脊柱骨質(zhì)疏松壓縮性骨折的手術(shù)治療課件

SURGICALTREATMENTOFSPINEOSTEOPOROSISConceptofOsteoporosisAsystemicskeletaldiseasecharacterizedbylowbonemassandmicroarchitecturaldeteriorationofbonetissue,withaconsequentincreaseinbonefragilityandasusceptibilitytofracture."

theabovedefinitiondevelopedinHongKongin1993PathophysiologyofOPBoneRemodelingImbalanceofboneremodeling,Inpathologicsituations,bonemassmaybesacrificedtosatisfythebody'sintra-andextracellularcalciumneeds.AspecificquantityofboneisresorbedfromtheremodelingsiteandthenareversaloccursandthecavityisoccupiedbyosteoblastswhichrefillthatcavitywithboneTheProgressionofBoneRemodeling

MechanismsofBoneLossAnincreasednumberofboneremodelingunitscanbeactivatedwhich,whencombinedwitheitheroftheabovetwoprocesses,mayresultinincreasedboneloss.bonelossisequaltoboneformationandtheamountofbonetissuepresentrepresentsnormalbonemass

increasednumberofremodelingsitesincreasedporosityofthebone,ietheremodelingspace,andthisgivesdecreasedbonemas

BoneLoss:Cancellousvs.CorticalBoneAlthoughcancellousbonemayaccountforlessthan25%ofthetotalbonemassinhealthyadults,itssurfaceareafarexceedsthatofcorticalbone.

BoneLoss:Cancellousvs.CorticalBoneCancellousboneismoremetabolicallyactivethancorticalbone.Ifboneremodelingbecomesuncoupled,withosteoclasticactivityexceedingosteoblasticactivity,themassandstructuralintegrityofcancellousboneismoreseverelyaffectedthancorticalbone.BoneLoss:Cancellousvs.CorticalBoneDuringtheacceleratedperiodofbonelossoccurringimmediatelypost-menopause,cancellousbonelossisincreased3-fold,whileratesofcorticalbonelossareslower.Therefore,fracturesrelatedtoosteoporosismostcommonlyoccurinareasrichincancellousbone(ie,thevertebraeandwrist),andBMDmeasurementshavefocusedonthesecriticalanatomicsiteshighturnoverwitheitherincreasedformationorincreasedresorptionorboth

PatternsofAge-RelatedBoneLossGradualbonelossbeginsinbothmenandwomenbetweentheage30and40,parallelinganage-relateddeclineinmusclemass.menopausewomenbeginaperiodofacceleratedboneloss,averagingfrom2%-5%peryearoverthenexttenyears.Estrogen-RelatedBoneLoss

althoughhighaffinityestrogenreceptorshavebeenidentifiedonbothosteoclastsandosteoblasts.Additionally,itisthoughtthatestrogendeficiencyismoredirectlyassociatedwithacceleratedboneloss,butnotage-relatedboneloss.AcceleratedBoneLossAcceleratedbonelossisgreatestinthefirst3-6yrsaftermenopause,levelsoff,andthengraduallyassumesthelevelofpremenopausalboneloss.Thisperiodofacceleratedboneloss,coupledwiththeloweraverageBMDinwomencomparedtomen,explainsthehigherincidenceofosteoporosisandosteoporoticfracturesinwomenVertebraeandCancellousBoneThevertebraehaveahighpercentageofcancellousbone.Therefore,vertebralfracturesarethemostcommonfracturesiteintheearlymenopausalyears;Hipfracturestendtooccurinlaterlife.Thedegreeofbonelossmayvaryfromsitetositeinthesameindividual.MenopausalBoneLossMenopausalbonelosscanvaryamongwomenfrom2%-5%peryear.Higherratesofbonelosshavebeenclassifiedas"fast"losers.Itisthoughtthatthiscategoryofwomen(about5%-10%ofallmenopausalwomen)maybeathigherriskforfractures;

NFORecommendationsforBMDTestingAllpostmenopausalwomenunderage65whohaveoneormoreadditionalriskfactorsforosteoporosis(besidesmenopause);Allwomenaged65andolder,regardlessofadditionalriskfactors;Postmenopausalwomenwhopresentwithfractures(toconfirmdiagnosisanddeterminediseaseseverity);NFORecommendationsforBMDTestingWomenwhoareconsideringtherapyforosteoporosis,iftheBMDtestingfacilitatethedecision;Womenonhormonereplacementtherapyforprolongedperiods.IssuesinBoneMineralTestingConsiderationsAwoman'swillingnesstobetreated;CommitmenttoHRTtherapy;PatientwhoisuncertainaboutHRT;Technologyandanatomicsiteconsiderations;BoneMineralDensity--DefiningDiagnosticCategoriesNormal.BMDwithin1SDofthe"youngnormal"adult(T-scoreabove-1).

Lowbonemass(osteopenia).

BMDisbetween1and2.5SDbelowthatofa"youngnormal"adult(T-scorebetween-1and-2.5).

BoneMineralDensity--DefiningDiagnosticCategoriesOsteoporosis.

BMDis2.5SDormorebelowthatofa"youngnormal"adult(T-scoreatorbelow-2.5).Womeninthisgroupwhohavealreadyexperiencedoneormorefracturesaredeemedtohavesevereor"established"osteoporosis.LimitationsofDiagnosticCriteriaBasedonT-ScoresTheuseofdifferentyoungnormalreferencedatabases,differentdensitometricdevices,thatmayresultindifferentT-scoresotherriskfactorsforfracturebesidesBMDandtheintermediarynatureofBMD.ThesevarydependingontheinstrumentusedtoobtainthedataOtherRiskFactorsforFractureNonmodifiable:PersonalhistoryoffractureasanadultHistoryoffractureinfirst-degreerelative

RaceAdvancedageFemalesexDementiaPoorhealth/frailtyOtherRiskFactorsforFracturePotentiallymodifiable:CurrentcigarettesmokingLowbodyweight/thinness(<127lbs.)Estrogendeficiency:Earlymenopause(<aged45)orbilateralovariectomyProlongedpremenopausalamenorrhea(>1year)OtherRiskFactorsforFracturePotentiallymodifiable:Lowcalciumintake(lifelong)AlcoholismImpairedeyesightdespiteadequatecorrectionRecurrentfallsInadequatephysicalactivityPoorhealth/frailtyWHODefinitionEstimates30%ofallpostmenopausalwhitewomenwillbediagnosedwithosteoporosis;54%willhavelowbonemassatthehip,spineorwrist.Morethanhalfthewomenwithosteoporosiswillhaveahistoryofpriorfractureoftheproximalfemur,spine,distalforearm,proximalhumerusorpelvis.FracturesAssociatedwithOPVertebralFractureHipFractureDistalForearmFractureOtherFractures

Fractureoftheproximalhumerus,pelvis,proximaltibiaanddistalfemur.ImpactofVertebralandHipFracturesBothfracturesmaybeassociatedwithsignificantmorbiditiesandincreasedmortalityasfollows:About1/2thewomenwithhipfractureswillspendsometimeinanursinghome.Only1/3ofhipfracturepatientsregaintheirprefractureleveloffunction,withmanyunabletowalkindependentlyorperformbasicactivitiesofdailyliving.

ImpactofVertebralandHipFractures20%ofwomenwhosufferahipfracturewilldieinthefollowingyearasanindirectconsequenceofthefracture.AhistoryofvertebralfractureisassociatedwithanincreasedriskofasubsequentfragilityfractureImpactofVertebralandHipFracturesVertebralfracturemaybeassociatedwithbackpain,disabilityorphysicaldeformity(eg,kyphosis,heightloss,abdominalprotrusion).Infact,thethreatofphysicaldeformitymaybeapowerfulinfluenceonawoman'scommitmenttotherapy.Additionally,thereisanincreaseinmortalityrelatedtofrailty,comorbiditiesandanincreasedriskofpneumonia.Vertebroplasty

andKyphoplastyAnewtechniqueofMinimalInvasiveSpinalSurgeryCarryoutinChinafrom2001Vertebroplasty-MinimalInvasiveTreatmentofCompressionFrxVertebroplastyliterallymeansfixingthevertebralbody.Ametalneedleispassedintothevertebralbodyandacementmixturecontainingpolymethylmethacrylate(PMMA),bariumpowder,tobramycin,andasolventareinjectedunderimagingguidancebythephysician.Vertebroplasty-MinimalInvasiveTreatmentofCompressionFracturesThecementhardensrapidlyandbuttressestheweakenedbone.Thebariummakesthecementvisibleonx-rayandthetobramycinisanantibiotic.

RisksofProcedure1).Leakageofcementintoveinsandorlungs

2).Infection

3).Bleeding

4).RiborPediclefracture

5).Pneumothorax

6).Worsenedpain

7).ParalysissecondarytoleakageofcementWhatareindicationsforVertebroplasty?1).Painfulcompressionfracturesecondarytoosteoporosis2).Painfulcompressionfracturesecondarytotumorwhichdoesnotrespondtoconventionaltherapy3).Preventfurthercompressionfractures4).ButtressweakenedboneforspinefusionsRelativeContraindicationsYoungpatient-thelongtermeffectsofthecementmixtureareunknownVertebralbodiesabovetheT5level-theprocedureisriskierandmoredifficultPatientswithpriorunsuccessfulspinesurgeryPatientEvaluation

1)HistoryandPhysicalExamination

2)Currentx-rays

3)MRI+/-bonescanSurgicalProcedure

ofVertebroplasty

becarriedoutinanoperatingroomorinaspecialX-raysuite.Aneedleisplacedinaveinsothatthepatientcangetmedicationforsedationandpain.Thepatientliespronewithpaddingunderthebodyandwiththehipsslightlybent.Thearmsarepositionedabovetheshoulder.

SurgicalProcedure

ofVertebroplasty

2,Aradiopaque(visibleonX-ray)markerisplacedonthepatientoverthevertebratobeinjected.Positioningofthemarkerisguidedbyfluoroscope(video-likeX-raymachine).Clearlyseeingthecorrectvertebraismoredifficultintheseverelyosteoporoticpatient

SurgicalProcedure

ofVertebroplasty

3,Localanesthetic;injectedintotheskinandalongthepathtowardthepedicleofthevertebratobeinjected.Theneedleisleftinagainstthepedicletomarkthepathofthespecialneedleusedforinjectingthecement.Thespecialneedleisan11-gaugebonebiopsyneedle.Asmallskinincisionismadeandbonebiopsyneedleinserted

SurgicalProcedure

ofVertebroplasty

4,Thetipofthebonebiopsyneedleisstuckforabout1-2mmintothepedicle.Positioningofthethisneedleiscontinuouslyguidedwiththefluoroscopeinboththeanterior-posterior(AP,fronttoback)andlateral(sidetoside)viewsSurgicalProcedure

ofVertebroplasty

5,

Advancethebonebiopsyneedletothefrontone-thirdofthevertebra.OntheAPviewtheneedleliesnearthemidlineofthebodyofthevertebra.Theneedleisfilledwithsalinetopreventairinjection.AcontrastsolutionthatcanbeseenonX-rayisinjected.TakesX-raypicturesduringtheinjectiontoseehowthecontrastflowsfromthecenterofthevertebraintothelocalveins.

SurgicalProcedure

ofVertebroplasty

6,Preparetheplasticmaterialtobeinjected.MixthePMMApowderwithtungstenpowderorbariumsulfatetomakeitvisibleonX-ray.Addtheliquidtothepowderandmixedtoathickyetpourableconsistencysimilartohoney

SurgicalProcedure

ofVertebroplasty

7,LoadthePMMAintoseveralsmallsyringes.Thesyringeisconnectedtothebonebiopsyneedleandinjectedunderfluoroscopicguidancetobesurethatthematerialdoesnotrunoffintotheveins.ThePMMAhardensafterinjectedtosupportthevertebra(Axialandsagittalanimations)

ComplicationsComplicationsoccurinapproximately3%ofosteoporoticpatients

approximately5%ofpatientswithhemagiomas

approximately10%ofpatientswithcancertothevertebra

ComplicationsThemostcommoncomplicationsare

RibfractureduetothedownwardonthebackneededtoinserttheneedleinthebonyvertebraIrritationofanadjacentnerverootThesecomplicationsusuallyresolveontheirowninafewmonths

Pneumothorax(puncturedlung)ComplicationsPneumothorax(puncturedlung)

FractureofthepediclePMMApulmonaryembolus-thePMMAenterstheveinsthroughtheboneandistakentothelungCompressionofthespinalcordwithparalysisorlossoffeelingComplicationsIncreasedbackpain

PMMAmaygooutsidetheboneintothesofttissuesWoundInfectionPneumonia

FollowUpCarePainmedications-usuallytaperedoverseveraldaysafterprocedureMusclerelaxantsAdjustmedicationstopreventfurtherminerallossVertebroplastyStatistics

>80%moderatetomarkedpainrelief<5%inducedfracturesfromprocedure<1%symptomaticembolismorinfection

ExperiencesofOurHospital

04.2001—08.200358patients，65vertebraL1

16，L2

12

，L3

7

，L4

5

T41,T8

2，T94，T10

4

T11

6，T12

8.Case1Female68yrsL1fracturebeforeoperationBackpainafterfallingonthegroundCase1female68yrsL1fracturepostoperationTowalkatthefirstdayafteroperationCase1female68yrsL1fracturepostoperationCTCase2Case3T12CompressionVertebraFractureDuringoperationCase3T12CompressionVertebraFracturePost-operationCase4PostoperationCASE5.Female,84YL2CompressionVertebraFractureDuringoperationCASE5.Female,84YL2CompressionVertebraFracturePostoperationCASE5.Female,84YL2CompressionVertebraFracturePostoperationCase672yrs,Female.CompressiveFrxCervicalSpineFracturesandOsteoporosisFracturesofthecervicalspineusuallyresultfrommajortrauma(trafficaccidents,fallsfromgreatheightsordivesintoshallowwater).Inelderlypatientsseverecervicalspineinjuriesmayalreadyresultfromsimplefalls.littleinformationavailableontreatmentandoutcomeofcervicalspineinjuriesintheelderly,especiallyregardingthesubaxialspineCervicalSpineFracturesandOsteoporosisInthegeneralpopulation,about50%offracturesinvolvetheC5-6andC6-7level,withdensfracturesbeingthesecondmostfrequentlocalization.Theincidenceoflowercervicalspineinjuriescontinuouslydeclineswithage.Incontrast,theincidenceofuppercervicalspineinjuriesrisesintheelderly.Fracturesofthedensarethemostcommonlocationinpatientsabovetheageof70yearsCervicalSpineFracturesandOsteoporosisA68-year-oldpatient,presentingwi