经皮椎体强化术后并发残余腰背痛的危险因素。方法：回顾性分析南京大学医学院附属鼓楼医院2020年6月至2022年6月收治的骨质疏松性椎体压缩骨折患者150例，采集患者临床资料，并采用视觉模拟评分法(Visual Analogue Scale，VAS)评估术后1 d、1周、1个月、3个月及6个月的腰背疼痛感，任意一次VAS评分4判定为术后残余腰背痛，将30例发生术后残余腰背痛者纳入残余痛组，将120例未发生术后残余腰背痛者纳入无残余痛组。对术后并发残余腰背痛的危险因素进行单因素、多因素logistic回归分析。结果：残余痛组术后1 d、1周、1个月、3个月VAS评分均高于无残余痛组(均P0.05)；单因素分析显示：残余痛组体重指数、骨密度、术后椎体高度恢复率、术后Cobb角改善率、有无腰背筋膜损伤、有无腰背痛史、有无邻椎骨折与无残余痛组比较，差异均有统计学意义(均P0.05)；多因素logistic回归分析显示：体重指数、骨密度、术后椎体高度恢复率、术后Cobb角改善率、腰背筋膜损伤、邻椎骨折最终进入回归方程(均P0.05)。结论：体重指数、骨密度、术后椎体高度恢复率、术后Cobb角改善率、腰背筋膜损伤、邻椎骨折是经皮椎体强化术后并发残余腰背痛的独立危险因素，临床应及时采取预防性措施，降低术后残余腰背痛的发生率。关键词 骨质疏松性椎体压缩骨折；经皮椎体强化术；残余腰背痛；危险因素Risk factors of residual low back pain after percutaneous vertebral augmentation for osteoporotic vertebral compression fracturesSU Xiaohui,RUI Jingjing,CHEN Wenyue,QIN Xiaodong(Department of Orthopedics,Gulou Hospital,School of Medicine,Nanjing University,Nanjing 210000,China)ABSTRACT Objective:To investigate the risk factors of residual low back pain after percutaneous vertebral augmentation for osteoporotic vertebral compression fractures.Methods:A total of 150 patients with osteoporotic vertebral compression fractures DOI：10.11817/j.issn.2095-6959.2023.222768收稿日期(Date of reception)：2022-12-26第一作者(First author)：苏晓慧，Email:suxiaohui_,ORCID:0009-0007-0018-4056通信作者(Corresponding author)：芮晶晶，Email:,ORCID:0009-0008-1737-54621384骨质疏松性椎体压缩骨折经皮椎体强化术后并发残余腰背痛的危险因素 苏晓慧，等admitted to Gulou Hospital,School of Medicine,Nanjing University from June 2020 to June 2022 were retrospectively studied.The clinical data of patients were collected and the visual analogue score(VAS)was obtained.The sense of lumbago and back pain was evaluated 1 d,1 week,1 month,3 months,and 6 months after the operation.Any VAS score4 points was determined as postoperative residual lumbago and back pain.Thirty patients with postoperative residual lumbago and back pain were included in the residual pain group,and 120 patients without postoperative residual lumbago and back pain were included in the non-residual pain group.The risk factors of postoperative residual low back pain were analyzed by univariate and multivariate logistic regression.Results:The VAS scores in the residual pain group were higher than those in the non-residual pain group 1 day,1 week,1 month,and 3 months after operation(all P0.05).Single factor analysis showed that compared with the non-residual pain group,the body mass index,bone mineral density,postoperative vertebral height recovery rate,postoperative Cobb angle improvement rate,whether there was back fascia injury,whether there was a history of back pain,whether there was adjacent vertebral fracture and whether there was residual pain in the residual pain group had significant difference(P0.05).Multiple factor logistic regression analysis showed that the body mass index,bone mineral density,postoperative vertebral height recovery rate,postoperative Cobb angle improvement rate,lumbar back fascia injury,and adjacent vertebral fracture finally entered the regression equation(all P0.05).Conclusion:Body mass index,bone mineral density,postoperative vertebral height recovery rate,postoperative Cobb angle improvement rate,lumbar back fascia injury,and adjacent vertebral fracture are independent risk factors for residual low back pain after percutaneous vertebral augmentation surgery.Preventive measures should be taken in time to reduce the incidence of residual low back pain after surgery.KEY WORDS osteoporotic vertebral compression fracture;percutaneous vertebral augmentation;residual low back pain;risk factors骨质疏松症作为临床常见全身性代谢性骨病，患者的主要临床症状为骨量减少及脆性骨折概率增加1。相关调查2结果表明：中国骨质疏松症患者数在6 000万以上，居于全球首位。骨质疏松性骨折是骨质疏松的严重并发症，约一半以上的骨折部位发生于椎体3。骨质疏松性椎体压缩骨折可造成患者腰背部剧烈疼痛，且限制活动，对其生活质量造成严重影响4。手术是目前治疗此类疾病的重要措施，其中经皮椎体强化术由于其具有创伤小、患者术后疼痛缓解迅速等优点，逐渐被广泛应用于临床。但部分患者在术后仍会发生残余腰背疼痛，因而使患者治疗满意度下降5-6。基于此，本研究对骨质疏松性椎体压缩骨折患者的病历资料进行分析，探究术后发生残余疼痛的危险因素，旨在为临床开展有效预防措施并提高治疗效果提供依据。1 对象与方法 1.1 对象回顾性分析南京大学医学院附属鼓楼医院2020年6月至2022年6月收治的行经皮椎体强化术治疗的骨质疏松性椎体压缩骨折患者150例，其中男63例，女87例，年龄(71.224.28)岁，其中胸椎71例、腰椎79例。纳入标准：年龄6080岁；经CT、MRI检查结合临床症状检查确诊为骨质疏松性椎体压缩骨折；初次行经皮椎体强化术治疗；单个椎体骨折；患者及家属签署同意书。排除标准：既往脊柱手术史；1385临床与病理杂志,2023,43(7)http:/强直性脊柱炎等腰背痛；存在退变性脊柱侧弯；术前CT检查可见椎体压缩程度超过75%，合并神经脊髓症状；合并全身多发伤；合并恶性肿瘤；合并严重心脑血管疾病；合并严重症状性腰椎退变性疾病；存在手术禁忌证；随访期间由于其他原因造成的腰背疼痛；无法配合定期随访。本研究经南京大学医学院附属鼓楼医院医学伦理委员会批准通过(审批号：2020LC2523)。1.2 方法所有患者均由医师采用经皮椎体强化治疗，患者取俯卧位，病变椎体以C型臂X线机进行定位，局麻后于病变椎体两侧椎弓根体表投影区作切口，长度为4 mm左右，经双侧椎弓根投影外上侧缘穿刺入路，经皮穿刺并沿椎弓根至患椎，进针至椎体后缘，再调整C型臂致使正、侧位像穿刺针尖分别位于中线及椎体前1/3处。对椎体骨皮破损明显，且在经济条件许可下可用球囊扩张，辅助塌陷的椎体复位；对经济条件不许可者待骨水泥进入“拉丝期”后将骨水泥注入患椎，并遵循少量多次的原则，详细记录注入量。骨水泥弥散良好后等待骨水泥块成团凝固，再拔除穿刺针，用无菌纱布覆盖皮肤切口。患者在术后24 h佩戴胸腰支具进行下地活动，出院后定期复查。在术后1 d、1周、1个月、3个月及6个月评估患者腰背疼痛感，任意一次VAS评分4则为存在术后残余疼痛，将患者分为无残余痛组(n=120)和残余痛组(n=30)。1.3 采集指标疼 痛 程 度：采 用 视 觉 模 拟 评 分 法(Visual Analogue Scale，VAS)评价患者腰背部疼痛程度。标尺010 cm表示010分：0分为无痛，13分为轻微疼痛；46分为中度疼痛；710分为重度疼痛7。临床资料：统计残余痛组、无残余痛组患者性别、年龄、病程、体重指数、骨折椎体部位、骨密度、骨水泥量、有无腰背筋膜损伤、有无腰背痛史、有无邻椎骨折、有无骨水泥渗漏、手术方式、手术节段情况等。椎体高度压缩率=骨折椎体前后缘相对高度/邻近椎体前后缘相对高度100%；椎体高度恢复率=恢复的椎体高度/丧失的椎体高度100%(恢复的椎体高度=术后椎体高度术前椎体高度；丧失的椎体高度=估算的原椎体高度术前椎体高度)；术后Cobb 角改善率=(术前 Cobb 角术后 Cobb 角)/术前Cobb角100%；腰背筋膜损伤判断标准：在MRI上表现为矢状面呈断续线条状、条带状、片状，T1加权像(T1 weighted image，T1WI)低信号，T2加权像(T2 weighted image，T2WI)高信号，T2加权频率衰减反转恢 复(T2 weighted imaging-spectral attenuated in-version recovery，T2WI-SPAIR)序列高信号；骨密度采用骨密度仪进行自动检测；手术节段：上段(T1T4)，中段(T5T8)，下段(T9T12)。1.4 统计学处理采用SPSS 22.0统计学软件分析数据。计量资料采用均数标准差(xs)表示，比较行t检验。计数资料采用例(%)表示，比较行2检验或Fisher确切概率法，患者术后并发残余腰背痛的危险因素进行单因素、多因素logistics回归分析。P0.05为差异有统计学意义。2 结 果 2.1 典型病例患者男，68岁，骨质疏松性椎体压缩骨折伴胸腰筋膜损伤，患者MRI检查见图15。图 1 骨质疏松性椎体压缩骨折伴胸腰筋膜损伤(箭头；MRI下T2-tirm示皮下高信号)Figure 1 Osteoporosis vertebral compression fracture with thoracolumbar fascia injury(arrows;T2-tirm MRI shows hypodermic hyperintense signal)1386骨质疏松性椎体压缩骨折经皮椎体强化术后并发残余腰背痛的危险因素 苏晓慧，等2.2 骨质疏松性椎体压缩骨折经皮椎体强化术患者VAS评分30例(20.00%)发生术后残余腰背痛(残余痛组)，120例(80.00%)未发生术后残余腰背痛(无残余痛组)。残余痛组术后1 d、术后1周、术后1个月、术后3个月VAS评分均高于无残余痛组(均P0.05，表1)。2.3 骨质疏松性椎体压缩骨折经皮椎体强化术后并发腰背残余痛的单因素分析单因素分析显示：与无残余痛组相比，残余痛组体重指数、术后 Cobb 角改善率、术后椎体高度恢复率、骨密度、有无腰背筋膜损伤、有无腰背痛史、有无邻椎骨折差异均有统计学意义(均 P0.05，表2)。2.4 变量赋值表将骨质疏松性椎体压缩骨折经皮椎体强化术患者术后是否并发残余腰背痛作为因变量(发生=1，未发生=0)，将单因素分析有统计学差异的变量纳入 多 因 素 logistic 回 归 分 析，自 变 量 赋 值 说 明见表3。2.5 骨质疏松性椎体压缩骨折经皮椎体强化术后并发腰背残余痛的多因素分析多因素logistic回归分析显示：体重指数、术后Cobb角改善率、术后椎体高度恢复率、骨密度、腰背筋膜损伤、邻椎骨折最终进入回归方程(均 P0.05，表4)。图4 骨水泥完全黏合骨折线Figure 4 Bone cement completely adhers to the fracture line图5 骨水泥未完全黏合骨折线(箭头)Figure 5 Fracture line doesn t fully bond with bone cement(arrows)图2 肋椎关节损伤(箭头)Figure 2 Injury of costal joint(arrow)图3 关节突关节损伤(箭头)Figure 3 Injury of facet joint(arrow)1387临床与病理杂志,2023,43(7)http:/表3 变量赋值表Table 3 Variable assignment table自变量X1X2X3X4X5X6X7名称腰背筋膜损伤腰背痛史邻椎骨折体重指数骨密度术后椎体高度恢复率术后Cobb角改善率赋值说明有=1，无=0有=1，无=0有=1，无=0表1 2组手术前后VAS评分比较(xs)Table 1 Comparison of VAS scores before and after operation between the 2 groups(xs)组别无残余痛组残余痛组tPn12030VAS评分术前7.411.277.381.300.1150.909术后1 d3.280.575.110.8314.2420.001术后1周3.010.454.830.7916.6980.001术后1个月2.140.393.890.5819.7610.001术后3个月1.830.352.900.4514.1020.001术后6个月1.620.441.650.410.3380.736VAS：视觉模拟评分法。表2 骨质疏松性椎体压缩骨折经皮椎体强化术后并发腰背残余痛的单因素分析Table 2 Univariate analysis of residual pain in the back and back after percutaneous vertebroplasty for osteoporotic vertebral compression fracture组别残余痛组无残余痛组t/2Pn30120性别/例男14490.3350.563女1671年龄/岁71.264.3871.194.170.0810.935病程/d5.931.446.011.370.2830.777体重指数/(kgm2)21.012.1824.722.298.0110.001骨折椎体部位(胸椎/腰椎)/例13/1758/620.2410.624骨密度T值/SD4.010.723.180.675.9790.001组别残余痛组无残余痛组t/2P骨水泥量/mL5.700.915.630.950.3640.716术前椎体高度压缩率/%37.927.4638.317.520.2540.800术后椎体高度恢复率/%37.897.4844.027.064.2030.001术后Cobb角改善率/%58.946.4665.377.934.1100.001腰背筋膜损伤(有/无)/例16/1435/856.2460.012组别残余痛组无残余痛组t/2P腰背痛史(有/无)/例15/1532/886.0730.014邻椎骨折(有/无)/例10/2019/1014.7130.030骨水泥渗漏(有/无)/例2/285/1150.0090.923手术方式(经皮椎体后凸成形术/经皮椎体成形术)/例14/1654/660.0270.870手术节段(上段/中段/下段)/例5/21/49/83/283.2880.193计量资料以均数标准差(xs)表示。1388骨质疏松性椎体压缩骨折经皮椎体强化术后并发残余腰背痛的危险因素 苏晓慧，等3 讨 论 目前临床对骨质疏松性椎体压缩骨折实施保守治疗及手术治疗时不仅起效慢，且脊柱畸形无法修复，此外长期卧床患者还可出现坠积性肺炎等并发症，对患者健康造成危害8。采用注射骨水泥至患者骨折椎体内，从而黏合骨折块可起到有效稳定作用，并改善骨折微动产生的疼痛。同时骨水泥聚合产生的热量可对神经末梢造成损伤，阻碍疼痛信号的正常传导。在不断改进手术方式及材料的前提下，经皮椎体成形术和经皮椎体后凸成形术已成为目前治疗骨质疏松性椎体压缩骨折的标准术式，其手术创伤小，患者术后疼痛缓解快9。但实际临床发现，部分患者术后可出现残余疼痛，使其卧床制动时间延长，部分患者对医师的治疗信任度降低。所以寻找行经皮椎体强化术后残余腰背痛的危险因素具有重要意义。过往有研究10认为，造成上述情况的原因主要为再骨折、感染、骨折不愈合等。而此次研究观察到，腰背筋膜损伤、邻椎骨折等为患者术后残余腰背痛的独立危险因素。分析其原因如下：1)骨密度与体重指数。骨密度可有效反映骨强度，是目前预测骨质疏松性骨折风险的指标之一。有研究11表明骨密度每下降一个标准差，发生脆性骨折的概率会上升约1.6倍。骨质疏松性椎体压缩骨折患者若存在低骨密度，则发生多节段椎体骨折的概率会明显增加，且患者可出现椎体塌陷，对脊柱冠状面、矢状面的平衡造成损害，最终引发术后残余疼痛12-13。由于低体重指数患者机体内体脂率较低，雌激素呈低水平，所以骨量丢失保护作用较低，其相比正常体重指数患者更易发生骨折14-15。且较低骨密度水平、较低体重的患者骨质结构较为薄弱，而骨水泥的机械强度较高，可导致骨小梁应力集中，使椎体内发生微骨折，再加上骨折椎体发生形变等，易引发术后疼痛16。所以临床应对老年患者强化骨质疏松相关知识宣教，并让其保持良好日常生活和饮食习惯，控制体质量。2)术后椎体高度恢复率与术后Cobb角改善率。骨质疏松椎体高度会直接影响患者脊柱的稳定性，椎体高度若未能恢复则可损害棘突关节，并致使椎间孔变窄，造成腰骶部、椎旁疼痛。患者骨折后残留的后凸畸形会造成矢状位前向失衡加重，使患者重心前移，造成邻椎应力增加，使患者脊椎的矢状面失衡，所以需通过骨盆、腰椎后凸增加进行补偿，患者在活动时会出现疼痛17-18。所以在确保手术效果及安全性下，恢复椎体高度及后凸角至适当水平可促进缓解患者相关疼痛。3)腰背筋膜损伤。骨质疏松性椎体压缩骨折患者发生腰背筋膜损伤的概率较高，骨折所造成的疼痛程度相较于软组织损伤更高，在骨质疏松性椎体压缩骨折的发病早期，医患双方所关注的重点在骨折，而治疗骨折后，原有被掩盖的软组织疼痛凸显出来，因此产生术后残余疼痛19。所以临床对于伴有腰背筋膜损伤者应采取腰围保护、镇痛药等有效预防措施，从而缓解腰背部组织水肿，缓解疼痛。4)邻椎骨折。骨水泥的弹性模量相较患者椎体的骨皮质和松质骨更大，因此在注入骨水泥后可造成骨折椎体与相邻椎骨的刚度差异性加大，使两者间应力分布发生变化，引起邻近椎体骨折、骨折椎体再发骨折等，从而造成术后患者疼痛20。因此临床可采用腰背支具、规律性应用抗骨质疏松药物治疗等预防性措施，从而减少术后残余腰背痛。表4 骨质疏松性椎体压缩骨折经皮椎体强化术后并发腰背残余痛的多因素分析Table 4 Multivariate analysis of residual pain in lumbar and back after percutaneous vertebroplasty for osteoporotic vertebral compression fracture因素体重指数骨密度术后椎体高度恢复率术后Cobb角改善率腰背筋膜损伤腰背痛史邻椎骨折B0.6381.4792.9273.0130.6050.6121.654Wald 24.7285.0043.9858.0225.9362.1174.996P0.0110.0090.0370.0010.0100.1090.010OR1.8934.38918.67220.3481.8310.5425.22895%CI1.3524.0221.0074.3381.0372.9171.9316.7251.3763.6260.7156.0252.11710.9271389临床与病理杂志,2023,43(7)http:/综上所述，体重指数、骨密度、术后椎体高度恢复率、术后Cobb角改善率、腰背筋膜损伤、邻椎骨折是经皮椎体强化术后患者发生残余腰背痛的独立危险因素，临床应及时采取预防性措施，降低术后残余腰背痛发生率。本研究不足之处在于所选样本量较少，且随访时间较短，统计学结果可能存在信息偏倚，今后应采取多中心、大样本进行长期研究以验证结论的可靠性。利益冲突声明：作者声称无任何利益冲突。参考文献1Inose H,Kato T,Ichimura S,et al.Predictors of residual low back pain after acute osteoporotic compression fractureJ.J Orthop Sci,2021,26(3):453-458.https:/doi.org/10.1016/j.jos.2020.04.015.2Fan XG,Li S,Zeng XS,et al.Risk factors for thoracolumbar pain following percutaneous vertebroplasty for osteoporotic vertebral compression 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