文献翻译－胸腰椎骨折－骨质疏松骨折的处理
发布于 2010-09-25 · 浏览 5436 · IP 浙江浙江
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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 inflation 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 insufficiency fractures are primarily the result of
osteopenia and osteoporosis, defined 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 patient’s 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 dis-
ease, such as diabetes, or tomedications, such as corticosteroids
or antiseizuremedications. Idiopathic osteoporosis, as the name
implies, has no identifiable cause.
疾病概况
世界卫生组织定义当t值小于﹣1～﹣2.5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 osteopo-
rosis 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. Asymp-
tomatic VCFsmay be identified incidentally on imaging stud-
ies or by the increasing kyphotic posture of the patient. Ap-
proximately 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, smok-
ing, 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 patient’s 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 body’s 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. Pa-
tients with a VCF are also at a 2 times greater risk for devel-
oping hip fractures.Mortality after VCF has been shown to be
as high as 20% within the first 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 age-
matched controls.
17
VCF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, in-
cluding 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
patient’s 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 difficult to evaluate with
conventional radiographs. Computed tomography may also
assist in preoperative planning, specifically in terms of eval-
uating 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 finding on a bone scan, leading to a possible false-
negative 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 absorp-
tiometry scan should be performed to assess the patient’s
BMD.Medical and/or cardiology consults should be obtained
as appropriate if surgery is planned. Consulting a pain man-
agement 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
Nonoperative
Initial 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-inflammatory
medications, antidepressants, and neuropathic agents. Each
of these classes ofmedications has substantial side-effect pro-
files, including sedation from narcotics and gastrointestinal
and cardiac effects from nonsteroidal anti-inflammatory
medications, which are accentuated in elderly patients. A
pain management specialist and the patient’s 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 patient’s
pain and to reduce the risk of future fractures.
20,21 Initially,
therapy should focus on core strengthening to improve pos-
ture 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 and
prevent 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 hyperexten-
sion braces, thoracolumbosacral orthoses, and posture-train-
ing support orthoses. Patient compliance with bracing may
be difficult 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 difficult to
fit 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 use-
ful for patients with a retropulsed fragment invading the spi-
nal canal but who are not good surgical candidates. Selective
nerve root injections may be used for patients with radicular-
type 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 patient’s osteoporosis or osteopenia. This treat-
ment should be orchestrated in a multidisciplinary fashion,
involving the surgeon, the patient’s primary care physician,
and potentially an endocrinologist. Asmentioned previously,
a dual-energy x-ray absorptiometry scan should be obtained
to measure the patient’s BMD. The patient’s nutrition should
be maximized, ensuring sufficient intake of vitamin D (800-
1000 IU/d)24 and calcium (1200 mg/d).
25 Medical manage-
ment may include the use of bisphosphonates, calcitonin,
estrogen, raloxifene (a selective estrogen analog), and para-
thyroid hormone. Currently, the American Board of Obstet-
rics and Gynecology recommends prescribing one of these
medications for any patient sustaining an osteoporotic frac-
ture, 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 con-
trol study evaluated the use of zoledronic acid (an intrave-
nously 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 au-
thors noted relatively minor complications with the medica-
tion, 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800－1000IU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。
Operative
Given that most VCFs occur in elderly patients without neu-
rologic deficits who havemedical comorbidities and osteope-
nia 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 sur-
gical 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 intro-
duced first 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 proce-
dure involves the inflation of a balloon-type bone tamp be-
fore 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 Surgery
The indications for vertebroplasty and kyphoplasty in the
treatment of VCFs include acute, painful, osteporotic or os-
teolytic VCFs; pathologic fractures in patients withmetastatic
disease; painful vertebral hemangioma; and Kummell’s dis-
ease.
30,31 It is important that only symptomatic fractures be
treated and not all fractures that are seen on imaging stud-
ies.
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, specifically, fat-
suppressed T2-weighted or short tau inversion recovery se-
quence 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（外伤后脊椎炎，脊柱受压骨折。英汉医学词典。译者注，但仍不太明白）。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-
ficiency of the posterior wall, local or systemic infection (sep-
sis), osteoblastic metastatic lesions, inability to obtain ade-
quate intraoperative imaging, and advanced or multiple
medical comorbidities. In addition, performing these proce-
dures 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 Technique
Patient positioning for vertebroplasty and kyphoplasty is
similar. Patients are usually positioned prone on a radiolu-
cent 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. Ide-
ally, the back should be extended to facilitate reduction. An-
esthesia may be general, sedation, or local, depending on the
circumstance and the patient’s 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
fluoroscopic images should be obtained in the anteroposte-
rior (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 fluoroscopic
imaging is essential, and the surgery should not proceed if the
images are not satisfactory. One or 2 fluoroscopy units can be
used, depending on machine availability and surgeon prefer- ence. The use of 2 fluoroscopy 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 postero-
lateral approach. The choice of approach should be identified
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 collapsed below the level of the pedicle.
The extrapedicular approach is usually used for higher tho-
racic levels or vertebrae with small pedicles. It has the advan-
tage of allowing more medial placement of the working can-
nula. The posterolateral approach is reserved for lumbar
vertebrae with extensive collapse or small pedicles, factors
which would make the standard transpedicular approach
technically challenging.
在病人摆好体位后，要增强的椎体要定位好。可能通过经椎弓根、椎弓根外、后外侧入路到达椎体前侧。入路的选择要根据影像和骨折的部位，术前就确定好。经椎弓根入路常用于T10－L5，对于椎弓根较小或椎体爆裂骨折位于椎弓根平面下者不合适。椎弓根外入路用于高位胸椎及椎弓根较小者，其优点在于套管可以更偏向内侧放置。后外侧入路用于腰椎严重爆裂或小椎弓根或采用标准经椎弓根困难者。For the transpedicular approach, an incision is made ap-
proximately 2-3 cm lateral from midline, in line with the
pedicle. The appropriate trocar or needle is selected and,
under fluoroscopic guidance, it is positioned on the supero-
lateral corner of the pedicle. The trocar is advanced using
firm but controlled pressure; frequent images are obtained
to confirm location. The trocar should be angled slightly
medial, but care should be taken that the needle does not
cross the medial border of the pedicle on the AP image
until it has reached the posterior aspect of the vertebral
body and the end of the pedicle on the lateral view. If the
trocar is noted to cross the medial border before this stage,
a medial breach should be suspected, and the trocar
should be withdrawn and redirected. After the trocar has
entered the vertebral body, it should continue to be angled
medially and should approach, but not cross, the midline.
An oblique view directed straight down the pediclemay be
helpful for confirming the position of the trocar within the
pedicle. This view is obtained by bringing the fluoroscopy
unit approximately 10° off the midline to provide a view
line with the path of the pedicle.
采用经椎弓根入路，在中线外约2－3cm处椎弓根线做切口。选择合适的套管针透视下置于椎弓根的外上角，稳稳控制前进，多透视以确定位置。套管针要轻度偏向内侧，但要注意，在侧位上到达椎体后壁、椎弓根末端之前在前后位上不要超过椎弓根的内侧界。如果在此之间套管就超过了椎弓根的内侧界，要考虑内侧壁穿破，套管针要取出重新定向。一旦套管针进入椎体，要尽量向内侧倾斜，但不要超过中线。将球管偏离中线10°使球管方向与椎弓根方向一致的斜位片有助于确定套管针是否位于椎弓根内。As mentioned previously, the extrapedicular approach is
typically used in the mid to upper thoracic spine. A transpe-
dicular approach at these levels usually results in an unac-
ceptably lateral placement of the trocar. To perform the ex-
trapedicular approach, the trocar is positioned just superior
and lateral to the pedicle, and medial to the head of the rib.
Occasionally, it is necessary to cannulate through the rib
head. The starting point should be at or anterior to the level of
the spinal canal on a lateral image, which minimizes the risk
of spinal canal violation. Care should be taken not to slide
inferior or superior off the rib head, where plunging with the
trocar risks injuring the lung.
如前所述，椎弓根外入路主要用于中至上胸椎，在这些部位，经椎弓根入路套管针的侧方位置无法接受。要采用椎弓根外入路，套管针必须位于椎弓根的外上方，并位于肋骨头的内侧。偶尔，必须穿过肋骨头。侧位像上起点要位于椎管水平或其前方。小心不要向上或向下滑过肋骨头，以免损伤肺脏。
Ideal medial-to-lateral positioning within the vertebral
body may vary, depending on the use of a unilateral or bilat-
eral approach (see discussion later). Additionally, ideal supe-
rior-inferior positioning depends on the nature of the frac-
ture. The trocar should be positioned in proximity to the
fractured endplate, that is, positioned adjacent to the supe- rior endplate for superior endplate fractures and vice versa
for inferior fractures. Steens et al
33 suggested that endplate-
to-endplate cement placement offers the best biomechanical
strength after augmentation. The location of the cement
within the vertebral body has not been shown to affect adja-
cent level fractures.
34
单侧入路和双侧入路椎体内的理想内外位置不同（见后述讨论）。理想的上下位置取决于骨折的性质。套管的位置要接近骨折的终板，也就是说，上终板骨折要邻近上终板，下终板骨折接近下终板。Steens等认为，终板骨水泥可便椎体强化获得最好的生物力学强度。椎体内骨水泥的位置不会造成邻近节段骨折。
Once the trocar is successfully positioned, the vertebral
body should be biopsied by passing a Craig or biopsy needle
hrough the working cannula. Although patient history,
physical examination, and imaging studies should suggest
whether the fracture is a result of malignancy, only biopsy
can confirm or refute this potential causative factor. Schoen-
eld et al
35 reviewed 80 vertebral augmentation procedures
on 50 patients, including 8 in patients who were suspected of
having VCFs because of malignancy. They reported 4 positive
biopsy results, including 3 in patientswhowere not suspected of
having amalignant process, leading to an 8%rate ofmalignancy.
Additionally, 7 of 8 patients suspected of having a malignant
racture were found to have benign fractures. Biopsy results can
have a substantial impact on patient care.
套管针成功置入后，可以通过工作通道用Craig或活检针做个活检。尽管病史、体检、影像都可以提示骨折是不是恶性肿瘤引起的，只有活检是唯一可以确定或排除这种可能的方法。Schoenfeld等回顾了80例椎体增强手术中的50例患者，包括8例考虑为恶性肿瘤引起的VCF。4例活检阳性，其中3例为没有考虑为恶性，恶性率为8％。8例考虑为恶性者，7例发现为良性。活检的结果对患者的治疗有重要的意义Once the trocar is in position, the techniques used for
vertebroplasty and kyphoplasty diverge. For vertebroplasty
(Fig. 1), the cement is injected directly into the vertebral
body through the trocar. The cement is injected in a less
viscous state and under relatively high pressure to allow per-
meation through the cancellous bone of the vertebral body.
29
When performing kyphoplasty (Fig. 2), an inflatable balloon
tamp is inserted through the working cannula to reduce the
fracture and to create a cavity into which the cement will be
injected. Care is taken to ensure that no additional endplate
fractures occur. If 2 balloons are used, they should be inflated
alternately to ensure even expansion. After adequate reduc-
tion is obtained, the balloons are deflated and withdrawn,
and the cement is then injected into the voids using the
trocar. Usually, cement-filled cannulas are placed in the void,
and their plungers are used to slowly push out the cement,
although other insertion devices are available. Cement injec-
tion during both techniques should be carefully monitored
under fluoroscopy and halted immediately if there are any
concerns for extravasation.
套管针放好后，椎体成形术与后凸形术的技术是不同的。椎体成形术（图1）将骨水泥通过套管针直接注入椎体，骨水泥在低稠状态下注入，注入的压力相对较高，以使骨水泥渗入松质骨中。后凸成形术（图2）则通过工作通道置入一个可扩张球囊对骨折进行复位，并制造出一个空腔，以利于骨水泥注入。注意确定没有另外的终板骨折发生。如果置入两个球囊，要交替进行扩张，以使膨胀均匀。复位充分后，让球囊萎陷，再取出。再注入骨水泥。通常将注满骨水泥的套管放在空腔处，再用内芯将骨水泥缓慢推出，也可能用别的器件。两种技术都要在透视监视下进行，一旦有骨水泥渗漏，立即停止。When performing kyphoplasty, 1 or 2 balloons can be
used.When 2 balloons are selected, 1 is advanced down each
pedicle and should be positioned fairly symmetrically in the
vertebral body. If 1 balloon is used, it should be positioned as
close to midline as possible, with care taken not to cross too
medially and violate the spinal canal. Using 1 balloon may be
advantageous for patients with small vertebral bodies, partic-
ularly in the higher thoracic levels. The 1-balloon technique
also has the advantages of shortened operating room time
and less radiation fromfluoroscopy because only 1 cannula is
passed. Chung et al
36 showed that using 2 balloons resulted
in increased fracture reduction and a lower incidence of loss
of reduction postoperatively. However, they found no differ-
ence in pain relief for the 2 techniques.
后凸成形术可以用一个或两个球囊。如果用两个球囊，两侧椎弓根各置一个，并要对称放置。如果只用一个，则要尽可能靠中线放置。注意不要越过中线侵入椎管。用一个球囊对椎体较小者较为合适，如高位胸椎。用一个球囊也可以减少手术时间和减少透视，因为只要置入一个插管。Chung等发现用两个球囊可以增加骨折复位，减少术后复位丢失的发生率。但他们也发现两种技术在疼痛缓解上没有区别。
Clinical Results
Numerous studies have evaluated the clinical effectiveness of
vertebroplasty and kyphoplasty for the treatment of osteopo- rotic and osteolytic VCFs. In a relatively large study, Garfin et
al
37 retrospectively reviewed 1439 patients with VCFs and
found that 90% had significant pain relief after kyphoplasty.
In addition, several recentmeta-analyses evaluating the treat-
ment of VCFs with vertebroplasty and kyphoplasty have
been reported. Eck et al
38 reported that the patients’ pain
scores on the Visual Analog Scale (VAS) decreased by 5.68
(8.36-2.68) after vertebroplasty and by 4.60 (8.06-3.46) after
kyphoplasty. These results are similar to those reported by
Hulme et al,
39 who found decreased VAS scores of 5.2 (8.2-
3.0) after vertebroplasty and 4.8 (7.2-3.4) after kyphoplasty.
The slight trend in better pain relief from vertebroplasty was
not seen in the meta-analysis performed by Gill et al,
40 which
found that VAS scores decreased by 5.44 after vertebroplasty
and 5.62 after kyphoplasty, or by the study performed by
Taylor et al,
41 which likewise showed no significant differ-
ence. Taylor et al
41 also showed decreased pain scores with
vertebral augmentation at 3, 6, 12, and 36 months compared
with nonoperative treatment and that the length of hospital-
ization decreased from13.4 to 7.4 days. In addition,multiple
studies have shown improved functional outcome scores af-
ter vertebral augmentation.
42-44
临床结果
关于椎体成形术和后凸成形术治疗VCF的效果的报道很多，在一项较大的研究中，Garfin等回顾了1439例VCF病例，发现后凸成形术后，90％疼痛获得了显著的缓解。另外，多中心meta分析椎体成形术和后凸成形术治疗VCF的效果已发表。Eck等报道视觉模糊评分（VAS）在椎体成形术后降低5.68（8.36－2.68）分，后凸成形术后降低4.6（8.06－3.46）分。与Hulme报道的结果相似，他发现椎体成形术后VAS分降低5.2（8.2－3.0）分，后凸成形降低4.8（7.2－3.4）分。在Gill等做的meta分析中看不到这种轻度的差别，他发现椎体成形术后VAS降低5.44分，后凸成形术后降低5.62分。Talor等也发现没有明显的差别。他的研究显示椎体增强后3、6、12、36个月的疼痛评分较非手术组低，住院时间从13.4天降为7.4天。
Recently, the preliminary results of the VERTOS study, a
randomized controlled trial of nonoperative management
and vertebroplasty, were reported.
45 Forty-six patients with
senile VCFs were randomized to receive optimal pain man-
agement or vertebroplasty. Thirty-four patients completed
the study; 18 were treated with vertebroplasty, and 16 were
treated with optimal pain management. The patients in the
vertebroplasty group had significantly lower pain scores at 1
day, but at 2 weeks, the pain scores were not significantly
different. The authors also reported that the patients receiv-
ing vertebroplasty used significantly fewer narcotics and had
higher quality-of-life scores. Interestingly, 14 of 16 patients
who were treated with painmanagement requested vertebro-
plasty at 2 weeks. Although this was a relatively small, short-
termstudy, a larger scale investigation (VERTOS II) was pub-
lished in 2007.
46
另外，已有多项研究显示，椎体增强术后可能增加功能结果评分。最近，VERTOS报道了椎体成形与非手术治疗的随机对照试验初步结果。46位老年性VCF病人随机接受最优疼痛治疗或椎体成形术，34位患者完成了研究，18例采用椎体成形术治疗，16例采用最优疼痛治疗。椎体成形术组术后第一天疼痛评分明显较低，但在2周时，疼痛评分没有明显差别。作者也报道了椎体成形术组麻醉用药更少，生活质量分数较高。有趣的是，16例疼痛控制组中的14例在2周后要求做椎体成形术。虽然这个研究规模相对较小，时间较短，一项更大规模的调查（VERTOS II）已在2007年发表。Despite numerous studies indicating the effectiveness of
vertebral augmentation in improving pain, none had shown
an effect on patient survival. In a retrospective study, Lavelle
et al
47 showed that the mortality rate of patients treated with
kyphoplasty was not statistically different from that of those
who were treated nonoperatively.
大量的研究显示椎体成形可以有效改善疼痛，但没有一个显示对患者的生存有何影响。在一个回顾性研究中，Lavelle等指出后凸成形的病人的生存率与采用非手术治疗者没有显著性差别。
Vertebroplasty
Versus Kyphoplasty
Multiple studies have sought to compare the results of
kyphoplasty to vertebroplasty. As noted above, some re-
cent meta-analyses have suggested that vertebroplasty
provides slightly better pain relief,
38,39 whereas others
have found no difference between the 2 methods.
40,41 Ky-
phoplasty does have an added benefit of facilitating frac-
ture reduction and correction of some of the resultant
deformity.
48,49 In a cadaver model, Belkoff et al
50 showed a
97% rate of fracture correction with kyphoplasty com-
pared with a 30%rate with vertebroplasty. Clinical studies
have shown height restoration ranging between 21% and
70%.
41,48,49,51,52 Taylor et al
41 also showed that the ky-
photic angle improved by 6.3°. Despite the results of these
studies, Pradhan et al
53 found that kyphoplasty did not
alter patients’ overall sagittal balance.
椎体成形术与后凸成形术比较
已有多项研究对比椎体成形术与后凸成形术。正如前面所提到的，一些meta分析认为椎体成形术对疼痛缓解略好，其他的研究则认为两者没有差别。后凸成形更有利于骨折复位和畸形矫正。在尸体模型中，Belkoff等发现后凸成形的骨折矫正率达到97％，而椎体成形则为30％。临床研究发现高度恢复在21％－70％。
Complications
As with any surgical procedure, vertebral augmentation is
not without its risk of complications (Table 2). The most
common complication seen with these procedures is ce-
ment extravasation.
38,39,41 Its incidence has been reported
be as high as 41% for vertebroplasty39 and 9% for kypho-
plasty.
43 The concern is that extruded cement may cause
damage to neurologic and vascular structures from a com-
pressive effect or a thermal effect of the cement as it un-
dergoes its exothermic cure process. Despite these rela-
tively high rates of cement extravasation, the incidence of
symptomatic leakage is relatively low: 1.6% for vertebro-
plasty and 0.3% for kyophoplasty.
38 Regardless of the
technique used, injection of cement must be performed
under careful fluoroscopic imaging and stopped as soon as
extravasation is noted.
并发症
和所有的外科手术一样，椎体增强也有并发症（表2）。最常见的并发症是骨水泥渗漏。其发生率在椎体成形为41％，后凸成形为9％。骨水泥渗漏可对血管神经造成压迫，发热治疗时可灼伤血管神经。尽管骨水泥渗漏率较高，但有症状的渗漏相对较少，椎体成形术为1.6％，而后凸成形术为0.3％。无论哪种技术，骨水泥注入时都要在透视监视下进行，一旦有渗漏，立即停止。
After vertebral augmentation, the osteoporotic spine re-
mains at risk for fractures at adjacent levels because these
vertebrae are alsoweakened andmay be exposed to abnormal
biomechanical loads secondary to the fracture. The reported
incidence of refracture is 10%-14% after kyphoplasty and
18%-20% after vertebroplasty.
38,41 This decreased rate of re-
fracture after kyphoplasty may be in part a result of correc-
tion of the deformity and resultant kyphosis, which may
improve the biomechanics of the spine. Taylor et al
41 found a
35% risk reduction for adjacent level fracture after kyphop-
lasty at 1 year. Some authors have suggested that a postoper-
ative back-strengthening program may help to lower further
the incidence of refracture.
54
椎体增强术后，骨质疏松的邻近节段脊柱仍有骨折的危险，因为这些椎体同样脆弱，同时，由于骨折而可能承受异常负荷。据报道，再骨折的发生率在后凸成形术后为10％－14％，而椎体成形为18％－20％。后凸成形术再骨折率较低的原因部分可能是矫正了后凸畸形，从而改善了脊柱的生物力学。Taylor等发现后凸成形术后1年，临近节段再骨折的发生率下降35％。一些作者建议术后进行背肌强化训练有助于降低再骨折发生率。
Patients undergoing vertebral augmentation are also at risk
for serious medical complications, such as pulmonary embo-
lism and myocardial infarction. However, overall the inci-
dence of these events is relatively low ( 1%).
38 The inci-
dence of other complications, such as infection, pneumonia,
and, hematoma, is also relatively low.
38
进行椎体增强的病人也有出现严重内科并发症的危险，如肺栓塞和心肌梗塞。所幸这类意外的发生率相当低。（＜1％¬）。其他并发症如感染、肺炎、血肿的发生率也相当低。
In addition to the patient risks associated with the procedure,
the risk of radiation exposure for the surgeon and surgical staff
must also be considered. These procedures require a consider-
able amount of fluoroscopy time for placement of the trocar and
injection of the cement, time reported to be as high as 5.7 min-
utes for a single-level kyphoplasty, 7.8 minutes for 2 levels, and
8.7 minutes for 3 levels.
54 The same authors estimated that at
those rates of fluoroscopy, radiation exposure would exceed
acceptable limits after approximately 300 cases per year.
55 We
suggest that radiation exposure be minimized by attempting to
limit the amount of fluoroscopy used per case to approximately
60-90 seconds per level and believe that this achievable while
maintaining the safety profile of the procedure and avoiding
cannula misplacement or cement extravasation.
除了病人的风险外，医生及医务人员暴露于射线下的危险也要考虑在内。置入套管和注射骨水泥需要大量透视，据报道，单节段后凸成形的透视时间高达5.7分钟，两节段则达7.8分钟，三节段则达8.7分钟。相同的作者估计，如果每年做到300例，其射线量将会超过人体限度。我们建议尽可能减少射线量至每例60－90秒每一节段，我们相信这已足以安全完成手术并避免错误置入及骨水泥渗漏。
Novel Materials
Although PMMA has remained the primary material used for
vertebral augmentation procedures, it may not be the ideal
material. It cures by an exothermic process, raising concern
that any extravasated cementmay cause thermal injury to the
neurovascular structures. The monomer it uses has also been
shown to cause hypotension in some patients.
56 Other avail-
able materials are calcium phosphate and calcium sulfate
cements, which have several advantages: they produce a less
exothermic reaction as they cure, are absorbable by the body,
and are considered more biocompatible.
57 Several of these
materials have been found to have biomechanical properties
similar to those of PMMA.
58 Grafe et al
59 showed no differ-
ence between PMMA and calcium phosphate cement in pa-
tients’ pain scores, functional outcomes, or height restoration
at 3 years. These materials, however, have not been as widely
studied as PMMA, and their cost-effectiveness has yet to be
proven.
新材料
虽然PMMA仍是椎体增强的首选材料，但并不是理想的材料。其发热反应增加了渗漏的骨水泥对血管神经结构的热损伤的顾虑。此外，单体可使某些病人血压下降。其他可选的材料包括磷酸钙骨水泥和硫酸钙骨水泥。这些材料的明显优点是不产生发热反应，骨折愈合后可以被骨吸收，生物相容性也更好。其中有些材料的生物力学特性与PMMA相似。Grafe等的报道显示3年时在疼痛评分、功能结果以及高度恢复磷酸钙均与PMMA没有明显差别，而费用效应还有待证明
。
Conclusions
The incidence of osteoporosis and osteoporotic VCFs is in-
creasing. Vertebral augmentation procedures (ie, kyphop-
lasty and vertebroplasty) can successfully relieve pain and
improve functional outcomes for patients with osteoporotic
VCFs. These procedures must be performed under careful
fluoroscopic guidance during positioning of the trocar and
cement injection. Kyphoplasty does offer more fracture re-
duction than vertebroplasty, although the clinical relevance
of this finding is unclear. Vertebroplasty has a significantly
greater risk of cement extravasation, but the risk of a symp-
tomatic leak remains low. Overall, both procedures are rela-
tively safe and effective. Although work continues on new
and improved augmentation materials, kyphoplasty and ver-
tebroplasty continue to be successful, effective treatment op-
tions for patients with VCFs.
结论
骨质疏松VCF正在增加，椎体增强技术（即后凸成形术和椎体成形术）能对VCF病人有效缓解疼痛，提高功能结果。在放置套管针和注入骨水泥时，要小心地透视监视。后凸成形术较椎体成形术复位更佳，但临床对此效应尚不确定。椎体成形术的骨水泥渗漏率很高，但有症状的较少。总体而言，两种技术都是安全有效的。尽管还在寻找新的和更好的椎体增强材料，椎体成形术与后凸成形术对骨质疏松椎体压缩性骨折的治疗是成功的，有效的。
参考文献（略）
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 inflation 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 insufficiency fractures are primarily the result of
osteopenia and osteoporosis, defined 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 patient’s 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 dis-
ease, such as diabetes, or tomedications, such as corticosteroids
or antiseizuremedications. Idiopathic osteoporosis, as the name
implies, has no identifiable cause.
疾病概况
世界卫生组织定义当t值小于﹣1～﹣2.5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 osteopo-
rosis 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. Asymp-
tomatic VCFsmay be identified incidentally on imaging stud-
ies or by the increasing kyphotic posture of the patient. Ap-
proximately 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, smok-
ing, 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 patient’s 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 body’s 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. Pa-
tients with a VCF are also at a 2 times greater risk for devel-
oping hip fractures.Mortality after VCF has been shown to be
as high as 20% within the first 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 age-
matched controls.
17
VCF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, in-
cluding 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
patient’s 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 difficult to evaluate with
conventional radiographs. Computed tomography may also
assist in preoperative planning, specifically in terms of eval-
uating 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 finding on a bone scan, leading to a possible false-
negative 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 absorp-
tiometry scan should be performed to assess the patient’s
BMD.Medical and/or cardiology consults should be obtained
as appropriate if surgery is planned. Consulting a pain man-
agement 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
Nonoperative
Initial 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-inflammatory
medications, antidepressants, and neuropathic agents. Each
of these classes ofmedications has substantial side-effect pro-
files, including sedation from narcotics and gastrointestinal
and cardiac effects from nonsteroidal anti-inflammatory
medications, which are accentuated in elderly patients. A
pain management specialist and the patient’s 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 patient’s
pain and to reduce the risk of future fractures.
20,21 Initially,
therapy should focus on core strengthening to improve pos-
ture 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 and
prevent 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 hyperexten-
sion braces, thoracolumbosacral orthoses, and posture-train-
ing support orthoses. Patient compliance with bracing may
be difficult 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 difficult to
fit 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 use-
ful for patients with a retropulsed fragment invading the spi-
nal canal but who are not good surgical candidates. Selective
nerve root injections may be used for patients with radicular-
type 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 patient’s osteoporosis or osteopenia. This treat-
ment should be orchestrated in a multidisciplinary fashion,
involving the surgeon, the patient’s primary care physician,
and potentially an endocrinologist. Asmentioned previously,
a dual-energy x-ray absorptiometry scan should be obtained
to measure the patient’s BMD. The patient’s nutrition should
be maximized, ensuring sufficient intake of vitamin D (800-
1000 IU/d)24 and calcium (1200 mg/d).
25 Medical manage-
ment may include the use of bisphosphonates, calcitonin,
estrogen, raloxifene (a selective estrogen analog), and para-
thyroid hormone. Currently, the American Board of Obstet-
rics and Gynecology recommends prescribing one of these
medications for any patient sustaining an osteoporotic frac-
ture, 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 con-
trol study evaluated the use of zoledronic acid (an intrave-
nously 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 au-
thors noted relatively minor complications with the medica-
tion, 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800－1000IU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。
Operative
Given that most VCFs occur in elderly patients without neu-
rologic deficits who havemedical comorbidities and osteope-
nia 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 sur-
gical 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 intro-
duced first 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 proce-
dure involves the inflation of a balloon-type bone tamp be-
fore 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 Surgery
The indications for vertebroplasty and kyphoplasty in the
treatment of VCFs include acute, painful, osteporotic or os-
teolytic VCFs; pathologic fractures in patients withmetastatic
disease; painful vertebral hemangioma; and Kummell’s dis-
ease.
30,31 It is important that only symptomatic fractures be
treated and not all fractures that are seen on imaging stud-
ies.
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, specifically, fat-
suppressed T2-weighted or short tau inversion recovery se-
quence 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（外伤后脊椎炎，脊柱受压骨折。英汉医学词典。译者注，但仍不太明白）。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-
ficiency of the posterior wall, local or systemic infection (sep-
sis), osteoblastic metastatic lesions, inability to obtain ade-
quate intraoperative imaging, and advanced or multiple
medical comorbidities. In addition, performing these proce-
dures 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 Technique
Patient positioning for vertebroplasty and kyphoplasty is
similar. Patients are usually positioned prone on a radiolu-
cent 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. Ide-
ally, the back should be extended to facilitate reduction. An-
esthesia may be general, sedation, or local, depending on the
circumstance and the patient’s 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
fluoroscopic images should be obtained in the anteroposte-
rior (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 fluoroscopic
imaging is essential, and the surgery should not proceed if the
images are not satisfactory. One or 2 fluoroscopy units can be
used, depending on machine availability and surgeon prefer- ence. The use of 2 fluoroscopy 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 postero-
lateral approach. The choice of approach should be identified
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 collapsed below the level of the pedicle.
The extrapedicular approach is usually used for higher tho-
racic levels or vertebrae with small pedicles. It has the advan-
tage of allowing more medial placement of the working can-
nula. The posterolateral approach is reserved for lumbar
vertebrae with extensive collapse or small pedicles, factors
which would make the standard transpedicular approach
technically challenging.
在病人摆好体位后，要增强的椎体要定位好。可能通过经椎弓根、椎弓根外、后外侧入路到达椎体前侧。入路的选择要根据影像和骨折的部位，术前就确定好。经椎弓根入路常用于T10－L5，对于椎弓根较小或椎体爆裂骨折位于椎弓根平面下者不合适。椎弓根外入路用于高位胸椎及椎弓根较小者，其优点在于套管可以更偏向内侧放置。后外侧入路用于腰椎严重爆裂或小椎弓根或采用标准经椎弓根困难者。For the transpedicular approach, an incision is made ap-
proximately 2-3 cm lateral from midline, in line with the
pedicle. The appropriate trocar or needle is selected and,
under fluoroscopic guidance, it is positioned on the supero-
lateral corner of the pedicle. The trocar is advanced using
firm but controlled pressure; frequent images are obtained
to confirm location. The trocar should be angled slightly
medial, but care should be taken that the needle does not
cross the medial border of the pedicle on the AP image
until it has reached the posterior aspect of the vertebral
body and the end of the pedicle on the lateral view. If the
trocar is noted to cross the medial border before this stage,
a medial breach should be suspected, and the trocar
should be withdrawn and redirected. After the trocar has
entered the vertebral body, it should continue to be angled
medially and should approach, but not cross, the midline.
An oblique view directed straight down the pediclemay be
helpful for confirming the position of the trocar within the
pedicle. This view is obtained by bringing the fluoroscopy
unit approximately 10° off the midline to provide a view
line with the path of the pedicle.
采用经椎弓根入路，在中线外约2－3cm处椎弓根线做切口。选择合适的套管针透视下置于椎弓根的外上角，稳稳控制前进，多透视以确定位置。套管针要轻度偏向内侧，但要注意，在侧位上到达椎体后壁、椎弓根末端之前在前后位上不要超过椎弓根的内侧界。如果在此之间套管就超过了椎弓根的内侧界，要考虑内侧壁穿破，套管针要取出重新定向。一旦套管针进入椎体，要尽量向内侧倾斜，但不要超过中线。将球管偏离中线10°使球管方向与椎弓根方向一致的斜位片有助于确定套管针是否位于椎弓根内。As mentioned previously, the extrapedicular approach is
typically used in the mid to upper thoracic spine. A transpe-
dicular approach at these levels usually results in an unac-
ceptably lateral placement of the trocar. To perform the ex-
trapedicular approach, the trocar is positioned just superior
and lateral to the pedicle, and medial to the head of the rib.
Occasionally, it is necessary to cannulate through the rib
head. The starting point should be at or anterior to the level of
the spinal canal on a lateral image, which minimizes the risk
of spinal canal violation. Care should be taken not to slide
inferior or superior off the rib head, where plunging with the
trocar risks injuring the lung.
如前所述，椎弓根外入路主要用于中至上胸椎，在这些部位，经椎弓根入路套管针的侧方位置无法接受。要采用椎弓根外入路，套管针必须位于椎弓根的外上方，并位于肋骨头的内侧。偶尔，必须穿过肋骨头。侧位像上起点要位于椎管水平或其前方。小心不要向上或向下滑过肋骨头，以免损伤肺脏。
Ideal medial-to-lateral positioning within the vertebral
body may vary, depending on the use of a unilateral or bilat-
eral approach (see discussion later). Additionally, ideal supe-
rior-inferior positioning depends on the nature of the frac-
ture. The trocar should be positioned in proximity to the
fractured endplate, that is, positioned adjacent to the supe- rior endplate for superior endplate fractures and vice versa
for inferior fractures. Steens et al
33 suggested that endplate-
to-endplate cement placement offers the best biomechanical
strength after augmentation. The location of the cement
within the vertebral body has not been shown to affect adja-
cent level fractures.
34
单侧入路和双侧入路椎体内的理想内外位置不同（见后述讨论）。理想的上下位置取决于骨折的性质。套管的位置要接近骨折的终板，也就是说，上终板骨折要邻近上终板，下终板骨折接近下终板。Steens等认为，终板骨水泥可便椎体强化获得最好的生物力学强度。椎体内骨水泥的位置不会造成邻近节段骨折。
Once the trocar is successfully positioned, the vertebral
body should be biopsied by passing a Craig or biopsy needle
hrough the working cannula. Although patient history,
physical examination, and imaging studies should suggest
whether the fracture is a result of malignancy, only biopsy
can confirm or refute this potential causative factor. Schoen-
eld et al
35 reviewed 80 vertebral augmentation procedures
on 50 patients, including 8 in patients who were suspected of
having VCFs because of malignancy. They reported 4 positive
biopsy results, including 3 in patientswhowere not suspected of
having amalignant process, leading to an 8%rate ofmalignancy.
Additionally, 7 of 8 patients suspected of having a malignant
racture were found to have benign fractures. Biopsy results can
have a substantial impact on patient care.
套管针成功置入后，可以通过工作通道用Craig或活检针做个活检。尽管病史、体检、影像都可以提示骨折是不是恶性肿瘤引起的，只有活检是唯一可以确定或排除这种可能的方法。Schoenfeld等回顾了80例椎体增强手术中的50例患者，包括8例考虑为恶性肿瘤引起的VCF。4例活检阳性，其中3例为没有考虑为恶性，恶性率为8％。8例考虑为恶性者，7例发现为良性。活检的结果对患者的治疗有重要的意义Once the trocar is in position, the techniques used for
vertebroplasty and kyphoplasty diverge. For vertebroplasty
(Fig. 1), the cement is injected directly into the vertebral
body through the trocar. The cement is injected in a less
viscous state and under relatively high pressure to allow per-
meation through the cancellous bone of the vertebral body.
29
When performing kyphoplasty (Fig. 2), an inflatable balloon
tamp is inserted through the working cannula to reduce the
fracture and to create a cavity into which the cement will be
injected. Care is taken to ensure that no additional endplate
fractures occur. If 2 balloons are used, they should be inflated
alternately to ensure even expansion. After adequate reduc-
tion is obtained, the balloons are deflated and withdrawn,
and the cement is then injected into the voids using the
trocar. Usually, cement-filled cannulas are placed in the void,
and their plungers are used to slowly push out the cement,
although other insertion devices are available. Cement injec-
tion during both techniques should be carefully monitored
under fluoroscopy and halted immediately if there are any
concerns for extravasation.
套管针放好后，椎体成形术与后凸形术的技术是不同的。椎体成形术（图1）将骨水泥通过套管针直接注入椎体，骨水泥在低稠状态下注入，注入的压力相对较高，以使骨水泥渗入松质骨中。后凸成形术（图2）则通过工作通道置入一个可扩张球囊对骨折进行复位，并制造出一个空腔，以利于骨水泥注入。注意确定没有另外的终板骨折发生。如果置入两个球囊，要交替进行扩张，以使膨胀均匀。复位充分后，让球囊萎陷，再取出。再注入骨水泥。通常将注满骨水泥的套管放在空腔处，再用内芯将骨水泥缓慢推出，也可能用别的器件。两种技术都要在透视监视下进行，一旦有骨水泥渗漏，立即停止。When performing kyphoplasty, 1 or 2 balloons can be
used.When 2 balloons are selected, 1 is advanced down each
pedicle and should be positioned fairly symmetrically in the
vertebral body. If 1 balloon is used, it should be positioned as
close to midline as possible, with care taken not to cross too
medially and violate the spinal canal. Using 1 balloon may be
advantageous for patients with small vertebral bodies, partic-
ularly in the higher thoracic levels. The 1-balloon technique
also has the advantages of shortened operating room time
and less radiation fromfluoroscopy because only 1 cannula is
passed. Chung et al
36 showed that using 2 balloons resulted
in increased fracture reduction and a lower incidence of loss
of reduction postoperatively. However, they found no differ-
ence in pain relief for the 2 techniques.
后凸成形术可以用一个或两个球囊。如果用两个球囊，两侧椎弓根各置一个，并要对称放置。如果只用一个，则要尽可能靠中线放置。注意不要越过中线侵入椎管。用一个球囊对椎体较小者较为合适，如高位胸椎。用一个球囊也可以减少手术时间和减少透视，因为只要置入一个插管。Chung等发现用两个球囊可以增加骨折复位，减少术后复位丢失的发生率。但他们也发现两种技术在疼痛缓解上没有区别。
Clinical Results
Numerous studies have evaluated the clinical effectiveness of
vertebroplasty and kyphoplasty for the treatment of osteopo- rotic and osteolytic VCFs. In a relatively large study, Garfin et
al
37 retrospectively reviewed 1439 patients with VCFs and
found that 90% had significant pain relief after kyphoplasty.
In addition, several recentmeta-analyses evaluating the treat-
ment of VCFs with vertebroplasty and kyphoplasty have
been reported. Eck et al
38 reported that the patients’ pain
scores on the Visual Analog Scale (VAS) decreased by 5.68
(8.36-2.68) after vertebroplasty and by 4.60 (8.06-3.46) after
kyphoplasty. These results are similar to those reported by
Hulme et al,
39 who found decreased VAS scores of 5.2 (8.2-
3.0) after vertebroplasty and 4.8 (7.2-3.4) after kyphoplasty.
The slight trend in better pain relief from vertebroplasty was
not seen in the meta-analysis performed by Gill et al,
40 which
found that VAS scores decreased by 5.44 after vertebroplasty
and 5.62 after kyphoplasty, or by the study performed by
Taylor et al,
41 which likewise showed no significant differ-
ence. Taylor et al
41 also showed decreased pain scores with
vertebral augmentation at 3, 6, 12, and 36 months compared
with nonoperative treatment and that the length of hospital-
ization decreased from13.4 to 7.4 days. In addition,multiple
studies have shown improved functional outcome scores af-
ter vertebral augmentation.
42-44
临床结果
关于椎体成形术和后凸成形术治疗VCF的效果的报道很多，在一项较大的研究中，Garfin等回顾了1439例VCF病例，发现后凸成形术后，90％疼痛获得了显著的缓解。另外，多中心meta分析椎体成形术和后凸成形术治疗VCF的效果已发表。Eck等报道视觉模糊评分（VAS）在椎体成形术后降低5.68（8.36－2.68）分，后凸成形术后降低4.6（8.06－3.46）分。与Hulme报道的结果相似，他发现椎体成形术后VAS分降低5.2（8.2－3.0）分，后凸成形降低4.8（7.2－3.4）分。在Gill等做的meta分析中看不到这种轻度的差别，他发现椎体成形术后VAS降低5.44分，后凸成形术后降低5.62分。Talor等也发现没有明显的差别。他的研究显示椎体增强后3、6、12、36个月的疼痛评分较非手术组低，住院时间从13.4天降为7.4天。
Recently, the preliminary results of the VERTOS study, a
randomized controlled trial of nonoperative management
and vertebroplasty, were reported.
45 Forty-six patients with
senile VCFs were randomized to receive optimal pain man-
agement or vertebroplasty. Thirty-four patients completed
the study; 18 were treated with vertebroplasty, and 16 were
treated with optimal pain management. The patients in the
vertebroplasty group had significantly lower pain scores at 1
day, but at 2 weeks, the pain scores were not significantly
different. The authors also reported that the patients receiv-
ing vertebroplasty used significantly fewer narcotics and had
higher quality-of-life scores. Interestingly, 14 of 16 patients
who were treated with painmanagement requested vertebro-
plasty at 2 weeks. Although this was a relatively small, short-
termstudy, a larger scale investigation (VERTOS II) was pub-
lished in 2007.
46
另外，已有多项研究显示，椎体增强术后可能增加功能结果评分。最近，VERTOS报道了椎体成形与非手术治疗的随机对照试验初步结果。46位老年性VCF病人随机接受最优疼痛治疗或椎体成形术，34位患者完成了研究，18例采用椎体成形术治疗，16例采用最优疼痛治疗。椎体成形术组术后第一天疼痛评分明显较低，但在2周时，疼痛评分没有明显差别。作者也报道了椎体成形术组麻醉用药更少，生活质量分数较高。有趣的是，16例疼痛控制组中的14例在2周后要求做椎体成形术。虽然这个研究规模相对较小，时间较短，一项更大规模的调查（VERTOS II）已在2007年发表。Despite numerous studies indicating the effectiveness of
vertebral augmentation in improving pain, none had shown
an effect on patient survival. In a retrospective study, Lavelle
et al
47 showed that the mortality rate of patients treated with
kyphoplasty was not statistically different from that of those
who were treated nonoperatively.
大量的研究显示椎体成形可以有效改善疼痛，但没有一个显示对患者的生存有何影响。在一个回顾性研究中，Lavelle等指出后凸成形的病人的生存率与采用非手术治疗者没有显著性差别。
Vertebroplasty
Versus Kyphoplasty
Multiple studies have sought to compare the results of
kyphoplasty to vertebroplasty. As noted above, some re-
cent meta-analyses have suggested that vertebroplasty
provides slightly better pain relief,
38,39 whereas others
have found no difference between the 2 methods.
40,41 Ky-
phoplasty does have an added benefit of facilitating frac-
ture reduction and correction of some of the resultant
deformity.
48,49 In a cadaver model, Belkoff et al
50 showed a
97% rate of fracture correction with kyphoplasty com-
pared with a 30%rate with vertebroplasty. Clinical studies
have shown height restoration ranging between 21% and
70%.
41,48,49,51,52 Taylor et al
41 also showed that the ky-
photic angle improved by 6.3°. Despite the results of these
studies, Pradhan et al
53 found that kyphoplasty did not
alter patients’ overall sagittal balance.
椎体成形术与后凸成形术比较
已有多项研究对比椎体成形术与后凸成形术。正如前面所提到的，一些meta分析认为椎体成形术对疼痛缓解略好，其他的研究则认为两者没有差别。后凸成形更有利于骨折复位和畸形矫正。在尸体模型中，Belkoff等发现后凸成形的骨折矫正率达到97％，而椎体成形则为30％。临床研究发现高度恢复在21％－70％。
Complications
As with any surgical procedure, vertebral augmentation is
not without its risk of complications (Table 2). The most
common complication seen with these procedures is ce-
ment extravasation.
38,39,41 Its incidence has been reported
be as high as 41% for vertebroplasty39 and 9% for kypho-
plasty.
43 The concern is that extruded cement may cause
damage to neurologic and vascular structures from a com-
pressive effect or a thermal effect of the cement as it un-
dergoes its exothermic cure process. Despite these rela-
tively high rates of cement extravasation, the incidence of
symptomatic leakage is relatively low: 1.6% for vertebro-
plasty and 0.3% for kyophoplasty.
38 Regardless of the
technique used, injection of cement must be performed
under careful fluoroscopic imaging and stopped as soon as
extravasation is noted.
并发症
和所有的外科手术一样，椎体增强也有并发症（表2）。最常见的并发症是骨水泥渗漏。其发生率在椎体成形为41％，后凸成形为9％。骨水泥渗漏可对血管神经造成压迫，发热治疗时可灼伤血管神经。尽管骨水泥渗漏率较高，但有症状的渗漏相对较少，椎体成形术为1.6％，而后凸成形术为0.3％。无论哪种技术，骨水泥注入时都要在透视监视下进行，一旦有渗漏，立即停止。
After vertebral augmentation, the osteoporotic spine re-
mains at risk for fractures at adjacent levels because these
vertebrae are alsoweakened andmay be exposed to abnormal
biomechanical loads secondary to the fracture. The reported
incidence of refracture is 10%-14% after kyphoplasty and
18%-20% after vertebroplasty.
38,41 This decreased rate of re-
fracture after kyphoplasty may be in part a result of correc-
tion of the deformity and resultant kyphosis, which may
improve the biomechanics of the spine. Taylor et al
41 found a
35% risk reduction for adjacent level fracture after kyphop-
lasty at 1 year. Some authors have suggested that a postoper-
ative back-strengthening program may help to lower further
the incidence of refracture.
54
椎体增强术后，骨质疏松的邻近节段脊柱仍有骨折的危险，因为这些椎体同样脆弱，同时，由于骨折而可能承受异常负荷。据报道，再骨折的发生率在后凸成形术后为10％－14％，而椎体成形为18％－20％。后凸成形术再骨折率较低的原因部分可能是矫正了后凸畸形，从而改善了脊柱的生物力学。Taylor等发现后凸成形术后1年，临近节段再骨折的发生率下降35％。一些作者建议术后进行背肌强化训练有助于降低再骨折发生率。
Patients undergoing vertebral augmentation are also at risk
for serious medical complications, such as pulmonary embo-
lism and myocardial infarction. However, overall the inci-
dence of these events is relatively low ( 1%).
38 The inci-
dence of other complications, such as infection, pneumonia,
and, hematoma, is also relatively low.
38
进行椎体增强的病人也有出现严重内科并发症的危险，如肺栓塞和心肌梗塞。所幸这类意外的发生率相当低。（＜1％¬）。其他并发症如感染、肺炎、血肿的发生率也相当低。
In addition to the patient risks associated with the procedure,
the risk of radiation exposure for the surgeon and surgical staff
must also be considered. These procedures require a consider-
able amount of fluoroscopy time for placement of the trocar and
injection of the cement, time reported to be as high as 5.7 min-
utes for a single-level kyphoplasty, 7.8 minutes for 2 levels, and
8.7 minutes for 3 levels.
54 The same authors estimated that at
those rates of fluoroscopy, radiation exposure would exceed
acceptable limits after approximately 300 cases per year.
55 We
suggest that radiation exposure be minimized by attempting to
limit the amount of fluoroscopy used per case to approximately
60-90 seconds per level and believe that this achievable while
maintaining the safety profile of the procedure and avoiding
cannula misplacement or cement extravasation.
除了病人的风险外，医生及医务人员暴露于射线下的危险也要考虑在内。置入套管和注射骨水泥需要大量透视，据报道，单节段后凸成形的透视时间高达5.7分钟，两节段则达7.8分钟，三节段则达8.7分钟。相同的作者估计，如果每年做到300例，其射线量将会超过人体限度。我们建议尽可能减少射线量至每例60－90秒每一节段，我们相信这已足以安全完成手术并避免错误置入及骨水泥渗漏。
Novel Materials
Although PMMA has remained the primary material used for
vertebral augmentation procedures, it may not be the ideal
material. It cures by an exothermic process, raising concern
that any extravasated cementmay cause thermal injury to the
neurovascular structures. The monomer it uses has also been
shown to cause hypotension in some patients.
56 Other avail-
able materials are calcium phosphate and calcium sulfate
cements, which have several advantages: they produce a less
exothermic reaction as they cure, are absorbable by the body,
and are considered more biocompatible.
57 Several of these
materials have been found to have biomechanical properties
similar to those of PMMA.
58 Grafe et al
59 showed no differ-
ence between PMMA and calcium phosphate cement in pa-
tients’ pain scores, functional outcomes, or height restoration
at 3 years. These materials, however, have not been as widely
studied as PMMA, and their cost-effectiveness has yet to be
proven.
新材料
虽然PMMA仍是椎体增强的首选材料，但并不是理想的材料。其发热反应增加了渗漏的骨水泥对血管神经结构的热损伤的顾虑。此外，单体可使某些病人血压下降。其他可选的材料包括磷酸钙骨水泥和硫酸钙骨水泥。这些材料的明显优点是不产生发热反应，骨折愈合后可以被骨吸收，生物相容性也更好。其中有些材料的生物力学特性与PMMA相似。Grafe等的报道显示3年时在疼痛评分、功能结果以及高度恢复磷酸钙均与PMMA没有明显差别，而费用效应还有待证明
。
Conclusions
The incidence of osteoporosis and osteoporotic VCFs is in-
creasing. Vertebral augmentation procedures (ie, kyphop-
lasty and vertebroplasty) can successfully relieve pain and
improve functional outcomes for patients with osteoporotic
VCFs. These procedures must be performed under careful
fluoroscopic guidance during positioning of the trocar and
cement injection. Kyphoplasty does offer more fracture re-
duction than vertebroplasty, although the clinical relevance
of this finding is unclear. Vertebroplasty has a significantly
greater risk of cement extravasation, but the risk of a symp-
tomatic leak remains low. Overall, both procedures are rela-
tively safe and effective. Although work continues on new
and improved augmentation materials, kyphoplasty and ver-
tebroplasty continue to be successful, effective treatment op-
tions for patients with VCFs.
结论
骨质疏松VCF正在增加，椎体增强技术（即后凸成形术和椎体成形术）能对VCF病人有效缓解疼痛，提高功能结果。在放置套管针和注入骨水泥时，要小心地透视监视。后凸成形术较椎体成形术复位更佳，但临床对此效应尚不确定。椎体成形术的骨水泥渗漏率很高，但有症状的较少。总体而言，两种技术都是安全有效的。尽管还在寻找新的和更好的椎体增强材料，椎体成形术与后凸成形术对骨质疏松椎体压缩性骨折的治疗是成功的，有效的。
参考文献（略）
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