脊柱骨质疏松压缩性骨折的手术治疗课件

SURGICALTREATMENTOFSPINEOSTEOPOROSISSURGICALTREATMENTOFSPINEOSConceptofOsteoporosisAsystemicskeletaldiseasecharacterizedbylowbonemassandmicroarchitecturaldeteriorationofbonetissue,withaconsequentincreaseinbonefragilityandasusceptibilitytofracture."

theabovedefinitiondevelopedinHongKongin1993ConceptofOsteoporosisAsystePathophysiologyofOPBoneRemodelingImbalanceofboneremodeling,Inpathologicsituations,bonemassmaybesacrificedtosatisfythebody'sintra-andextracellularcalciumneeds.PathophysiologyofOPBoneRemoAspecificquantityofboneisresorbedfromtheremodelingsiteandthenareversaloccursandthecavityisoccupiedbyosteoblastswhichrefillthatcavitywithboneTheProgressionofBoneRemodeling

AspecificquantityofboneisMechanismsofBoneLossAnincreasednumberofboneremodelingunitscanbeactivatedwhich,whencombinedwitheitheroftheabovetwoprocesses,mayresultinincreasedboneloss.MechanismsofBoneLossAnincrbonelossisequaltoboneformationandtheamountofbonetissuepresentrepresentsnormalbonemass

increasednumberofremodelingsitesincreasedporosityofthebone,ietheremodelingspace,andthisgivesdecreasedbonemas

bonelossisequaltoboneforBoneLoss:Cancellousvs.CorticalBoneAlthoughcancellousbonemayaccountforlessthan25%ofthetotalbonemassinhealthyadults,itssurfaceareafarexceedsthatofcorticalbone.

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

highturnoverwitheitherincrPatternsofAge-RelatedBoneLossGradualbonelossbeginsinbothmenandwomenbetweentheage30and40,parallelinganage-relateddeclineinmusclemass.menopausewomenbeginaperiodofacceleratedboneloss,averagingfrom2%-5%peryearoverthenexttenyears.PatternsofAge-RelatedBoneL脊柱骨质疏松压缩性骨折的手术治疗课件Estrogen-RelatedBoneLoss

althoughhighaffinityestrogenreceptorshavebeenidentifiedonbothosteoclastsandosteoblasts.Additionally,itisthoughtthatestrogendeficiencyismoredirectlyassociatedwithacceleratedboneloss,butnotage-relatedboneloss.Estrogen-RelatedBoneLossa脊柱骨质疏松压缩性骨折的手术治疗课件AcceleratedBoneLossAcceleratedbonelossisgreatestinthefirst3-6yrsaftermenopause,levelsoff,andthengraduallyassumesthelevelofpremenopausalboneloss.Thisperiodofacceleratedboneloss,coupledwiththeloweraverageBMDinwomencomparedtomen,explainsthehigherincidenceofosteoporosisandosteoporoticfracturesinwomenAcceleratedBoneLossAcceleratVertebraeandCancellousBoneThevertebraehaveahighpercentageofcancellousbone.Therefore,vertebralfracturesarethemostcommonfracturesiteintheearlymenopausalyears;Hipfracturestendtooccurinlaterlife.Thedegreeofbonelossmayvaryfromsitetositeinthesameindividual.VertebraeandCancellousBoneTMenopausalBoneLossMenopausalbonelosscanvaryamongwomenfrom2%-5%peryear.Higherratesofbonelosshavebeenclassifiedas"fast"losers.Itisthoughtthatthiscategoryofwomen(about5%-10%ofallmenopausalwomen)maybeathigherriskforfractures;

MenopausalBoneLossMenopausalNFORecommendationsforBMDTestingAllpostmenopausalwomenunderage65whohaveoneormoreadditionalriskfactorsforosteoporosis(besidesmenopause);Allwomenaged65andolder,regardlessofadditionalriskfactors;Postmenopausalwomenwhopresentwithfractures(toconfirmdiagnosisanddeterminediseaseseverity);NFORecommendationsforBMDTeNFORecommendationsforBMDTestingWomenwhoareconsideringtherapyforosteoporosis,iftheBMDtestingfacilitatethedecision;Womenonhormonereplacementtherapyforprolongedperiods.NFORecommendationsforBMDTeIssuesinBoneMineralTestingConsiderationsAwoman'swillingnesstobetreated;CommitmenttoHRTtherapy;PatientwhoisuncertainaboutHRT;Technologyandanatomicsiteconsiderations;IssuesinBoneMineralTestingBoneMineralDensity--DefiningDiagnosticCategoriesNormal.BMDwithin1SDofthe"youngnormal"adult(T-scoreabove-1).

Lowbonemass(osteopenia).

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

BoneMineralDensity--DefiniBoneMineralDensity--DefiningDiagnosticCategoriesOsteoporosis.

BMDis2.5SDormorebelowthatofa"youngnormal"adult(T-scoreatorbelow-2.5).Womeninthisgroupwhohavealreadyexperiencedoneormorefracturesaredeemedtohavesevereor"established"osteoporosis.BoneMineralDensity--Defini脊柱骨质疏松压缩性骨折的手术治疗课件脊柱骨质疏松压缩性骨折的手术治疗课件LimitationsofDiagnosticCriteriaBasedonT-ScoresTheuseofdifferentyoungnormalreferencedatabases,differentdensitometricdevices,thatmayresultindifferentT-scoresotherriskfactorsforfracturebesidesBMDandtheintermediarynatureofBMD.ThesevarydependingontheinstrumentusedtoobtainthedataLimitationsofDiagnosticCritOtherRiskFactorsforFractureNonmodifiable:PersonalhistoryoffractureasanadultHistoryoffractureinfirst-degreerelative

RaceAdvancedageFemalesexDementiaPoorhealth/frailtyOtherRiskFactorsforFracturOtherRiskFactorsforFracturePotentiallymodifiable:CurrentcigarettesmokingLowbodyweight/thinness(<127lbs.)Estrogendeficiency:Earlymenopause(<aged45)orbilateralovariectomyProlongedpremenopausalamenorrhea(>1year)OtherRiskFactorsforFracturOtherRiskFactorsforFracturePotentiallymodifiable:Lowcalciumintake(lifelong)AlcoholismImpairedeyesightdespiteadequatecorrectionRecurrentfallsInadequatephysicalactivityPoorhealth/frailtyOtherRiskFactorsforFracturWHODefinitionEstimates30%ofallpostmenopausalwhitewomenwillbediagnosedwithosteoporosis;54%willhavelowbonemassatthehip,spineorwrist.Morethanhalfthewomenwithosteoporosiswillhaveahistoryofpriorfractureoftheproximalfemur,spine,distalforearm,proximalhumerusorpelvis.WHODefinitionEstimates30%ofFracturesAssociatedwithOPVertebralFractureHipFractureDistalForearmFractureOtherFractures

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

ImpactofVertebralandHipFrImpactofVertebralandHipFractures20%ofwomenwhosufferahipfracturewilldieinthefollowingyearasanindirectconsequenceofthefracture.AhistoryofvertebralfractureisassociatedwithanincreasedriskofasubsequentfragilityfractureImpactofVertebralandHipFrImpactofVertebralandHipFracturesVertebralfracturemaybeassociatedwithbackpain,disabilityorphysicaldeformity(eg,kyphosis,heightloss,abdominalprotrusion).Infact,thethreatofphysicaldeformitymaybeapowerfulinfluenceonawoman'scommitmenttotherapy.Additionally,thereisanincreaseinmortalityrelatedtofrailty,comorbiditiesandanincreasedriskofpneumonia.ImpactofVertebralandHipFrVertebroplasty

andKyphoplastyAnewtechniqueofMinimalInvasiveSpinalSurgeryCarryoutinChinafrom2001Vertebroplasty

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

Vertebroplasty-MinimalInvasi

脊柱骨质疏松压缩性骨折的手术治疗课件RisksofProcedure1).Leakageofcementintoveinsandorlungs

2).Infection

3).Bleeding

4).RiborPediclefracture

5).Pneumothorax

6).Worsenedpain

7).ParalysissecondarytoleakageofcementRisksofProcedure1).LeakageWhatareindicationsforVertebroplasty?1).Painfulcompressionfracturesecondarytoosteoporosis2).Painfulcompressionfracturesecondarytotumorwhichdoesnotrespondtoconventionaltherapy3).Preventfurthercompressionfractures4).ButtressweakenedboneforspinefusionsWhatareindicationsforVerteRelativeContraindicationsYoungpatient-thelongtermeffectsofthecementmixtureareunknownVertebralbodiesabovetheT5level-theprocedureisriskierandmoredifficultPatientswithpriorunsuccessfulspinesurgeryRelativeContraindicationsYounPatientEvaluation

1)HistoryandPhysicalExamination

2)Currentx-rays

3)MRI+/-bonescanPatientEvaluation

1)HistoSurgicalProcedure

ofVertebroplasty

becarriedoutinanoperatingroomorinaspecialX-raysuite.Aneedleisplacedinaveinsothatthepatientcangetmedicationforsedationandpain.Thepatientliespronewithpaddingunderthebodyandwiththehipsslightlybent.Thearmsarepositionedabovetheshoulder.

SurgicalProcedure

ofVertebrSurgicalProcedure

ofVertebroplasty

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

SurgicalProcedure

ofVertebrSurgicalProcedure

ofVertebroplasty

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

SurgicalProcedure

ofVertebrSurgicalProcedure

ofVertebroplasty

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

ofVertebrSurgicalProcedure

ofVertebroplasty

5,

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

SurgicalProcedure

ofVertebrSurgicalProcedure

ofVertebroplasty

6,Preparetheplasticmaterialtobeinjected.MixthePMMApowderwithtungstenpowderorbariumsulfatetomakeitvisibleonX-ray.Addtheliquidtothepowderandmixedtoathickyetpourableconsistencysimilartohoney

SurgicalProcedure

ofVertebrSurgicalProcedure

ofVertebroplasty

7,LoadthePMMAintoseveralsmallsyringes.Thesyringeisconnectedtothebonebiopsyneedleandinjectedunderfluoroscopicguidancetobesurethatthematerialdoesnotrunoffintotheveins.ThePMMAhardensafterinjectedtosupportthevertebra(Axialandsagittalanimations)

SurgicalProcedure

ofVertebrComplicationsComplicationsoccurinapproximately3%ofosteoporoticpatients

approximately5%ofpatientswithhemagiomas

approximately10%ofpatientswithcancertothevertebra

ComplicationsComplicationsoccComplicationsThemostcommoncomplicationsare

RibfractureduetothedownwardonthebackneededtoinserttheneedleinthebonyvertebraIrritationofanadjacentnerverootThesecomplicationsusuallyresolveontheirowninafewmonths

Pneumothorax(puncturedlung)ComplicationsThemostcommoncComplicationsPneumothorax(puncturedlung)

FractureofthepediclePMMApulmonaryembolus-thePMMAenterstheveinsthroughtheboneandistakentothelungCompressionofthespinalcordwithparalysisorlossoffeelingComplicationsPneumothorax(punComplicationsIncreasedbackpain

PMMAmaygooutsidetheboneintothesofttissuesWoundInfectionPneumonia

ComplicationsIncreasedbackpaFollowUpCarePainmedications-usuallytaperedoverseveraldaysafterprocedureMusclerelaxantsAdjustmedicationstopreventfurtherminerallossFollowUpCarePainmedicationsVertebroplastyStatistics

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

VertebroplastyStatistics

>80%脊柱骨质疏松压缩性骨折的手术治疗课件ExperiencesofOurHospital

04.2001—08.200358patients，65vertebraL1

16，L2

12

，L3

7

，L4

5

T41,T8

2，T94，T10

4

T11

6，T12

8.ExperiencesofOurHospital04Case1Female68yrsL1fracturebeforeoperationBackpainafterfallingonthegroundCase1Female68yrsL1fractCase1female68yrsL1fracturepostoperationTowalkatthefirstdayafteroperationCase1female68yrsL1fracturCase1female68yrsL1fracturepostoperationCTCase1female68yrsL1fractCase2Case2Case3T12CompressionVertebraFractureDuringoperationCase3Case3T12CompressionVertebraFracturePost-operationCase3Case4PostoperationCase4PostoperationCASE5.Female,84YL2CompressionVertebraFractureDuringoperationCASE5.Female,84YL2CompreCASE5.Female,84YL2CompressionVertebraFracturePostoperationCASE5.CASE5.Female,84YL2CompressionVertebraFracturePostoperationCASE5.Case672yrs,Female.CompressiveFrxCase6CervicalSpineFracturesandOsteoporosisFracturesofthecervicalspineusuallyresultfrommajortrauma(trafficaccidents,fallsfromgreatheightsordivesintoshallowwater).Inelderlypatientsseverecervicalspineinjuriesmayalreadyresultfromsimplefalls.littleinformationavailableontreatmentandoutcomeofcervicalspineinjuriesintheelderly,especiallyregardingthesubaxialspineCervicalSpineFracturesandOCervicalSpineFracturesandOsteoporosisInthegeneralpopulation,about50%offracturesinvolvetheC5-6andC6-7level,withdensfracturesbeingthesecondmostfrequentlocalization.Theincidenceoflowercervicalspineinjuriescontinuouslydeclineswithage.Incontrast,theincidenceofuppercervicalspineinjuriesrisesintheelderly.Fracturesofthedensarethemostcommonlocationinpatientsabovetheageof70yearsCervicalSpineFracturesandOCervicalSpineFracturesandOsteoporosisA68-year-oldpatient,presentingwithincompletetetraplegiaafterfallingfromatree.Thelateralradiographshowsnoapparentfracture,butthereisadvancedmultileveldegeneration,MRIc