CT导引下椎体成形术在胸腰段椎体压缩性病变治疗中的临床应用
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发布者:贺玉玺 王小平 索文华
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时间:2011年1月20日 09:17
【摘要】 目的:探讨椎体成形术在治疗胸 11-腰3椎体压缩性病变的应用及临床治疗效果。方法:经DR、CT、MRI检查,结合临床表现、病史明确诊断18例椎体压缩性病变,共涉及20个椎体,应用椎体成形术治疗。在CT导引下注入骨水泥,术中行CT扫描观察骨水泥注入量及椎体膨胀情况,临床观察患者疗效及并发症情况。结果:CT导引下经皮穿刺椎体成形术操作成功,经临床1~18个月不定期随访,16例患者在术后1个月内疼痛症状完全缓解;1例患者在术后时有神经根刺激症状,用药后症状可以改善,3个月复查症状完全缓解;1例患者手术前后症状未见明显变化;所有患者未出现严重并发症。术后1个月、3个月对病变行CT椎体扫描,18个椎体明显饱满扩大,骨水泥涵于椎体内;2个椎体外形轻度变化,骨水泥外溢于椎旁间隙。结论:CT定位导引下经皮穿刺椎体成形术,路径设计合理,穿刺成功率高,避免多次重复穿刺,所以创伤小、并发症少;有效地解除了由于椎体压缩性病变而引起的多种临床症状。体育论文发表
【关键词】 CT扫描;椎体成形术;椎体压缩;骨水泥
Abstract Object:To evaluate the clinical application as well as its therapeutic effects of percutaneous vertebroplasty (PVP) in the treatment of vertebral compression damage between thoracic vertebrae T11 to lumbar vertebrae L3. Methods: Through following examination such as CT scanning, DR and MRI, along with evaluation of clinical symptoms and medical history, 18 cases of vertebral compression damage have been diagnosed with certainty and PVP operation was adopted for the treatment of the 20 vertebrae affected. Bone cement was injected under CT guidance. The injection amount and the corresponding expansion in the vertebral body injected were also carefully monitored with CT scanning during PVP operation. The therapeutic effects as well as any possible complication were evaluated afterwards. Results: 18 CT-guided PVP operations were all successfully performed. After follow-up visit to all the patients during a time period ranging from 1 to 18 months, it has been found that as many as 16 patients exhibit complete relief of pain symptoms within as short as 1 month after operation; 1 patient exhibits irritating symptoms related to nerve root, which was alleviated upon medicine administration and completely relieved 3 months later. Only 1 patient exhibits no significant improvement in pain symptoms after PVP. No clinically significant complication was found in all patients. CT follow-up evaluation of previously damaged vertebral bodies was carried out twice at the time point 1 month and 3 month after PVP, respectively. The results show that 18 vertebral bodies were obviously enlarged and plump in appearance due to accumulation of bone cement injected within and 2 other vertebral bodies were slightly deformed with bone cement leaking into paravertebral space. Conclusion: CT-guided PVP operation is a safe technique reasonably designed with much less operation-related trauma as well as post-operation complication and much higher rate of puncture success for the effective relief of clinical symptoms caused by vertebral compression damage.
Key words CT scan; Percutaneous vertebroplasty; Vertebral compression; Bone cement
椎体压缩性病变是骨科临床常见病,由于椎体的变形造成脊柱的不稳定,患者的主要临床症状是不可耐受的腰背部疼痛,行动极其不便,甚至生活不能自理,给患者身心带来很大痛苦。用传统手法与物理治疗虽有一定的疗效,但其治疗时间过长,患者往往不能坚持,且症状易复发加重。外科治疗疗效明显,但由于其创伤大,患者常常不易接受。经皮穿刺椎体成形术(percutaneous vertebroplasty,PVP)近年来已广泛用于临床[1-4]。我们于2005年5月以来开展了CT导引下PVP技术,收治了18例椎体变窄性病变的患者,在穿刺路径的设计和操作上体会到更加合理、简便实用、创伤更小、并发症更少,临床治疗效果满意,具体报告如下。
体育论文发表
1 资料与方法
1.1 临床资料 2005年5月开始,我们采用CT导引下PVP收治了18例椎体压缩性病变患者,共20个椎体。男性7例,女性11例,年龄45~71岁,平均61.7 岁。椎体血管瘤T11 1例,T12 2例;转移瘤T11 1例,L1 1例;椎体骨囊肿T12、L1各1例;椎体骨质疏松椎体压缩变窄T12 3例,L1 4例,L2 2例;腰椎压缩性骨折L1 2例,L2 1例,L3 1例。有2例同时涉及两个椎体。临床病史主诉腰背部疼痛半年至3年,康复理疗及手法治疗效果不明显,药物治疗症状缓解甚微。所有病例PVP术前进行了数字化拍片(DR)及CT检查;3例椎体血管瘤、2例转移瘤、2例椎体囊肿均有核磁共振(MRI)术前检查诊断。所有病例结合病史及影像检查明确诊断,无明确 PVP禁忌证。
1.2 器械与材料 PVP穿刺套装(COOK公司生产):11G骨科活检针,骨科钢锤,螺旋骨水泥注射器;欧乃派克100mL造影剂(碘370,安盛药业),骨水泥套装(美国Stryker公司):甲基丙烯酸甲酯粉剂,液态甲基丙烯酸树脂单体,对比剂钽粉。
1.3 术前准备 明确诊断,制定手术方案,进行术前适应证与禁忌证分析,详细告知患者手术风险及疗效,完善理化检查,患者知情同意签字。
1.4 操作技术 患者俯卧于CT扫描床上,用铅防护遮挡患者非操作区域及对射线敏感部位。对靶椎体进行薄层扫描,选择最佳层面进行穿刺路径设置,准确测量进针角度、深度、位置,做好体表标记。消毒、铺巾后用1%利多卡因作皮下及深部软组织麻醉。沿设置好的穿刺路径将穿刺针尖达椎弓根外缘,用钢锤轻锤穿刺针,针尖置于椎体中央远侧,改变针尖位置推注造影剂,CT扫描确认造影剂无外溢征。进行骨水泥注入,骨水泥配制比例:甲基丙烯酸甲酯粉剂∶甲基丙烯酸树脂液体∶钽粉=20mg∶10mL∶2g,调制成适量均匀糊状液体,用骨水泥注射枪缓慢注入到椎体内,总量在3~10mL。骨水泥推注早期、中期、结束期分别进行 CT扫描观察。注入完毕后5分钟CT扫描,确认骨水泥均匀分布于椎体内且无外溢征后,轻缓拔除穿刺针,局部包扎。患者送回病房,平卧限制躯干活动6小时。给予抗生素3~5天预防感染,对出现的并发症作相应处理,一般情况下1周内出院。
2 结果体育论文发表
本组PVP治疗了 18例患者20个病变椎体,均是在CT扫描设置好的穿刺路径导引下,从椎弓根外缘穿刺入椎体,手术操作顺利,20个椎体均成功完成PVP。术中患者无明显不适,术后1个月、3个月行CT复查,18个椎体上下径明显增宽;2例L1、L3椎体压缩性骨折PVP术后1个月CT检查,见骨水泥脱出于椎旁组织间隙内,椎体轻度变形。临床随访1~18个月,疗效评价按照WHO疼痛分级标准[2],腰部疼痛缓解程度分为四级:完全缓解(CR),部分缓解(PR),轻微缓解(MR),无缓解(NR)。16例患者为CR,疼痛完全缓解,生活完全自理。1例患者为PR,疼痛缓解明显,生活基本能够自理,偶有神经根刺激症状,用药或休息后可以缓解,3个月后症状缓解明显。1例患者为NR,由于术后伴发L5椎体滑脱,疼痛症状缓解不明显,手术前后患者疼痛症状未见明显变化。
3 讨论
PVP应用于临床已得到临床和患者的认可,其适应证涉及多类椎体压缩性病变,欧美医学界认为对于骨质疏松所致的椎体变窄,PVP是首选改善疼痛的方法[3]。本组病例涉及椎体骨质疏松、椎体变窄、椎体血管瘤、椎体囊肿及外伤性椎体压缩骨折变窄。我们认为施行PVP有以下几点禁忌:(1)椎体不规则变窄,上下径小于椎体1/3;(2)椎体前后缘严重楔形变;(3)椎体虽有压缩性变窄,但无临床症状;(4)椎体粉碎骨折,骨片游离伴骨性椎管狭窄;(5)伴椎间盘突出症者;(6)椎体骨性感染或椎旁脓肿者;(7)其他脏器功能障碍及其它方面原因而影响PVP操作。
本组PVP的技术特点是在CT定位导引下操作完成的,CT薄层平扫病变椎体,应用CT 测量软件,准确测量穿刺部位、角度、深度,设置精确穿刺路径。本组穿刺成功率100%,其特点是从椎弓根外缘椎体进针,避免了对椎弓的损伤。我们认为在 CT定位导引下,PVP操作具有简便、准确、并发症少的优点,与Barr[5]的报道观点一致。骨水泥的作用主要是充实变窄的椎体,增加椎体的支撑力,改善椎体的不稳定性。另外骨水泥凝固聚合时的热反应可能破坏椎体疼痛的末梢神经,从而起到了止痛效果。所以把握骨水泥的调制浓度、调制时间、注入量、注入时间在技术操作中显得非常重要。CT扫描可清楚的观察骨水泥在椎体中的分布情况,可以指导针尖位置和注入量而使骨水泥在椎体中均匀分布。
疗效分析评价与发生并发症是手术是否成功的主要指标。本组18例患者中,17例PVP术后胸腰段稳定性增强,症状缓解快而明显,生活质量提高。3例椎体血管瘤、2例转移瘤、2例椎体囊肿、9例椎体骨质疏松、1例椎体压缩骨折均100%完全缓解症状,1例L1、L3椎体压缩性骨折患者术后发生L5椎体滑脱,症状未见明显改善。PVP术后疼痛总缓解有效率94%,与文献报道基本一致。本组病例由于CT设计操作路径准确合理,一次穿刺成功率高,操作时间短,组织创伤小而未出现严重并发症,虽有部分病例出现发热现象,经3~5天抗生素治疗后症状消除。2例患者发生骨水泥呈泪滴状外溢于椎旁软组织间隙内,CT复查未见移动征象,患者无明显不适。
CT定位导引下施行PVP具有定位准确、穿刺精确、操作快而简单、安全有效、创伤小、并发症少等优点。可以随时扫描观察穿刺针的位置、骨水泥的注入量及其在椎体内的分布情况,单侧穿刺即可满足技术操作。椎弓根外缘入路可以避免椎弓、椎板甚至椎小关节的损伤,有利于脊柱的稳定。本组病例最长随访18个月,患者对疗效满意。
体育论文发表
【参考文献】
[1] Golibrt P,Deramond H.Percutanecus acrylie vertebroplasty as a treatment of vertebral angioma as well as painful and debilitating diseases[J].Chirurgic,1990,116(4):326-334.
[2] 何士诚,滕皋军,邓钢,等.再次椎体成形术的应用[J].介入放射学杂志,2005,14(3):270-273.
[3] 倪才方,杨惠林,唐天驷.经皮椎体成形术的初步临床应用[J].介入放射学杂志,2002,11(4):275-277.
[4] 念丁芳,周军,李文华,等.经皮椎体成形术在椎体压缩性骨折治疗中的应用[J].介入放射学杂志,2005,14(4):416-418.
体育论文发表
[5] Barr JD,Barr MS,Lemley TJ,et al.Percutaneous vertebroplasty for pain relief and spinal stabilization[J].Spine,2000,24:45-59.
【关键词】 CT扫描;椎体成形术;椎体压缩;骨水泥
Abstract Object:To evaluate the clinical application as well as its therapeutic effects of percutaneous vertebroplasty (PVP) in the treatment of vertebral compression damage between thoracic vertebrae T11 to lumbar vertebrae L3. Methods: Through following examination such as CT scanning, DR and MRI, along with evaluation of clinical symptoms and medical history, 18 cases of vertebral compression damage have been diagnosed with certainty and PVP operation was adopted for the treatment of the 20 vertebrae affected. Bone cement was injected under CT guidance. The injection amount and the corresponding expansion in the vertebral body injected were also carefully monitored with CT scanning during PVP operation. The therapeutic effects as well as any possible complication were evaluated afterwards. Results: 18 CT-guided PVP operations were all successfully performed. After follow-up visit to all the patients during a time period ranging from 1 to 18 months, it has been found that as many as 16 patients exhibit complete relief of pain symptoms within as short as 1 month after operation; 1 patient exhibits irritating symptoms related to nerve root, which was alleviated upon medicine administration and completely relieved 3 months later. Only 1 patient exhibits no significant improvement in pain symptoms after PVP. No clinically significant complication was found in all patients. CT follow-up evaluation of previously damaged vertebral bodies was carried out twice at the time point 1 month and 3 month after PVP, respectively. The results show that 18 vertebral bodies were obviously enlarged and plump in appearance due to accumulation of bone cement injected within and 2 other vertebral bodies were slightly deformed with bone cement leaking into paravertebral space. Conclusion: CT-guided PVP operation is a safe technique reasonably designed with much less operation-related trauma as well as post-operation complication and much higher rate of puncture success for the effective relief of clinical symptoms caused by vertebral compression damage.
Key words CT scan; Percutaneous vertebroplasty; Vertebral compression; Bone cement
椎体压缩性病变是骨科临床常见病,由于椎体的变形造成脊柱的不稳定,患者的主要临床症状是不可耐受的腰背部疼痛,行动极其不便,甚至生活不能自理,给患者身心带来很大痛苦。用传统手法与物理治疗虽有一定的疗效,但其治疗时间过长,患者往往不能坚持,且症状易复发加重。外科治疗疗效明显,但由于其创伤大,患者常常不易接受。经皮穿刺椎体成形术(percutaneous vertebroplasty,PVP)近年来已广泛用于临床[1-4]。我们于2005年5月以来开展了CT导引下PVP技术,收治了18例椎体变窄性病变的患者,在穿刺路径的设计和操作上体会到更加合理、简便实用、创伤更小、并发症更少,临床治疗效果满意,具体报告如下。
体育论文发表
1 资料与方法
1.1 临床资料 2005年5月开始,我们采用CT导引下PVP收治了18例椎体压缩性病变患者,共20个椎体。男性7例,女性11例,年龄45~71岁,平均61.7 岁。椎体血管瘤T11 1例,T12 2例;转移瘤T11 1例,L1 1例;椎体骨囊肿T12、L1各1例;椎体骨质疏松椎体压缩变窄T12 3例,L1 4例,L2 2例;腰椎压缩性骨折L1 2例,L2 1例,L3 1例。有2例同时涉及两个椎体。临床病史主诉腰背部疼痛半年至3年,康复理疗及手法治疗效果不明显,药物治疗症状缓解甚微。所有病例PVP术前进行了数字化拍片(DR)及CT检查;3例椎体血管瘤、2例转移瘤、2例椎体囊肿均有核磁共振(MRI)术前检查诊断。所有病例结合病史及影像检查明确诊断,无明确 PVP禁忌证。
1.2 器械与材料 PVP穿刺套装(COOK公司生产):11G骨科活检针,骨科钢锤,螺旋骨水泥注射器;欧乃派克100mL造影剂(碘370,安盛药业),骨水泥套装(美国Stryker公司):甲基丙烯酸甲酯粉剂,液态甲基丙烯酸树脂单体,对比剂钽粉。
1.3 术前准备 明确诊断,制定手术方案,进行术前适应证与禁忌证分析,详细告知患者手术风险及疗效,完善理化检查,患者知情同意签字。
1.4 操作技术 患者俯卧于CT扫描床上,用铅防护遮挡患者非操作区域及对射线敏感部位。对靶椎体进行薄层扫描,选择最佳层面进行穿刺路径设置,准确测量进针角度、深度、位置,做好体表标记。消毒、铺巾后用1%利多卡因作皮下及深部软组织麻醉。沿设置好的穿刺路径将穿刺针尖达椎弓根外缘,用钢锤轻锤穿刺针,针尖置于椎体中央远侧,改变针尖位置推注造影剂,CT扫描确认造影剂无外溢征。进行骨水泥注入,骨水泥配制比例:甲基丙烯酸甲酯粉剂∶甲基丙烯酸树脂液体∶钽粉=20mg∶10mL∶2g,调制成适量均匀糊状液体,用骨水泥注射枪缓慢注入到椎体内,总量在3~10mL。骨水泥推注早期、中期、结束期分别进行 CT扫描观察。注入完毕后5分钟CT扫描,确认骨水泥均匀分布于椎体内且无外溢征后,轻缓拔除穿刺针,局部包扎。患者送回病房,平卧限制躯干活动6小时。给予抗生素3~5天预防感染,对出现的并发症作相应处理,一般情况下1周内出院。
2 结果体育论文发表
本组PVP治疗了 18例患者20个病变椎体,均是在CT扫描设置好的穿刺路径导引下,从椎弓根外缘穿刺入椎体,手术操作顺利,20个椎体均成功完成PVP。术中患者无明显不适,术后1个月、3个月行CT复查,18个椎体上下径明显增宽;2例L1、L3椎体压缩性骨折PVP术后1个月CT检查,见骨水泥脱出于椎旁组织间隙内,椎体轻度变形。临床随访1~18个月,疗效评价按照WHO疼痛分级标准[2],腰部疼痛缓解程度分为四级:完全缓解(CR),部分缓解(PR),轻微缓解(MR),无缓解(NR)。16例患者为CR,疼痛完全缓解,生活完全自理。1例患者为PR,疼痛缓解明显,生活基本能够自理,偶有神经根刺激症状,用药或休息后可以缓解,3个月后症状缓解明显。1例患者为NR,由于术后伴发L5椎体滑脱,疼痛症状缓解不明显,手术前后患者疼痛症状未见明显变化。
3 讨论
PVP应用于临床已得到临床和患者的认可,其适应证涉及多类椎体压缩性病变,欧美医学界认为对于骨质疏松所致的椎体变窄,PVP是首选改善疼痛的方法[3]。本组病例涉及椎体骨质疏松、椎体变窄、椎体血管瘤、椎体囊肿及外伤性椎体压缩骨折变窄。我们认为施行PVP有以下几点禁忌:(1)椎体不规则变窄,上下径小于椎体1/3;(2)椎体前后缘严重楔形变;(3)椎体虽有压缩性变窄,但无临床症状;(4)椎体粉碎骨折,骨片游离伴骨性椎管狭窄;(5)伴椎间盘突出症者;(6)椎体骨性感染或椎旁脓肿者;(7)其他脏器功能障碍及其它方面原因而影响PVP操作。
本组PVP的技术特点是在CT定位导引下操作完成的,CT薄层平扫病变椎体,应用CT 测量软件,准确测量穿刺部位、角度、深度,设置精确穿刺路径。本组穿刺成功率100%,其特点是从椎弓根外缘椎体进针,避免了对椎弓的损伤。我们认为在 CT定位导引下,PVP操作具有简便、准确、并发症少的优点,与Barr[5]的报道观点一致。骨水泥的作用主要是充实变窄的椎体,增加椎体的支撑力,改善椎体的不稳定性。另外骨水泥凝固聚合时的热反应可能破坏椎体疼痛的末梢神经,从而起到了止痛效果。所以把握骨水泥的调制浓度、调制时间、注入量、注入时间在技术操作中显得非常重要。CT扫描可清楚的观察骨水泥在椎体中的分布情况,可以指导针尖位置和注入量而使骨水泥在椎体中均匀分布。
疗效分析评价与发生并发症是手术是否成功的主要指标。本组18例患者中,17例PVP术后胸腰段稳定性增强,症状缓解快而明显,生活质量提高。3例椎体血管瘤、2例转移瘤、2例椎体囊肿、9例椎体骨质疏松、1例椎体压缩骨折均100%完全缓解症状,1例L1、L3椎体压缩性骨折患者术后发生L5椎体滑脱,症状未见明显改善。PVP术后疼痛总缓解有效率94%,与文献报道基本一致。本组病例由于CT设计操作路径准确合理,一次穿刺成功率高,操作时间短,组织创伤小而未出现严重并发症,虽有部分病例出现发热现象,经3~5天抗生素治疗后症状消除。2例患者发生骨水泥呈泪滴状外溢于椎旁软组织间隙内,CT复查未见移动征象,患者无明显不适。
CT定位导引下施行PVP具有定位准确、穿刺精确、操作快而简单、安全有效、创伤小、并发症少等优点。可以随时扫描观察穿刺针的位置、骨水泥的注入量及其在椎体内的分布情况,单侧穿刺即可满足技术操作。椎弓根外缘入路可以避免椎弓、椎板甚至椎小关节的损伤,有利于脊柱的稳定。本组病例最长随访18个月,患者对疗效满意。
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【参考文献】
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[2] 何士诚,滕皋军,邓钢,等.再次椎体成形术的应用[J].介入放射学杂志,2005,14(3):270-273.
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[5] Barr JD,Barr MS,Lemley TJ,et al.Percutaneous vertebroplasty for pain relief and spinal stabilization[J].Spine,2000,24:45-59.