文献翻译－胸腰椎骨折－球囊辅助复位在高能量爆裂骨折中的应用
发布于 2010-09-21 · 浏览 3120 · IP 浙江浙江
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Balloon-Assisted Fracture Reduction in High-Energy Burst Fractures球囊辅助复位在高能量爆裂骨折中的应用
Dalip Pelinkovic, MD,* Ranjith Kamal Udayakumar, MD,† and Frank M. Phillips, MD*
The combination of percutaneus vertebral augmentation with posterior instrumentation may be an attractive treatment option for certain high energy burst fractures. Biomaterials such as calcium phosphate cement are biocompatible, share similar biomechanical prop¬erties to bone, and are gradually replaced by host bone tissue. Early biomechanical and clinical results indicate that the anterior column may be restored without the need of a traditional anterior surgical approach. Further clinical studies are needed to confirm that this less invasive approach improves patient outcome. Semin Spine Surg 22:67-72 © 2010 Elsevier Inc. All rights reserved.
对于某些高能量爆裂骨折而言，经皮椎体增强联合后路器械固定是一个很有吸引力选择。有些生物材料，如磷酸钙骨水泥，具有良好的生物相容性，与骨的生物力学特性相似，可以逐渐被宿主骨替代。早期生物力学和临床结果显示，前柱获得了恢复，不需要再进行传统的前路手术。还需要更多的临床研究来证实这种微创方法对患者结果的促进作用。KEYWORDS burst fracture, percutaneus, balloon-assisted, reduction
关键词：爆裂骨折，经皮，球囊辅助，复位。
high-energy thoracolumbar burst fractures can be treated with decompression and anterior, posterior, or circum¬ferential fusion. Traditionally, reconstruction of the posterior tension band with a rod hook or rod screw construct is ap¬plied to assist in providing stability and reestablishing the sagittal balance. Ligamentotaxis may also assist in reducing the vertebra. Despite excellent initial fracture reduction, in¬adequate anterior column support may lead to loss of reduc¬tion, poor long-term fixation, or even failure of treatment over time.1-3 Insufficiency of the anterior column is caused by both the vertebral body fracture and also migration of the disk tissue through the endplate into the fractured vertebral body, which may not be restored with indirect reduction through posterior instrumentation.4 More extensive anterior procedures, such as anterior instrumentation and strut graft¬ing, or cage implantation may successfully restore the ante¬rior spinal column support and are proven to be effective and spare motion segments.5,6 However, anterior procedures are more invasive and are associated with increased hospitaliza¬tion, blood loss, increased surgical morbidity, or even mor¬tality.5
高能量胸腰椎爆裂骨折常采用减压，前路、后路或环形融合进行治疗。传统后侧张力带结构常采用钩棒或钉棒结构来提供稳定和重建矢状面平衡。韧带整复术有助于复位椎体。尽管早期复位非常好，如果前柱支持不足，可能导致复位丢失、内固定失效、甚至治疗失败。前柱缺损可由于椎体骨折和椎间盘组织经终板嵌入骨折椎体引起，而这是无法通过后路器械进行间接复位的。通过更广泛的前路手术进行器械固定支撑、cage植入等方法可以有效恢复前柱支撑，减少节段活动。但是前路手术的创伤较大，且住院时间更长，出血更多，增加了外科手术率，甚至病死率。Recently, percutaneous instrumentation combined with percutaneous vertebral body augmentation (kyphoplasty/ vertebroplasty) has been added to the surgical armamentar¬ium. In osteoporotic vertebral fractures, kyphoplasty has proven to be a safe procedure with excellent outcomes.7 However, the pathoanatomy of a high-energy burst fracture is distinct from osteoporotic vertebral fractures. Three frac¬ture patterns-wedge, crush, and biconcave-have been de¬scribed in the osteoporotic patient.8,9 The posterior wall and endplates are mostly intact. In addition, the osteoporotic bone with decreased number and connectivity of trabeculae allows restoration of the vertebral height as balloon tamp inflation compresses the soft cancellous bone and elevates the end plates.7,10近来，经皮器械和经皮椎体增强技术（后凸成形和椎体成形术）已成为外科手段。对于骨质疏松性骨折，后凸成形术已被证实是十分安全有效的。然而高能量爆裂骨折与骨质疏松性骨折的病理解剖是不同的。骨质疏松性骨折有三种骨折形式：楔形、爆裂、双凹，后壁和终板多数是完整的。而且，骨质疏松的骨骼由于骨小梁减少，连接力降低，当球囊扩张时，可挤压松软的松质骨，抬高终板，从而恢复椎体高度。
In contrast, high-energy traumatic burst fractures are usu¬ally caused by substantial axial loading, which results in com¬pression failure of at least the middle and anterior spinal column. The sudden axial load results in a vertebral endplate failure as adjacent disk tissue is driven into the vertebral body. The vast majority of burst fractures cause some canal compromise, typically because of osseous fragments from the superior endplate. Determinants of instability are progressive neurological deficit, progressive kyphosis, radiographic evi¬dence of substantial posterior column instability, greater than 50% loss of vertebral body height in association with kypho¬sis. Fractured and depressed endplates increase the chance of disk displacement into the vertebral body with subsequent focal spinal deformity and failure of the treatment. Conse¬quently, the combination of indirect reduction of thoraco¬lumbar burst fractures with balloon-assisted endplate re¬duction may recreate a stable anterior column, and stable endplates with long-term maintenance of the sagittal alignment (Fig. 1). Advantages of minimal invasive tech¬niques are quicker recovery, less pain, decreased surgical morbidity, and potentially a more stable construct than isolated posterior or anterior stabilization because of less tissue disruption.
相反，高能量爆裂骨折通常由巨大的轴向负荷引起，至少可使前柱和中柱的压缩破坏。突然的轴向负荷可破坏椎体终板，使邻近的椎间盘组织疝入椎体。大多数爆裂骨折可引起椎管侵害，骨块特别常来自上终板。进行性神经损害、进行性后凸、放射学证实的后柱不稳、椎体高度丧失大于50%伴有后凸者被认为是不稳定。骨折和凹陷的终板增加了椎间盘疝入椎体、局部畸形、治疗失败的机会。这样一来，对胸腰椎爆裂骨折通过间接复位辅以球囊扩张使终板复位就可以重建前柱和终板的稳定，从而保持矢状序列的长期稳定。微创的优势在于恢复快、疼痛轻、减少了外科手术率、由于对组织破坏少，可能更稳定。
Transpedicular vertebral cancellous bone grafting for the treatment of vertebral compression fractures has been de¬scribed in the published data with little success in maintain¬ing the anterior column of the spine and was associated with a high failure rate.11-15 Transpedicular hydroxyapatite stick grafting is another technique, which is currently under inves¬tigation.16经椎弓根植骨治疗椎体压缩骨折，文献报道难以维持前柱，并有很高的失败率。近来导航下经椎弓根羟基磷灰石棒植入是另一项技术。Basic Science Studies
Mermelstein et al17 showed in their cadaveric burst fracture study that vertebroplasty with calcium phosphate cement (CPC) reinforced the anterior column and reduced the stress on the pedicle-screw rod construct. In another cadaveric study18 balloon-assisted endplate reduction was used to sig¬nificantly restore vertebral height and end plate anatomy af¬ter short segmental instrumentation. A follow-up study by the same group used a detailed 3-dimensional radiography at different phases of the model, from fracture to balloon-as¬sisted endplate reduction and cement injection. They dem¬onstrated no collapse after removal of the balloons, mainte¬nance of the vertebral height with cement injection, and no cement extravasation.18
Another study investigated the role of the longitudinal lig¬aments during balloon-assisted endplate reduction in thora¬columbar burst fractures.19 In a human cadaveric burst frac¬ture model, the anterior and posterior bone displacement was assessed after applying short segmental fixation followed by kyphoplasty. Although anterior bone and posterior bone displacement occurred with the inflation of the balloons, the effect subsided after deflation and did not recur with injec¬tion of the cement. The amount of displacement (�1 mm) was thought to be of little clinical significance. According to this study, an intact posterior longitudinal ligament does not appear to be necessary to prevent posterior bone displace¬ment. They could also not confirm the importance of the posterior longitudinal ligament with reduction through liga¬mentotaxis.
基础研究
Mermelstein等研究发现，磷酸钙骨水泥可以强化爆裂骨折的前柱，减少椎弓根钉的的压力。在另一项尸体研究中，采用球囊复位终板，短节段固定，使椎体高度和终板解剖显著恢复，该研究采用三维X线对从骨折－球囊扩张终板复位－骨水泥注入的不同阶段进行详细观测，他们发现球囊取出后椎体不会塌陷，骨水泥注入后椎体高度得以保持，没有骨水泥渗漏。另一项研究调查了后纵韧带在胸腰椎爆裂骨折球囊辅助终板复位中的作用。在一个人类尸体爆裂骨折模型中，采用短节段固 定辅以后凸成形，评估前后骨块移位。虽然球囊扩张时前后骨块发生移位，但球囊收缩时，这种作用就减小了，且椎体内注入骨水泥后，也没有再发生。其移位的程度（＜1mm）没有临床意义。根据这项研究，完整的后纵韧带无法阻止后方骨块的移位。他们也无法确定韧带复位技术中后纵韧带的重要性。
Clinical Studies
Afzal et al reported on 16 patients (age, 22-53 years) with high-energy burst fractures (12 Denis type B and 4 Denis type C burst fractures) who were followed up for 1 month clini¬cally and radiographically.20 Patients with posterior longitu¬dinal ligament injury were excluded. After short segment pedicle screw fixation, a balloon-assisted kyphoplasty was performed with CPC. In addition, a removable plastic jacket was prescribed for 8 weeks. Cement leakage was observed in 3 patients (2 in the spinal canal, 1 in the disk space), with no clinical consequences. No posterior wall displacement was recorded. The average kyphosis angle of the segment was reduced by 10°.
临床研究
Afzal等报道了16例（年龄，22－53岁）高能量爆裂骨折病例（12例Denis B型,4例Denis C型爆裂骨折），临床与X线进行随访1个月。后纵韧带损伤者排除在外。短节段椎弓根钉固定后，采用CPC进行球囊辅助后凸成形术。可拆式塑料夹克固定8周。3例患者发生骨水泥渗漏（2例在椎管，1例在椎间隙），没有临床症状。没有发生后壁移位，平均后凸角减少10°。
Another investigation included 18 patients (64 � 15 years) with severe thoracolumbar burst and compression fractures (Figs. 2-4).21 All patients were treated with short segment percutaneous posterior instrumentation and bal¬loon kyphoplasty with CPC within 24 hours of injury and were followed up for 22 months. Kyphosis improved from an average of 16°-2°. Cement leakage was observed only ante¬rior to the vertebral body without clinical sequelae. A second study by the same group treating thoracolumbar burst frac¬tures with calcium phosphate and an open approach for pos¬terior spinal instrumentation showed similarly encouraging results at 24 months without major complications (Fig. 1).22 另一项研究有18例病人（64±15岁），严重的胸腰椎爆裂和压缩骨折（图2－4）。所有的病人都在伤后24小时内采用后路经皮短节段固定CPC球囊后凸成形术，随访22个月。后凸从平均16°恢复至2°。骨水泥仅渗漏至椎体前方，没有后遗症。同一小组采用羟基磷灰石和开放后路固定取得了相似的效果，随访24个月，没有严重并发症发生（图1）。A prospective case series on standalone kyphoplasty with CPC in Magerl type A fractures without deficit noted a decrease of pain on the visual analogue scale from 8.7 preoperatively to 3.1 postoperatively in 7 days, and 1 at the last follow-up at 30 months.23 The Roland Morris Disability score demonstrated a similar decrease in the early postoper¬ative time period. Two anterior wall perforations by cannulas during the procedure, and 6 cement leakages were observed on postoperative computed tomography (CT) scans (5 cases into the disk space, 1 case with small leakage in the lateral portion of the spinal canal). All were without neurological or vascular consequences. Also, no long-term complications were observed at the last 30 month follow up. Twenty per¬cent cement resorption and substitution was noted on CT scans at 1 year postoperatively. Loss of correction was 9° (0°-17°) from immediate postoperatively to the last fol¬low-up at 30 months. This may relate to loss of vertebral height as the resorbable cement is remodeled.
一项单独采用CPC后凸成形治疗没有神经损害的Magerl A型骨折的病例回顾中，术后7天疼痛视觉模糊评分从术前8.7分恢复至3.1分，术后30个月恢复至1分。Roland Morris 残疾评分在术后早期也相应下降。两例前壁穿孔，6例术后CT发生骨水泥渗漏入椎间隙，1例少量渗漏至椎管侧方。所有病人没有出现神经或血管并发症。30个月随访没有长期并发症。20%在术后1年CT观察时骨水泥吸收替代，从术后即时至术后30个月的矫正丢失为9°（0°－17°），这可能与可吸收骨水泥吸收后引起的高度丢失有关。
Filler Choice
Considerations for materials for vertebral augmentation for high-energy thoracolumbar burst fractures are different from those in osteoporotic fractures. The cement should be inject¬able through cannulas, easy handling, appropriately viscous, have an adequate working time (15 min), low curing temper¬ature, adapting and lasting mechanical properties, high ra¬dioopacity, biocompatibility, bioactivity, and slow biodegra¬dation. The optimal mechanical properties have not yet been determined for high-energy burst fractures. Stiffness and yield strength should be similar the host bone. Presently, polymethylmethacrylate (PMMA) cement is most widely used for vertebral augmentation procedures, with an exten¬sive history of in vitro and in vivo use. It cures with an exothermic reaction, which might be desirable in painful osteoporotic vertebral fractures, but which might be detri¬mental to the healing potential of high-energy vertebral frac¬tures. PMMA is nondegradable and is significantly stronger in compression than the host bone.24-26
充填物的选择
高能量胸腰椎爆裂骨折椎体增强材料与骨质疏松骨折是不同的。水泥必须可以通过管道注入，易于处理，适当的粘稠性，有足够的工作时间（15min），较低的固化温度，适当和持续的力学性质，不透X线，生物相容性，生物活性，和低降解性等。对于高能量爆裂骨折的最合适力学性质还没有定论。硬度和强度应该与宿主骨相似。目前，聚甲基丙烯酸甲酯（PMMA）水泥广泛用于椎体强化，在体内体外均有较长的应用史。固化过程会产生发热反应，这对疼痛性骨质疏松性骨折是合适的，但对高能量椎体骨折可能会损伤其愈合潜力。PMMA无法降解，且在压力强度上远高于宿主骨。
In contrast, the immediate mechanical properties of CPC are closer to bone; however, the mechanical properties dur¬ing the resorptive phase are important as well. There is some evidence that bone formed under the influence of CPC has similar mechanical properties to native host bone during its resorptive phase.26,27 In most studies CPC has been used. It consists of 61% alpha tricalcium phosphate, 26% calcium-hydrogeno-phosphate, and 3% hydroxylapatite.
相对而言，CPC的力学特性更接近于骨，但在吸收阶段的力学特性也是很重要的。有证据表明，在CPC吸收期间形成的骨与自然宿主骨有相似的力学特性。CPC已用于大多数研究中。其由61%的α磷酸三钙、26%磷酸氢钙、3%5。
This alpha tricalcium cement is marketed as Calcibon (Bi¬omet, Merck, Wehrheim, Germany). Mixed with liquid-to¬powder ratio of 0.35, a paste is obtained with a cohesion time of 1 minute, an initial setting time of 3 minutes, and a final setting time of 7.5 minutes at 37°C without an exothermic reaction. A compressive strength of 60 Mpa is obtained at 3 days.26,28 An osteoconductive potential after 6 months with¬out cellular toxicity was shown in an animal model.26,29-31 However, CPCs are inherently brittle with inferior tensile properties compared with PMMA. Further biomechanical studies under cycling loading are needed, especially when CPC is used without posterior fixation.这种α三钙水泥的商品名为Calcibon(Bi¬omet, Merck, Wehrheim, Germany),其液体与粉的比率为0.35，混合1分钟后变为糊状，在37℃条件下，初始固化时间为3分钟，最终固化时间为7.5分钟，不产热。3天压强达到60Mpa。在动物模型中，6个月后诱导骨形成，没有细胞毒作用。然而，CPC的本身较脆，其抗张性低于PMMA。还要做更多循环负荷下的生物力学研究，特别是CPC单独应用没有后侧固定的情况下。Another important consideration is the interaction of the cement with the intervertebral disk tissue. Because we would not only expect direct contact of cement with host bone, but also with the intervertebral disk tissue, its effects on the via¬bility of the disk become important.32另一个要考虑的重要问题是水泥与椎间盘组织的反应。我们要想到水泥不仅与宿主骨直接接触，而且与椎间盘组织接触，其对椎间盘活力的影响变得十分重要。Indications
Most reports of kyphoplasty with posterior fixation have been described after a type A 3 injury with intact posterior longitudinal ligament. Oner et al33 analyzed complications of common treatment schemes of thoracolumbar fractures. He concludes that some of the complications can be predicted with magnetic resonance imaging. In the case of nonopera¬tively treated low-grade thoracolumbar fractures patients’ age and anterior columns involvement appeared to be predictive of subsequent increase of the kyphotic angle as well as per¬sistent pain. The most common mechanism of kyphosis in¬crease was through a progressive settling of the disk into the fractured endplate and vertebral body. In the operative group a high degree of endplate comminution (especially of the central endplate), the amount of kyphosis reduction and in¬volvement of the posterior longitudinal ligament complex was predictive of kyphosis recurrence. However, they found no significant correlation between pain and radiographic findings.
适应症
后凸成形结合后侧固定大多数报道用于后纵韧带完整的A3型骨折。Oner等分析了一般胸腰椎骨折治疗方案的并发症，他推断有些并发症可通过MRI预见。对于一个胸腰椎骨折年纪较轻、前柱受累的非手术治疗患者，持续的疼痛意味着后凸角可能增大。大多数后凸角增大的机制在于椎间盘组织进行性疝入骨折的终板和椎体中。对于手术的患者，粉碎的终板(特别是中央终板)、后凸的角度、及后纵韧带复合体是否受累等可以推断后凸畸形是否再发生。但他们发现疼痛与放射异常之间没有显著的相关性。
In fact, traditional short segment posterior fixation is prone to anterior spinal column failure. Kramer et al2 fol¬lowed up 11 patients treated with short segmental instru¬mentation and posterolateral fusion. During the 2-year fol¬low-up period, the kyphosis angle increased by 12.9° and the construct failed in 4 of 11 patients. Furthermore, the main¬tenance of fracture reduction was most predictive of patients’ outcome parameters.实际上，传统的后侧短节段固定易于出现前柱衰竭，Kramer等随访了11例短节段固定后外侧融合的患者，随访2年，后凸角增加了12.9°，11例中4例内固定失败。而骨折复位的保持是患者预后的重要参数。
Another study by McLain et al3 reported 3 methods of failure of these constructs (n � 19): progressive kyphosis secondary to the bending of screws (6 patients), kyphosis secondary to osseous collapse or vertebral translation with¬out bending of the hardware (3 patients), and segmental kyphosis after a caudad screw in the lumbar construct broke (1 patient, who had had a combined instrumentation for multiple fractures). Patients who had progressive kyphosis of more than 10° had substantially more pain than did those who had little or no progression. Ebelke et al34 pointed out the importance of anterior column support in his survivor-ship analysis in 21 patients with burst fractures who were treated with a short construct either with transpedicular anterior augmentation (n � 13) and without anterior aug¬mentation (n � 8). The patients treated with the anterior augmentation had a 100% survival after 22 months, whereas the group without augmentation had a 50% survival rate at 19 months. Recurrence of kyphosis after short segment pedi¬cle screw fixation raises the question as to whether anterior column augmentation with balloon-assisted endplate reduc¬tion is beneficial.
在另一项研究中，McLain等报道了内固定失败的三种形式（n=19）：螺钉弯曲引起进行性后凸（6例）、骨塌陷或椎体滑移，没有内植物弯曲（3例）、腰椎上的尾侧螺钉断裂形成节段后凸（1例，由于多处骨折采用联合固定）。进行性后凸角度超过10°者，较没有或很少进行性后凸者更疼痛。Ebelke等在21例爆裂骨折中采用短节段固定，13例加以经椎弓根增强，8例没有增强的生存分析中指出了前柱支撑的重要性，有前侧增强者，22个月随访时存活良好。没有前侧增强者，19个月随访时，有50%出现了失败。经椎弓根短节段固定后后凸畸形的再发引发球囊辅助终板复位前柱增强是否有益的问题。Magnetic resonance imaging appears to be a very helpful in assessing endplate comminution, and posterior ligamentous complex involvement after vertebral fracture. One cadaveric study suggests that short segmental fixation in combination with kyphoplasty can be applied to type B and C injuries with disrupted posterior longitudinal ligament.19 The role of the posterior longitudinal ligament for the indirect reduction and safety of the balloon-assisted endplate reduction is ques¬tioned in this study.19
MRI对判断终板粉碎及后侧韧带损伤十分有用。一项尸体研究建议，短节段固定联合后凸成形可用于后纵韧带断裂的B型和C型骨折。该研究对后纵韧带在间接复位中的作用及球囊辅助终板复位的安全性提出了质疑。
Technique
Balloon augmented vertebral endplate reduction is performed under anesthesia and antibiotic prophylaxis. Ideally, reduction is assisted by proper positioning of the patient prone with slight lordosis on a radiolucent table. Then, the posterior instrumen¬tation is implanted in either an open or percutaneous manner. If necessary, slight distraction through the posterior instrumenta¬tion can be applied to assist in fracture reduction. An inflatable balloon tamp is then used to restore the vertebral body height, and correct the vertebral endplate collapse before injection of the bone cement. A trans-or extrapedicular approach for ky-phoplasty can be used (Figs. 3 and 4).
技术
球囊扩张椎体终板复位术要在麻醉下进行，并使用抗生素预防感染。俯卧于透X线床上，保持轻度脊柱前凸的正确位置有助于复位。而后切开或经皮植入后侧器械。必要时可将后侧器械轻度撑开，以利于复位。而后置入可扩张的球囊恢复椎体高度，复位终板，而后注入骨水泥。经椎弓根或椎弓根外入路均可应用（图3、图4）。
Choice of the approach depends on the pathoanatomy of the fracture to achieve a maximum reduction of the end-plates. It is believed to be important that the inflatable bone tamps are directed toward the fracture lines in the case of a traumatic fracture to facilitate fracture reduction. After ini¬tially accessing the vertebral body, working cannulas are placed over the guide wires. Balloon size depends on the vertebral body size. The inflatable bone tamp is placed in the anterior third of the vertebrae to minimize the risk of poste¬rior fragment displacement in the canal. Balloons are inflated bilaterally simultaneously. In young patient, 200 psi are quickly obtained with low injection volumes. The initial pressure should decrease while the endplates are being re¬duced. When the desired reduction is achieved, both bal¬loons are removed and the cement is injected into the cavity. In case of loss of reduction this procedure can be repeated. Especially with posterior fixation, early mobilization can be achieved.入路的选择取决于骨折的病理解剖，以使终板获得最大程度的复位。对于创伤骨折而言，将可扩张球囊杆置入骨折线是很重要的，这有利于骨折复位。一旦进入椎体，就可以通过导丝置入工作套管。球囊的大小取决于椎体的大小。球囊置入椎体的前三分之一，以减少后侧骨块移位入椎管的危险。球囊要双侧同时进行扩张。在年轻患者，只要注入少量即可使压力达到200磅，当终板复位时，初始压力就会下降。获得满意的复位后，取出双侧球囊，将骨水泥注入空腔。如果复位丢失，可以重复以上步骤。后侧固定者，可以早期活动。
Tips and Tricks are as follows:
early intervention (less than 3 weeks after fracture)
study the pathoanatomy of the fracture on preopera¬tive CT
determine the integrity of the posterior longitudinal lig¬ament
confirm intact pedicles
fluoroscopy with every reduction and injection maneuver
bioactive cement does not have an exothermic reaction and may be remodeled into bone.
以下是一些小技巧
早期干预（伤后3周内进行）
在术前CT上研究骨折的病理解剖
判断后纵韧带的完整性
确定椎弓根完好
复位和注射过程要透视监测
生物水泥不发生产热反应，并可被骨重塑。
Conclusions
The combination of vertebral augmentation with posterior in¬strumentation is an attractive strategy to restoring spinal stability after certain burst fractures. The anterior column is restored without the morbidity of a direct anterior approach to the spine.
结论
椎体增强联合后路器械固定恢复脊柱的稳定性对一些爆裂骨折而言是一项令人瞩目的方法，不需要前路手术即可恢复前柱。
Future Directions
Further research is required to determine whether certain types of traumatic fractures can be managed with kyphoplasty with¬out supplemental posterior column stabilization. Posterior in¬strumentation may assist in fracture reduction, but removal of the posterior fixation might be feasible in the immediate or early postoperative period. In the near future, we expect to see reports of case series with an all-percutaneous approach for internal fixation as well as balloon-assisted endplate reduction. Further research is also required to determine the optimal bone filler to augment the vertebral body in younger patients with traumatic fractures. Using resorbable cements, the biomechanics immedi¬ately after application as well as during resorption are signifi¬cant. Because neither recurrence of kyphosis, nor final kyphotic deformity have proven to correlate with patient outcome after operative treatment,33,35 we should critically assess the out¬comes of the approaches described in this article.
将来的方向
还需要更多的研究来确定对某些创伤骨折是否可以仅行后凸成形术而不必后路器械固定，后路器械有助于骨折复位，可能可以在术后立即或早期去除后路器械，在不久的将来，我们希望看到和球囊终板复位一样的全经皮内固定病例报道。还要做更多的研究来确定对年轻创伤骨折患者，什么是最好的椎体增强充填物。应用可吸收骨水泥后即时和吸收期间的生物力学有很大的差别。由于术后后凸畸形的复发及最终的后凸畸形均与患者的结果非直接相关，我们要严格评估文中描述的该方法的结果。
Dalip Pelinkovic, MD,* Ranjith Kamal Udayakumar, MD,† and Frank M. Phillips, MD*
The combination of percutaneus vertebral augmentation with posterior instrumentation may be an attractive treatment option for certain high energy burst fractures. Biomaterials such as calcium phosphate cement are biocompatible, share similar biomechanical prop¬erties to bone, and are gradually replaced by host bone tissue. Early biomechanical and clinical results indicate that the anterior column may be restored without the need of a traditional anterior surgical approach. Further clinical studies are needed to confirm that this less invasive approach improves patient outcome. Semin Spine Surg 22:67-72 © 2010 Elsevier Inc. All rights reserved.
对于某些高能量爆裂骨折而言，经皮椎体增强联合后路器械固定是一个很有吸引力选择。有些生物材料，如磷酸钙骨水泥，具有良好的生物相容性，与骨的生物力学特性相似，可以逐渐被宿主骨替代。早期生物力学和临床结果显示，前柱获得了恢复，不需要再进行传统的前路手术。还需要更多的临床研究来证实这种微创方法对患者结果的促进作用。KEYWORDS burst fracture, percutaneus, balloon-assisted, reduction
关键词：爆裂骨折，经皮，球囊辅助，复位。
high-energy thoracolumbar burst fractures can be treated with decompression and anterior, posterior, or circum¬ferential fusion. Traditionally, reconstruction of the posterior tension band with a rod hook or rod screw construct is ap¬plied to assist in providing stability and reestablishing the sagittal balance. Ligamentotaxis may also assist in reducing the vertebra. Despite excellent initial fracture reduction, in¬adequate anterior column support may lead to loss of reduc¬tion, poor long-term fixation, or even failure of treatment over time.1-3 Insufficiency of the anterior column is caused by both the vertebral body fracture and also migration of the disk tissue through the endplate into the fractured vertebral body, which may not be restored with indirect reduction through posterior instrumentation.4 More extensive anterior procedures, such as anterior instrumentation and strut graft¬ing, or cage implantation may successfully restore the ante¬rior spinal column support and are proven to be effective and spare motion segments.5,6 However, anterior procedures are more invasive and are associated with increased hospitaliza¬tion, blood loss, increased surgical morbidity, or even mor¬tality.5
高能量胸腰椎爆裂骨折常采用减压，前路、后路或环形融合进行治疗。传统后侧张力带结构常采用钩棒或钉棒结构来提供稳定和重建矢状面平衡。韧带整复术有助于复位椎体。尽管早期复位非常好，如果前柱支持不足，可能导致复位丢失、内固定失效、甚至治疗失败。前柱缺损可由于椎体骨折和椎间盘组织经终板嵌入骨折椎体引起，而这是无法通过后路器械进行间接复位的。通过更广泛的前路手术进行器械固定支撑、cage植入等方法可以有效恢复前柱支撑，减少节段活动。但是前路手术的创伤较大，且住院时间更长，出血更多，增加了外科手术率，甚至病死率。Recently, percutaneous instrumentation combined with percutaneous vertebral body augmentation (kyphoplasty/ vertebroplasty) has been added to the surgical armamentar¬ium. In osteoporotic vertebral fractures, kyphoplasty has proven to be a safe procedure with excellent outcomes.7 However, the pathoanatomy of a high-energy burst fracture is distinct from osteoporotic vertebral fractures. Three frac¬ture patterns-wedge, crush, and biconcave-have been de¬scribed in the osteoporotic patient.8,9 The posterior wall and endplates are mostly intact. In addition, the osteoporotic bone with decreased number and connectivity of trabeculae allows restoration of the vertebral height as balloon tamp inflation compresses the soft cancellous bone and elevates the end plates.7,10近来，经皮器械和经皮椎体增强技术（后凸成形和椎体成形术）已成为外科手段。对于骨质疏松性骨折，后凸成形术已被证实是十分安全有效的。然而高能量爆裂骨折与骨质疏松性骨折的病理解剖是不同的。骨质疏松性骨折有三种骨折形式：楔形、爆裂、双凹，后壁和终板多数是完整的。而且，骨质疏松的骨骼由于骨小梁减少，连接力降低，当球囊扩张时，可挤压松软的松质骨，抬高终板，从而恢复椎体高度。
In contrast, high-energy traumatic burst fractures are usu¬ally caused by substantial axial loading, which results in com¬pression failure of at least the middle and anterior spinal column. The sudden axial load results in a vertebral endplate failure as adjacent disk tissue is driven into the vertebral body. The vast majority of burst fractures cause some canal compromise, typically because of osseous fragments from the superior endplate. Determinants of instability are progressive neurological deficit, progressive kyphosis, radiographic evi¬dence of substantial posterior column instability, greater than 50% loss of vertebral body height in association with kypho¬sis. Fractured and depressed endplates increase the chance of disk displacement into the vertebral body with subsequent focal spinal deformity and failure of the treatment. Conse¬quently, the combination of indirect reduction of thoraco¬lumbar burst fractures with balloon-assisted endplate re¬duction may recreate a stable anterior column, and stable endplates with long-term maintenance of the sagittal alignment (Fig. 1). Advantages of minimal invasive tech¬niques are quicker recovery, less pain, decreased surgical morbidity, and potentially a more stable construct than isolated posterior or anterior stabilization because of less tissue disruption.
相反，高能量爆裂骨折通常由巨大的轴向负荷引起，至少可使前柱和中柱的压缩破坏。突然的轴向负荷可破坏椎体终板，使邻近的椎间盘组织疝入椎体。大多数爆裂骨折可引起椎管侵害，骨块特别常来自上终板。进行性神经损害、进行性后凸、放射学证实的后柱不稳、椎体高度丧失大于50%伴有后凸者被认为是不稳定。骨折和凹陷的终板增加了椎间盘疝入椎体、局部畸形、治疗失败的机会。这样一来，对胸腰椎爆裂骨折通过间接复位辅以球囊扩张使终板复位就可以重建前柱和终板的稳定，从而保持矢状序列的长期稳定。微创的优势在于恢复快、疼痛轻、减少了外科手术率、由于对组织破坏少，可能更稳定。
Transpedicular vertebral cancellous bone grafting for the treatment of vertebral compression fractures has been de¬scribed in the published data with little success in maintain¬ing the anterior column of the spine and was associated with a high failure rate.11-15 Transpedicular hydroxyapatite stick grafting is another technique, which is currently under inves¬tigation.16经椎弓根植骨治疗椎体压缩骨折，文献报道难以维持前柱，并有很高的失败率。近来导航下经椎弓根羟基磷灰石棒植入是另一项技术。Basic Science Studies
Mermelstein et al17 showed in their cadaveric burst fracture study that vertebroplasty with calcium phosphate cement (CPC) reinforced the anterior column and reduced the stress on the pedicle-screw rod construct. In another cadaveric study18 balloon-assisted endplate reduction was used to sig¬nificantly restore vertebral height and end plate anatomy af¬ter short segmental instrumentation. A follow-up study by the same group used a detailed 3-dimensional radiography at different phases of the model, from fracture to balloon-as¬sisted endplate reduction and cement injection. They dem¬onstrated no collapse after removal of the balloons, mainte¬nance of the vertebral height with cement injection, and no cement extravasation.18
Another study investigated the role of the longitudinal lig¬aments during balloon-assisted endplate reduction in thora¬columbar burst fractures.19 In a human cadaveric burst frac¬ture model, the anterior and posterior bone displacement was assessed after applying short segmental fixation followed by kyphoplasty. Although anterior bone and posterior bone displacement occurred with the inflation of the balloons, the effect subsided after deflation and did not recur with injec¬tion of the cement. The amount of displacement (�1 mm) was thought to be of little clinical significance. According to this study, an intact posterior longitudinal ligament does not appear to be necessary to prevent posterior bone displace¬ment. They could also not confirm the importance of the posterior longitudinal ligament with reduction through liga¬mentotaxis.
基础研究
Mermelstein等研究发现，磷酸钙骨水泥可以强化爆裂骨折的前柱，减少椎弓根钉的的压力。在另一项尸体研究中，采用球囊复位终板，短节段固定，使椎体高度和终板解剖显著恢复，该研究采用三维X线对从骨折－球囊扩张终板复位－骨水泥注入的不同阶段进行详细观测，他们发现球囊取出后椎体不会塌陷，骨水泥注入后椎体高度得以保持，没有骨水泥渗漏。另一项研究调查了后纵韧带在胸腰椎爆裂骨折球囊辅助终板复位中的作用。在一个人类尸体爆裂骨折模型中，采用短节段固 定辅以后凸成形，评估前后骨块移位。虽然球囊扩张时前后骨块发生移位，但球囊收缩时，这种作用就减小了，且椎体内注入骨水泥后，也没有再发生。其移位的程度（＜1mm）没有临床意义。根据这项研究，完整的后纵韧带无法阻止后方骨块的移位。他们也无法确定韧带复位技术中后纵韧带的重要性。
Clinical Studies
Afzal et al reported on 16 patients (age, 22-53 years) with high-energy burst fractures (12 Denis type B and 4 Denis type C burst fractures) who were followed up for 1 month clini¬cally and radiographically.20 Patients with posterior longitu¬dinal ligament injury were excluded. After short segment pedicle screw fixation, a balloon-assisted kyphoplasty was performed with CPC. In addition, a removable plastic jacket was prescribed for 8 weeks. Cement leakage was observed in 3 patients (2 in the spinal canal, 1 in the disk space), with no clinical consequences. No posterior wall displacement was recorded. The average kyphosis angle of the segment was reduced by 10°.
临床研究
Afzal等报道了16例（年龄，22－53岁）高能量爆裂骨折病例（12例Denis B型,4例Denis C型爆裂骨折），临床与X线进行随访1个月。后纵韧带损伤者排除在外。短节段椎弓根钉固定后，采用CPC进行球囊辅助后凸成形术。可拆式塑料夹克固定8周。3例患者发生骨水泥渗漏（2例在椎管，1例在椎间隙），没有临床症状。没有发生后壁移位，平均后凸角减少10°。
Another investigation included 18 patients (64 � 15 years) with severe thoracolumbar burst and compression fractures (Figs. 2-4).21 All patients were treated with short segment percutaneous posterior instrumentation and bal¬loon kyphoplasty with CPC within 24 hours of injury and were followed up for 22 months. Kyphosis improved from an average of 16°-2°. Cement leakage was observed only ante¬rior to the vertebral body without clinical sequelae. A second study by the same group treating thoracolumbar burst frac¬tures with calcium phosphate and an open approach for pos¬terior spinal instrumentation showed similarly encouraging results at 24 months without major complications (Fig. 1).22 另一项研究有18例病人（64±15岁），严重的胸腰椎爆裂和压缩骨折（图2－4）。所有的病人都在伤后24小时内采用后路经皮短节段固定CPC球囊后凸成形术，随访22个月。后凸从平均16°恢复至2°。骨水泥仅渗漏至椎体前方，没有后遗症。同一小组采用羟基磷灰石和开放后路固定取得了相似的效果，随访24个月，没有严重并发症发生（图1）。A prospective case series on standalone kyphoplasty with CPC in Magerl type A fractures without deficit noted a decrease of pain on the visual analogue scale from 8.7 preoperatively to 3.1 postoperatively in 7 days, and 1 at the last follow-up at 30 months.23 The Roland Morris Disability score demonstrated a similar decrease in the early postoper¬ative time period. Two anterior wall perforations by cannulas during the procedure, and 6 cement leakages were observed on postoperative computed tomography (CT) scans (5 cases into the disk space, 1 case with small leakage in the lateral portion of the spinal canal). All were without neurological or vascular consequences. Also, no long-term complications were observed at the last 30 month follow up. Twenty per¬cent cement resorption and substitution was noted on CT scans at 1 year postoperatively. Loss of correction was 9° (0°-17°) from immediate postoperatively to the last fol¬low-up at 30 months. This may relate to loss of vertebral height as the resorbable cement is remodeled.
一项单独采用CPC后凸成形治疗没有神经损害的Magerl A型骨折的病例回顾中，术后7天疼痛视觉模糊评分从术前8.7分恢复至3.1分，术后30个月恢复至1分。Roland Morris 残疾评分在术后早期也相应下降。两例前壁穿孔，6例术后CT发生骨水泥渗漏入椎间隙，1例少量渗漏至椎管侧方。所有病人没有出现神经或血管并发症。30个月随访没有长期并发症。20%在术后1年CT观察时骨水泥吸收替代，从术后即时至术后30个月的矫正丢失为9°（0°－17°），这可能与可吸收骨水泥吸收后引起的高度丢失有关。
Filler Choice
Considerations for materials for vertebral augmentation for high-energy thoracolumbar burst fractures are different from those in osteoporotic fractures. The cement should be inject¬able through cannulas, easy handling, appropriately viscous, have an adequate working time (15 min), low curing temper¬ature, adapting and lasting mechanical properties, high ra¬dioopacity, biocompatibility, bioactivity, and slow biodegra¬dation. The optimal mechanical properties have not yet been determined for high-energy burst fractures. Stiffness and yield strength should be similar the host bone. Presently, polymethylmethacrylate (PMMA) cement is most widely used for vertebral augmentation procedures, with an exten¬sive history of in vitro and in vivo use. It cures with an exothermic reaction, which might be desirable in painful osteoporotic vertebral fractures, but which might be detri¬mental to the healing potential of high-energy vertebral frac¬tures. PMMA is nondegradable and is significantly stronger in compression than the host bone.24-26
充填物的选择
高能量胸腰椎爆裂骨折椎体增强材料与骨质疏松骨折是不同的。水泥必须可以通过管道注入，易于处理，适当的粘稠性，有足够的工作时间（15min），较低的固化温度，适当和持续的力学性质，不透X线，生物相容性，生物活性，和低降解性等。对于高能量爆裂骨折的最合适力学性质还没有定论。硬度和强度应该与宿主骨相似。目前，聚甲基丙烯酸甲酯（PMMA）水泥广泛用于椎体强化，在体内体外均有较长的应用史。固化过程会产生发热反应，这对疼痛性骨质疏松性骨折是合适的，但对高能量椎体骨折可能会损伤其愈合潜力。PMMA无法降解，且在压力强度上远高于宿主骨。
In contrast, the immediate mechanical properties of CPC are closer to bone; however, the mechanical properties dur¬ing the resorptive phase are important as well. There is some evidence that bone formed under the influence of CPC has similar mechanical properties to native host bone during its resorptive phase.26,27 In most studies CPC has been used. It consists of 61% alpha tricalcium phosphate, 26% calcium-hydrogeno-phosphate, and 3% hydroxylapatite.
相对而言，CPC的力学特性更接近于骨，但在吸收阶段的力学特性也是很重要的。有证据表明，在CPC吸收期间形成的骨与自然宿主骨有相似的力学特性。CPC已用于大多数研究中。其由61%的α磷酸三钙、26%磷酸氢钙、3%5。
This alpha tricalcium cement is marketed as Calcibon (Bi¬omet, Merck, Wehrheim, Germany). Mixed with liquid-to¬powder ratio of 0.35, a paste is obtained with a cohesion time of 1 minute, an initial setting time of 3 minutes, and a final setting time of 7.5 minutes at 37°C without an exothermic reaction. A compressive strength of 60 Mpa is obtained at 3 days.26,28 An osteoconductive potential after 6 months with¬out cellular toxicity was shown in an animal model.26,29-31 However, CPCs are inherently brittle with inferior tensile properties compared with PMMA. Further biomechanical studies under cycling loading are needed, especially when CPC is used without posterior fixation.这种α三钙水泥的商品名为Calcibon(Bi¬omet, Merck, Wehrheim, Germany),其液体与粉的比率为0.35，混合1分钟后变为糊状，在37℃条件下，初始固化时间为3分钟，最终固化时间为7.5分钟，不产热。3天压强达到60Mpa。在动物模型中，6个月后诱导骨形成，没有细胞毒作用。然而，CPC的本身较脆，其抗张性低于PMMA。还要做更多循环负荷下的生物力学研究，特别是CPC单独应用没有后侧固定的情况下。Another important consideration is the interaction of the cement with the intervertebral disk tissue. Because we would not only expect direct contact of cement with host bone, but also with the intervertebral disk tissue, its effects on the via¬bility of the disk become important.32另一个要考虑的重要问题是水泥与椎间盘组织的反应。我们要想到水泥不仅与宿主骨直接接触，而且与椎间盘组织接触，其对椎间盘活力的影响变得十分重要。Indications
Most reports of kyphoplasty with posterior fixation have been described after a type A 3 injury with intact posterior longitudinal ligament. Oner et al33 analyzed complications of common treatment schemes of thoracolumbar fractures. He concludes that some of the complications can be predicted with magnetic resonance imaging. In the case of nonopera¬tively treated low-grade thoracolumbar fractures patients’ age and anterior columns involvement appeared to be predictive of subsequent increase of the kyphotic angle as well as per¬sistent pain. The most common mechanism of kyphosis in¬crease was through a progressive settling of the disk into the fractured endplate and vertebral body. In the operative group a high degree of endplate comminution (especially of the central endplate), the amount of kyphosis reduction and in¬volvement of the posterior longitudinal ligament complex was predictive of kyphosis recurrence. However, they found no significant correlation between pain and radiographic findings.
适应症
后凸成形结合后侧固定大多数报道用于后纵韧带完整的A3型骨折。Oner等分析了一般胸腰椎骨折治疗方案的并发症，他推断有些并发症可通过MRI预见。对于一个胸腰椎骨折年纪较轻、前柱受累的非手术治疗患者，持续的疼痛意味着后凸角可能增大。大多数后凸角增大的机制在于椎间盘组织进行性疝入骨折的终板和椎体中。对于手术的患者，粉碎的终板(特别是中央终板)、后凸的角度、及后纵韧带复合体是否受累等可以推断后凸畸形是否再发生。但他们发现疼痛与放射异常之间没有显著的相关性。
In fact, traditional short segment posterior fixation is prone to anterior spinal column failure. Kramer et al2 fol¬lowed up 11 patients treated with short segmental instru¬mentation and posterolateral fusion. During the 2-year fol¬low-up period, the kyphosis angle increased by 12.9° and the construct failed in 4 of 11 patients. Furthermore, the main¬tenance of fracture reduction was most predictive of patients’ outcome parameters.实际上，传统的后侧短节段固定易于出现前柱衰竭，Kramer等随访了11例短节段固定后外侧融合的患者，随访2年，后凸角增加了12.9°，11例中4例内固定失败。而骨折复位的保持是患者预后的重要参数。
Another study by McLain et al3 reported 3 methods of failure of these constructs (n � 19): progressive kyphosis secondary to the bending of screws (6 patients), kyphosis secondary to osseous collapse or vertebral translation with¬out bending of the hardware (3 patients), and segmental kyphosis after a caudad screw in the lumbar construct broke (1 patient, who had had a combined instrumentation for multiple fractures). Patients who had progressive kyphosis of more than 10° had substantially more pain than did those who had little or no progression. Ebelke et al34 pointed out the importance of anterior column support in his survivor-ship analysis in 21 patients with burst fractures who were treated with a short construct either with transpedicular anterior augmentation (n � 13) and without anterior aug¬mentation (n � 8). The patients treated with the anterior augmentation had a 100% survival after 22 months, whereas the group without augmentation had a 50% survival rate at 19 months. Recurrence of kyphosis after short segment pedi¬cle screw fixation raises the question as to whether anterior column augmentation with balloon-assisted endplate reduc¬tion is beneficial.
在另一项研究中，McLain等报道了内固定失败的三种形式（n=19）：螺钉弯曲引起进行性后凸（6例）、骨塌陷或椎体滑移，没有内植物弯曲（3例）、腰椎上的尾侧螺钉断裂形成节段后凸（1例，由于多处骨折采用联合固定）。进行性后凸角度超过10°者，较没有或很少进行性后凸者更疼痛。Ebelke等在21例爆裂骨折中采用短节段固定，13例加以经椎弓根增强，8例没有增强的生存分析中指出了前柱支撑的重要性，有前侧增强者，22个月随访时存活良好。没有前侧增强者，19个月随访时，有50%出现了失败。经椎弓根短节段固定后后凸畸形的再发引发球囊辅助终板复位前柱增强是否有益的问题。Magnetic resonance imaging appears to be a very helpful in assessing endplate comminution, and posterior ligamentous complex involvement after vertebral fracture. One cadaveric study suggests that short segmental fixation in combination with kyphoplasty can be applied to type B and C injuries with disrupted posterior longitudinal ligament.19 The role of the posterior longitudinal ligament for the indirect reduction and safety of the balloon-assisted endplate reduction is ques¬tioned in this study.19
MRI对判断终板粉碎及后侧韧带损伤十分有用。一项尸体研究建议，短节段固定联合后凸成形可用于后纵韧带断裂的B型和C型骨折。该研究对后纵韧带在间接复位中的作用及球囊辅助终板复位的安全性提出了质疑。
Technique
Balloon augmented vertebral endplate reduction is performed under anesthesia and antibiotic prophylaxis. Ideally, reduction is assisted by proper positioning of the patient prone with slight lordosis on a radiolucent table. Then, the posterior instrumen¬tation is implanted in either an open or percutaneous manner. If necessary, slight distraction through the posterior instrumenta¬tion can be applied to assist in fracture reduction. An inflatable balloon tamp is then used to restore the vertebral body height, and correct the vertebral endplate collapse before injection of the bone cement. A trans-or extrapedicular approach for ky-phoplasty can be used (Figs. 3 and 4).
技术
球囊扩张椎体终板复位术要在麻醉下进行，并使用抗生素预防感染。俯卧于透X线床上，保持轻度脊柱前凸的正确位置有助于复位。而后切开或经皮植入后侧器械。必要时可将后侧器械轻度撑开，以利于复位。而后置入可扩张的球囊恢复椎体高度，复位终板，而后注入骨水泥。经椎弓根或椎弓根外入路均可应用（图3、图4）。
Choice of the approach depends on the pathoanatomy of the fracture to achieve a maximum reduction of the end-plates. It is believed to be important that the inflatable bone tamps are directed toward the fracture lines in the case of a traumatic fracture to facilitate fracture reduction. After ini¬tially accessing the vertebral body, working cannulas are placed over the guide wires. Balloon size depends on the vertebral body size. The inflatable bone tamp is placed in the anterior third of the vertebrae to minimize the risk of poste¬rior fragment displacement in the canal. Balloons are inflated bilaterally simultaneously. In young patient, 200 psi are quickly obtained with low injection volumes. The initial pressure should decrease while the endplates are being re¬duced. When the desired reduction is achieved, both bal¬loons are removed and the cement is injected into the cavity. In case of loss of reduction this procedure can be repeated. Especially with posterior fixation, early mobilization can be achieved.入路的选择取决于骨折的病理解剖，以使终板获得最大程度的复位。对于创伤骨折而言，将可扩张球囊杆置入骨折线是很重要的，这有利于骨折复位。一旦进入椎体，就可以通过导丝置入工作套管。球囊的大小取决于椎体的大小。球囊置入椎体的前三分之一，以减少后侧骨块移位入椎管的危险。球囊要双侧同时进行扩张。在年轻患者，只要注入少量即可使压力达到200磅，当终板复位时，初始压力就会下降。获得满意的复位后，取出双侧球囊，将骨水泥注入空腔。如果复位丢失，可以重复以上步骤。后侧固定者，可以早期活动。
Tips and Tricks are as follows:
early intervention (less than 3 weeks after fracture)
study the pathoanatomy of the fracture on preopera¬tive CT
determine the integrity of the posterior longitudinal lig¬ament
confirm intact pedicles
fluoroscopy with every reduction and injection maneuver
bioactive cement does not have an exothermic reaction and may be remodeled into bone.
以下是一些小技巧
早期干预（伤后3周内进行）
在术前CT上研究骨折的病理解剖
判断后纵韧带的完整性
确定椎弓根完好
复位和注射过程要透视监测
生物水泥不发生产热反应，并可被骨重塑。
Conclusions
The combination of vertebral augmentation with posterior in¬strumentation is an attractive strategy to restoring spinal stability after certain burst fractures. The anterior column is restored without the morbidity of a direct anterior approach to the spine.
结论
椎体增强联合后路器械固定恢复脊柱的稳定性对一些爆裂骨折而言是一项令人瞩目的方法，不需要前路手术即可恢复前柱。
Future Directions
Further research is required to determine whether certain types of traumatic fractures can be managed with kyphoplasty with¬out supplemental posterior column stabilization. Posterior in¬strumentation may assist in fracture reduction, but removal of the posterior fixation might be feasible in the immediate or early postoperative period. In the near future, we expect to see reports of case series with an all-percutaneous approach for internal fixation as well as balloon-assisted endplate reduction. Further research is also required to determine the optimal bone filler to augment the vertebral body in younger patients with traumatic fractures. Using resorbable cements, the biomechanics immedi¬ately after application as well as during resorption are signifi¬cant. Because neither recurrence of kyphosis, nor final kyphotic deformity have proven to correlate with patient outcome after operative treatment,33,35 we should critically assess the out¬comes of the approaches described in this article.
将来的方向
还需要更多的研究来确定对某些创伤骨折是否可以仅行后凸成形术而不必后路器械固定，后路器械有助于骨折复位，可能可以在术后立即或早期去除后路器械，在不久的将来，我们希望看到和球囊终板复位一样的全经皮内固定病例报道。还要做更多的研究来确定对年轻创伤骨折患者，什么是最好的椎体增强充填物。应用可吸收骨水泥后即时和吸收期间的生物力学有很大的差别。由于术后后凸畸形的复发及最终的后凸畸形均与患者的结果非直接相关，我们要严格评估文中描述的该方法的结果。
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