胸腰椎骨质疏松骨折的处理

Management of Osteoporotic Fractures of the Thoracolumbar Spine胸腰椎骨质疏松骨折的处理,Gregory P. Gebauer, MD, MS, and A. Jay Khanna, MD, MBA,Approximately 2 million people sustain an osteoporotic fracture in the United States each year; 25% of those are vertebral compression fractures. Most fractures can be treated nonoperatively, using a combination of bracing, physical therapy, and pain medications.Surgical treatment may be considered for patients with severe pain or who have failed nonoperative options. Surgical treatment options include vertebroplasty and kyphoplasty, which involve the injection of bone cement (polymethylmethacrylate) to augment vertebral bone strength; kyphoplasty adds the in?ation of a balloon tamp to help reduce the fracture and create a space for the cement. The risk of cement extravasation is relatively high, especially during vertebroplasty; however, the incidence of symptomatic leaks is relatively low. Overall, both procedures offer low complication rates, excellent pain relief, and improved function after vertebral compression fractures. Semin Spine Surg 22:58-66 ? 2010 Elsevier Inc. All rights reserved.KEYWORDS vertebral compression fracture, osteoporosis, vertebroplasty, kyphoplasty, man- Agement在美国，每年大约有200万人发生骨质疏松骨折，其中25是椎体压缩性骨折。大多数骨折可以采用支具、理疗、止痛药等联合的非手术治疗，对于严重疼痛或非手术治疗失败者可以采用手术治疗。手术治疗包括后凸成形和椎体成形术，通过注入骨水泥（聚甲基丙烯酸甲酯）增强椎体。后凸成形通过球囊扩张来复位骨折，并为骨水泥制造一个空间。骨水泥渗漏的机会比较高，特别是椎体成形术。但产生症状者较少。总体而言，两种手术的并发症都很低，都能显著缓解疼痛，提高椎体压缩性骨折的功能。关键词：椎体压缩性骨折，骨质疏松，椎体成形术，后凸成形术，治疗。,Spectrum of Disease Senile or insuf?ciency fractures are primarily the result of osteopenia and osteoporosis, de?ned by the World Health Organization as a t score less than 1 and less than 2.5, respectively. 1 The t score is the number of standard devia- tions between the patients bone mineral density (BMD) and that of the reference value of the BMD of a young adult. It is believed that osteoporosis develops because of the uncou- pling of the normal balance between bone resorption and new bone formation, 2 resulting in a net decrease in bone mass. Osteoporosis can be primary, secondary, or idiopathic. Primary osteoporosis, the most common form, can be divided into 2 subgroups, senile and postmenopausal. Senile osteopo- rosis is a slow, gradual loss of bone mass, and is considered a normal part of the aging process. Postmenopausal osteoporosis is a rapid decrease in BMD seen after a woman enters meno- pause. Secondary osteoporosis can be related to a systemic disease, such as diabetes, or tomedications, such as corticosteroids or antiseizuremedications. Idiopathic osteoporosis, as the name implies, has no identi?able cause.疾病概况世界卫生组织定义当t值小于12.5时，为骨质疏松，其首发症状常是骨折。t值是患者的骨密度（BMP与年轻成年人骨密度参考值的标准差。骨质疏松是由于骨吸收与骨形成之间失衡，从而引起骨量减少。骨质疏松分为原发性、继发性和特发性。原发性骨质疏松是最常见的类型，可再分为老年性和绝经后。老年性骨质疏松骨量丢失逐渐发生，进展较慢，为老年的正常改变。绝经后骨质疏松在停经后骨密度迅速下降。继发性骨质疏松多源于系统性疾病（如糖尿病）或药物（如皮质激素或抗癫痫药物）。特发性骨质疏松正如其名所示，没有明确的原因。,The National Osteoporosis Foundation estimates that there are 8 million women and 2 million men with osteoporosis in the United States. 3 Another 34 million people are believed to have osteopenia. 3 It is estimated that one-half of women and one-quarter of men aged more than 50 years will sustain an osteoporosis-related fracture in their lifetime, 4 which translates into approximately 2 million fractures per year in the United States, including approximately 300,000 hip fractures and 550,000 vertebral compression fractures (VCF). 4 VCFs currently lead to an estimated $17 billion in direct medical costs, which may increase to $25.3 billion by 20254 and $50 billion by 2040. 5 These fractures also result in more than 400,000 hospital admissions annually.3国际骨质疏松基金会估计，美国有800万妇女和200万男性患有骨质疏松症，另有3400万人骨量减少。大约一半的妇女和四分之一的男性在年龄超过50岁后会发生骨质疏松性骨折，其中大约200万发生骨折，包括30万的髋部骨折和55万的椎体压缩骨折（VCF）。VCF目前的直接医疗消费大约为170亿美元，到了2025年增加到253亿美元，2040年将达到500亿美元。每年因这些骨折而住院的人数超过40万。,Approximately 2 million people sustain an osteoporotic fracture in the United States each year; 25% of those are VCFs, which can be symptomatic or asymptomatic. Asymptomatic VCFsmay be identi?ed incidentally on imaging studies or by the increasing kyphotic posture of the patient. Approximately one-third (23%-33%) of patients with VCFs present with acute pain. 6 Both symptomatic and occult of VCFs may occur spontaneously or may be the result of low-energy trauma, such as a fall. Some of the more common risk factors for VCF include female gender, increased age, smoking, and frequent falls (Table 1). 7-10 In men, a low testoster-one level is a substantial risk factor.美国每年骨质疏松骨折的人数约为200万，25为VCF，其中有些有症状，有些没有症状。无症状性骨质疏松可因偶然拍片或进行性后凸发现。约有三分之一的VCF患者出现急性疼痛。无症状或症状性VCF均可由低能量损伤（如跌倒）引起。发生VCF的危险因素包括：女性，老龄，吸烟，频繁跌倒等（表1）。对于男性，睾酮低下是重要的危险因素。,VCFs can also have a serious effect on a patients overall health. Each fracture has been estimated to result in a 9% decrease in forced vital capacity11 and has also been shown to decrease forced expiratory volume. 12 In addition, patients who have sustained a VCF are at a 5 times greater risk for developing another VCF than is the rest of the population. 13 Of patients with VCFs, 20% will have an additional VCF within 1 year13 and 50% will have an additional VCF within 3 years. 14 This high fracture risk may be related to the in-creased kyphosis caused by the anterior wedging of the initial VCFs. With increased kyphosis, the bodys center of mass is shifted anteriorly, which in turn shifts the load carried by the spine anteriorly andmay lead to abnormal stresses within the vertebral body, which then may lead to new fractures. Patients with a VCF are also at a 2 times greater risk for developing hip fractures.Mortality after VCF has been shown to be as high as 20% within the ?rst year. 15,16 Long-term mortality rates have been reported as 46.1% at 3 years, 69.1% at 5 years, and 89.5% at 7 years; roughly twice those of agematched controls.17VCF可对患者的总体健康状况产生严重的影响。据估计，每骨折一次，存活率下降9，同时也使患者的呼吸能力下降。此外，VCF的患者，再骨折的机会是没有骨折者的5倍，其中20在1年内会再出现VCF，50在3年内会出现VCF。这种高骨折风险与初始VCF后椎体前侧楔变从而引起进行性后凸有关。由于进行性后凸，身体的重心前移，从而使负荷由椎体前方传导，在椎体上形成异常的压力，从而形成新的骨折。VCF患者髋部骨折的发生率也将增加两倍。VCF后第一年的死亡率达到20%。3年死亡率46.1%，5年死亡率69.1%，7年死亡率则达89.5%，大致为对照组的两倍。,Diagnosis and Evaluation VCFs should be suspected in at-risk individuals with axial back pain or increasing kyphotic posture. Rarely, patients may have radicular- or stenotic-type symptoms. Evaluation begins with a complete medical history, with attention to any history of cancer, and a thorough physical examination, including assessment of lower extremity neurologic function. The initial imaging study is conventional radiographs, which will frequently show the fracture; standing radiographs are not usually required, but they may be useful in assessing the patients overall kyphosis and sagittal balance. In some cases, computed tomography imaging may be needed to visualize fractures that are suspected but not seen on poor-quality radiographs or for the evaluation of fractures in the upper thoracic spine, which is known to be dif?cult to evaluate with conventional radiographs. Computed tomography may also assist in preoperative planning, speci?cally in terms of evaluating the integrity of the posterior wall of the vertebral body. Magnetic resonance imaging (MRI) helps to distinguish new, acute fractures from older, healed ones. Acute fractures show increased signal intensity on T2-weighted, fat-suppressed T2-weighted, and short tau inversion recovery images. If the patient is unable to obtain an MRI study, a bone scan may be used, but there may be a lag time between fracture onset and a positive ?nding on a bone scan, leading to a possible falsenegative result. The acuity of the fracture is an important distinction: some authors believe that healed fractures are less likely to respond to vertebral augmentation surgery.18 MRImay also be helpful in evaluating any compression of the neural elements, whether from retropulsion of the posterior wall or from narrowing of the neural foramen. Diffusion-weighted images may help to distinguish pathologic from benign compression fractures. 19 A dual-energy x-ray absorptiometry scan should be performed to assess the patients BMD.Medical and/or cardiology consults should be obtained as appropriate if surgery is planned. Consulting a pain management specialist may also be helpful.诊断与评估背痛和进行性后凸应怀疑椎体压缩性骨折。患者很少有根性或狭窄症状。评估要从完整的病史开始，注意任何癌症史，并做全面的体格检查，包括下肢神经功能。常规X线片通常可以显示骨折，站立位不是必须的，但有助于评估患者的整体后凸情况及矢状面平衡。对某些X线不清楚而怀疑骨折或普通X线难以辨认的上胸椎患者，CT有助于看清骨折。CT也有助于术前评估，特别是椎体后壁的完整性。MRI有助于区别新鲜骨折还是陈旧骨折。急性骨折在T2加权、T2加权压脂相、短梯度翻转还原相上表现为高信号。如果不能做MRI，也可以做一个骨扫描，但由于骨折发生与骨扫描阳性之间有一个时间迟滞现象，可能出现错误的阴性结果。鉴别出新鲜的骨折十分重要，因为治愈的骨折对椎体增强无反应。MRI也有助于神经受压情况，如椎体后壁骨折块移位或椎间孔狭窄。弥散加权像有助于区别是不是病理性骨折。还必须做一个双能X线吸收扫描来评估一下患者的骨密度。如果计划手术，要请内科或心血管科会诊，疼痛专家会诊也是很有用的。,Treatment NonoperativeInitial treatment of VCFs is nonoperative: a combination of pain medication, physical therapy, and possibly bracing. Pain medications should be multimodal and may include combinations of narcotics, nonsteroidal anti-in?amatory medications, antidepressants, and neuropathic agents. Each of these classes ofmedications has substantial side-effect pro-?les, including sedation from narcotics and gastrointestinal and cardiac effects from nonsteroidal anti-in?amatory medications, which are accentuated in elderly patients. A pain management specialist and the patients primary care physician should be involved in the prescribing of any of these medications.治疗非手术治疗VCF的首选治疗是非手术治疗，止痛药、理疗、支具相结合。止痛药有多种机制，包括麻醉药、非甾体抗炎药、抗抑郁药、神经营养药等。每种药都有一定的副作用，包括麻醉药的镇静作用、非甾体抗炎药的胃肠道反应和心血管反应，尤其是老年人。疼痛专家和患者的初级治疗师也要参与其中。,Physical therapy has been shown to improve a patients pain and to reduce the risk of future fractures. 20,21 Initially, therapy should focus on core strengthening to improve posture and spinal mechanics. 22 Focusing on strengthening the back extensors may help to decrease loads on the spine. 21 Proprioceptive training may help reduce the risk of fall andprevent further injury.23理疗可以减轻疼痛，并减少再发骨折的危险。最初的治疗着重改进姿势和脊柱力学。强化背伸肌有助于减少脊柱上的负荷。本体觉的训练有助于减少跌倒，防止更多的损伤。,The use of a bracemay help to immobilize and support the spine, decreasing the pain associatedwith the fracture. Braces may also help to improve posture, decreasing some of the load on the spine. Multiple bracing options are available, including Jewett and cruciform anterior spinal hyperextension braces, thoracolumbosacral orthoses, and posture-training support orthoses. Patient compliance with bracing may be dif?cult because the braces can be uncomfortable and hard to put on and take off. In addition, patients who are overweight or who have a severe deformitymay be dif?cult to ?t with braces.支具有助于制动，支持脊柱，减少骨折引起的疼痛。支具也有助于改善姿势，减少脊柱上的负荷。目前有多种支具可选，包括Jewett支具、十字形过伸支具、胸腰骶支具、姿势训练支具等。患者可能不愿佩戴支具，因为支具可能不舒服，穿脱也很困难。另外，体重过大或严重畸形者，也很难使用支具。,Selective nerve root injections or spinal epidural injections may be helpful for patients with fractures that compress the neural elements. Epidural injections may be particularly useful for patients with a retropulsed fragment invading the spinal canal but who are not good surgical candidates. Selective nerve root injections may be used for patients with radiculartype symptoms.选择性神经阻滞或硬膜外阻滞对骨折伴有神经受压者是有用的。硬膜外阻滞对椎管占位但又没有手术指征者特别有用，选择性神经根阻滞对有神经根症状者有效。,In addition to treating the fracture, the clinician should address the patients osteoporosis or osteopenia. This treatment should be orchestrated in a multidisciplinary fashion, involving the surgeon, the patients primary care physician, and potentially an endocrinologist. Asmentioned previously, a dual-energy x-ray absorptiometry scan should be obtained to measure the patients BMD. The patients nutrition should be maximized, ensuring suf?cient intake of vitamin D (800-1000 IU/d)24 and calcium (1200 mg/d). 25 Medical management may include the use of bisphosphonates, calcitonin, estrogen, raloxifene (a selective estrogen analog), and parathyroid hormone. Currently, the American Board of Obstetrics and Gynecology recommends prescribing one of these medications for any patient sustaining an osteoporotic fracture, a woman with a t score of less than 2, or a patient with a t score of less than 1 with at least 1 associated risk factor. 26 Recently, a large, multicenter, prospective randomized control study evaluated the use of zoledronic acid (an intravenously administered bisphosphonate) after osteoporotic hip fractures and found a 35% reduction of risk for new fracture and a 28% reduction in mortality at 1.9 years. 27 Those authors noted relatively minor complications with the medication, including myalgia, pyrexia, and musculoskeletal pain. There were no episodes of jaw necrosis, and the rates of renal and cardiac events were in both the treatment and placebo groups.治疗骨折，临床医师要确定有无骨质疏松或骨质减少。治疗必须多学科综合配合，包括外科医师、患者的初级治疗师、也可能要内分泌医师。正如前文所提的，要做双能X线吸收扫描，以测定患者的BMD.患者的营养要充分，保证每天摄入8001000IU的维生素D和1200mg的钙。内科治疗包括双膦酸盐、钙、雌激素、雷洛昔芬（一种选择性雌激素类似物），甲状旁腺素等。最近，美国妇产科委员会提出，一旦有骨质疏松骨折或T值小于2的妇女，或T值小于1同时至少有一个危险因素者应开始服药治疗。最近一项大型、多中心、前瞻性随机对照研究发现，唑来膦酸（一种静脉用双膦酸盐）用于骨质疏松髋部骨折，可以降低35的再骨折发生率，在1.9年可降低28的死亡率。这些作者提到了少量的并发症，包括肌痛，发热、骨骼肌肉疼痛等。没有出现下颌坏死这种少见情况。治疗组与安慰剂对照组的肾脏与心脏并发症均有发生。,OperativeGiven that most VCFs occur in elderly patients without neurologic de?cits who havemedical comorbidities and osteopenia or osteoporosis, conventional surgical techniques, such as instrumented fusion, have been avoided for the treatment of VCFs. However, with the advent of percutaneous vertebral augmentation, such patients have become candidates for surgical intervention. There are 2 basic forms of percutaneous vertebral augmentation, vertebroplasty and kyphoplasty. Both procedures are similar in position and approach, but they have technical differences. Vertebroplasty was introduced ?rst in France in 1984 and was described in 1987 by Galibert et al. 28 It was not introduced in the United States until 1994. 29 Vertebroplasty involves the injection of cement, usually polymethylmethacrylate (PMMA), into the fracture site. Recently, kyphoplasty has been introduced. This procedure involves the in?ation of a balloon-type bone tamp before the injection of the PMMA, which may allow for the partial reduction of the fracture and the creation of a void into which the cement can be inserted under low pressure.手术治疗由于大多数VCF没有神经损害，同时有内科并存病和骨质疏松，传统的外科手术如器械固定融合并不合适。随着经皮椎体增强技术的出现，这类病人可以进行外科干预。经皮椎体增强技术有两种方式：椎体成形术和后凸成形术。两种手术的体位和入路相同，但有技术上的不同。椎体成形术1984年在法国开始应用，1987年Galibert等首先报道。在美国，直到1994年后才开始应用。椎体成形术是将骨水泥（通常是聚甲基丙烯酸甲酯，PMMA）注入骨折部位。近来，后凸成形术开始应用，后凸成形术是通过一个球囊进行扩张，使骨折部分复位，并制造一个空腔，这样就可以在比较低的压力下注入骨水泥。,Indications for SurgeryThe indications for vertebroplasty and kyphoplasty in the treatment of VCFs include acute, painful, osteporotic or osteolytic VCFs; pathologic fractures in patients withmetastatic disease; painful vertebral hemangioma; and Kummells disease. 30,31 It is important that only symptomatic fractures be treated and not all fractures that are seen on imaging studies. 31 Most commonly, VCFs are treated acutely, although chronic fractures may also respond to treatment. The best method for differentiating acute or subacute VCFs from chronic fractures is via the use of MRI and, speci?cally, fat suppressed T2-weighted or short tau inversion recovery sequence images. Fractures that show increased signal intensity (compatible with edema) on these pulse sequences are likely to be acute or subacute and have a high chance of responding favorably to vertebral augmentation procedures in terms of pain relief.手术适应症椎体成形术和后凸成形术的手术适应症包括：急性、疼痛性骨质疏松性椎体压缩骨折；转移癌引起的病理性骨折；痛性椎体血管瘤；Kummell氏病。只有有症状的骨折才需要治疗，而不是所有影像所见的骨折都需要治疗。虽然慢性骨折对治疗也有效，但VCF大多在急性期治疗。区别急性或亚急性骨折与陈旧性骨折的最好方法是MRI，特别是压脂T2加权或短T翻转恢复序列，在这些序列上信号增高的（可能有血肿），可能是急性或亚急性骨折，椎体增强的止痛效果较好。,Contraindications for vertebral augmentation include de?ciency of the posterior wall, local or systemic infection (sepsis), osteoblastic metastatic lesions, inability to obtain adequate intraoperative imaging, and advanced or multiple medical comorbidities. In addition, performing these procedures on fractures with severe collapse and vertebra plana may be technically challenging.椎体增强的禁忌症包括：后壁不完整，局部或全身感染，成骨性转移灶，术中无法提供影像支持，伴有多发或严重的内科并存病。此外，在严重塌陷和扁平椎实施该手术也是一项技术挑战。,Surgical TechniquePatient positioning for vertebroplasty and kyphoplasty is similar. Patients are usually positioned prone on a radiolucent table. As with all prone patients, care should be taken to protect the eyes and to pad all bony prominences. In rare cases, patients may be positioned in the lateral position. Ideally, the back should be extended to facilitate reduction. Anesthesia may be general, sedation, or local, depending on the circumstance and the patients medical condition.外科技术椎体成形术和后凸成形术的体位相似。患者通常俯卧于可透视床上，由于是俯卧位，要注意保护眼睛，并在骨突上置垫。少数情况下，也可以置于侧卧位。背部过伸，以利复位。麻醉可用全麻、镇静或局部麻醉，取决于具体情况和患者条件。,After the patient has been positioned on the table, initial ?uoroscopic images should be obtained in the anteroposterior (AP) and lateral planes. The images in the AP view should be adjusted into kyphosis or lordosis as needed until a true AP view of the vertebral body in question is obtained. When properly positioned, both vertebral endplates should be clearly visualized, and the pedicles should be symmetric and equidistant from the spinous process. Adequate ?uoroscopic imaging is essential, and the surgery should not proceed if the images are not satisfactory. One or 2 ?uoroscopy units can be used, depending on machine availability and surgeon prefer- ence. The use of 2 ?uoroscopy units has been shown to decrease operating room time and decrease the incidence of cement extravasation.32病人摆好体位后，先做个正侧位透视，前后位要调整适应病椎的前凸或后凸，以获得真正的前后位。如果位置正确，椎体上下终板显示清晰，双侧椎弓根对称，与棘突的距离相等。良好的影像十分重要，如果图像不满意就不应进行手术。用一台还是两台透视机取决于条件和外科医生的喜好。两台透视机有助于减少手术时间和减少骨水泥渗漏的机会。,After the patient is successfully positioned, the vertebra to be augmented is localized. The anterior vertebral body can be approached via a transpedicular, extrapedicular, or posterolateral approach. The choice of approach should be identi?ed preoperatively, based on the imaging studies and location of the fracture. The transpedicular approach is typically used for vertebrae between T10 and L5. This approach may be disadvantageous for patients with small pedicles or for those whose vertebrae are co