脊柱骨质疏松压缩性骨折的手术治疗课件.ppt

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1、SURGICAL TREATMENT OF SPINE OSTEOPOROSISConcept of OsteoporosisA systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue,with a consequent increase in bone fragility and a susceptibility to fracture.theabovedefinitiondevelopedinHongKongin1993Patho

2、physiology of OPBone RemodelingImbalanceofboneremodeling,Inpathologicsituations,bonemassmaybesacrificedtosatisfythebodysintra-andextracellularcalciumneeds.A specific quantity of bone is resorbed from the remodeling site and then a reversal occurs and the cavity is occupied by osteoblasts which refil

3、l that cavity with boneT Th he e P Pr ro og gr re es ss si io on n o of f B Bo on ne e R Re emmo od de el li in ng g Mechanisms of Bone LossAn increased number of bone remodeling units can be activated which,when combined with either of the above two processes,may result in increased bone loss.bone

4、loss is equal to bone formation and the amount of bone tissue present represents normal bone mass increased number of remodeling sites increased porosity of the bone,ie the remodeling space,and this gives decreased bone mas Bone Loss:Cancellous vs.Cortical BoneAlthough cancellous bone may account fo

5、r less than 25%of the total bone mass in healthy adults,its surface area far exceeds that of cortical bone.Bone Loss:Cancellous vs.Cortical BoneCancellous bone is more metabolically active than cortical bone.If bone remodeling becomes uncoupled,with osteoclastic activity exceeding osteoblastic activ

6、ity,the mass and structural integrity of cancellous bone is more severely affected than cortical bone.Bone Loss:Cancellous vs.Cortical BoneDuringtheacceleratedperiodofbonelossoccurringimmediatelypost-menopause,cancellousbonelossisincreased3-fold,whileratesofcorticalbonelossareslower.Therefore,fractu

7、resrelatedtoosteoporosismostcommonlyoccurinareasrichincancellousbone(ie,thevertebraeandwrist),andBMDmeasurementshavefocusedonthesecriticalanatomicsiteshigh turnover with either increased formation or increased resorption or both Patterns of Age-Related Bone LossGradual bone loss begins in both men a

8、nd women between the age 30 and 40,paralleling an age-related decline in muscle mass.menopause women begin a period of accelerated bone loss,averaging from 2%-5%per year over the next ten years.Estrogen-Related Bone Lossalthoughhighaffinityestrogenreceptorshavebeenidentifiedonbothosteoclastsandosteo

9、blasts.Additionally,itisthoughtthatestrogendeficiencyismoredirectlyassociatedwithacceleratedboneloss,butnotage-relatedboneloss.Accelerated Bone LossAccelerated bone loss is greatest in the first 3-6 yrs after menopause,levels off,and then gradually assumes the level of premenopausal bone loss.This p

10、eriod of accelerated bone loss,coupled with the lower average BMD in women compared to men,explains the higher incidence of osteoporosis and osteoporotic fractures in womenVertebrae and Cancellous BoneThe vertebrae have a high percentage of cancellous bone.Therefore,vertebral fractures are the most

11、common fracture site in the early menopausal years;Hip fractures tend to occur in later life.The degree of bone loss may vary from site to site in the same individual.Menopausal Bone LossMenopausalbonelosscanvaryamongwomenfrom2%-5%peryear.Higherratesofbonelosshavebeenclassifiedasfastlosers.Itisthoug

12、htthatthiscategoryofwomen(about5%-10%ofallmenopausalwomen)maybeathigherriskforfractures;NFO Recommendations for BMD TestingAll postmenopausal women under age 65 who have one or more additional risk factors for osteoporosis(besides menopause);All women aged 65 and older,regardless of additional risk

13、factors;Postmenopausal women who present with fractures(to confirm diagnosis and determine disease severity);NFO Recommendations for BMD TestingWomen who are considering therapy for osteoporosis,if the BMD testing facilitate the decision;Women on hormone replacement therapy for prolonged periods.Iss

14、ues in Bone Mineral Testing ConsiderationsA womans willingness to be treated;Commitment to HRT therapy;Patient who is uncertain about HRT;Technology and anatomic site considerations;Bone Mineral Density-Defining Diagnostic CategoriesNormal.BMD within 1 SD of the young normal adult(T-score above-1).L

15、ow bone mass(osteopenia).BMD is between 1 and 2.5 SD below that of a young normal adult(T-score between-1 and-2.5).Bone Mineral Density-Defining Diagnostic CategoriesOsteoporosis.BMD is 2.5 SD or more below that of a young normal adult(T-score at or below-2.5).Women in this group who have already ex

16、perienced one or more fractures are deemed to have severe or established osteoporosis.Limitations of Diagnostic Criteria Based on T-ScoresThe use of different young normal reference databases,different densitometric devices,that may result in different T-scores other risk factors for fracture beside

17、s BMD and the intermediary nature of BMD.These vary depending on the instrument used to obtain the data Other Risk Factors for FractureNonmodifiable:Personal history of fracture as an adult History of fracture in first-degree relative Race Advanced age Female sex Dementia Poor health/frailty Other R

18、isk Factors for FracturePotentially modifiable:Current cigarette smoking Low body weight/thinness(127 lbs.)Estrogen deficiency:Early menopause(1 year)Other Risk Factors for FracturePotentially modifiable:Low calcium intake(lifelong)Alcoholism Impaired eyesight despite adequate correction Recurrent f

19、alls Inadequate physical activity Poor health/frailty WHO Definition Estimates30%ofallpostmenopausalwhitewomenwillbediagnosedwithosteoporosis;54%willhavelowbonemassatthehip,spineorwrist.Morethanhalfthewomenwithosteoporosiswillhaveahistoryofpriorfractureoftheproximalfemur,spine,distalforearm,proximal

20、humerusorpelvis.Fractures Associated with OPVertebral FractureHip FractureDistal Forearm FractureOther FracturesFractureoftheproximalhumerus,pelvis,proximaltibiaanddistalfemur.Impact of Vertebral and Hip FracturesBoth fractures may be associated with significant morbidities and increased mortality a

21、s follows:About 1/2 the women with hip fractures will spend some time in a nursing home.Only 1/3 of hip fracture patients regain their prefracture level of function,with many unable to walk independently or perform basic activities of daily living.Impact of Vertebral and Hip Fractures20%of women who

22、 suffer a hip fracture will die in the following year as an indirect consequence of the fracture.A history of vertebral fracture is associated with an increased risk of a subsequent fragility fracture Impact of Vertebral and Hip FracturesVertebral fracture may be associated with back pain,disability

23、 or physical deformity(eg,kyphosis,height loss,abdominal protrusion).In fact,the threat of physical deformity may be a powerful influence on a womans commitment to therapy.Additionally,there is an increase in mortality related to frailty,comorbidities and an increased risk of pneumonia.Vertebroplast

24、yand KyphoplastyAnewtechniqueofMinimalInvasiveSpinalSurgeryCarryoutinChinafrom2001Vertebroplasty-Minimal Invasive Treatment of Compression FrxVertebroplasty literally means fixing the vertebral body.A metal needle is passed into the vertebral body and a cement mixture containing polymethylmethacryla

25、te(PMMA),barium powder,tobramycin,and a solvent are injected under imaging guidance by the physician.Vertebroplasty-Minimal Invasive Treatment of Compression FracturesThe cement hardens rapidly and buttresses the weakened bone.The barium makes the cement visible on x-ray and the tobramycin is an ant

26、ibiotic.Risks of Procedure1).Leakage of cement into veins and or lungs2).Infection 3).Bleeding4).Rib or Pedicle fracture 5).Pneumothorax 6).Worsened pain 7).Paralysis secondary to leakage of cementWhat are indications for Vertebroplasty?1).Painful compression fracture secondary to osteoporosis 2).Pa

27、inful compression fracture secondary to tumor which does not respond to conventional therapy 3).Prevent further compression fractures 4).Buttress weakened bone for spine fusionsRelative Contraindications1)Young patient-the long term effects of the cement mixture are unknown2)Vertebral bodies above t

28、he T5 level-the procedure is riskier and more difficult3)Patients with prior unsuccessful spine surgeryPatient Evaluation1)History and Physical Examination 2)Current x-rays3)MRI+/-bone scanSurgical Procedure of Vertebroplasty1.be carried out in an operating room or in a special X-ray suite.A needle

29、is placed in a vein so that the patient can get medication for sedation and pain.The patient lies prone with padding under the body and with the hips slightly bent.The arms are positioned above the shoulder.Surgical Procedure of Vertebroplasty2,A radiopaque(visible on X-ray)marker is placed on the p

30、atient over the vertebra to be injected.Positioning of the marker is guided by fluoroscope(video-like X-ray machine).Clearly seeing the correct vertebra is more difficult in the severely osteoporotic patientSurgical Procedure of Vertebroplasty3,Local anesthetic;injected into the skin and along the p

31、ath toward the pedicle of the vertebra to be injected.The needle is left in against the pedicle to mark the path of the special needle used for injecting the cement.The special needle is an 11-gauge bone biopsy needle.A small skin incision is made and bone biopsy needle insertedSurgical Procedure of

32、 Vertebroplasty4,The tip of the bone biopsy needle is stuck for about 1-2 mm into the pedicle.Positioning of the this needle is continuously guided with the fluoroscope in both the anterior-posterior(AP,front to back)and lateral(side to side)viewsSurgical Procedure of Vertebroplasty5,Advance the bon

33、e biopsy needle to the front one-third of the vertebra.On the AP view the needle lies near the midline of the body of the vertebra.The needle is filled with saline to prevent air injection.A contrast solution that can be seen on X-ray is injected.Takes X-ray pictures during the injection to see how

34、the contrast flows from the center of the vertebra into the local veins.Surgical Procedure of Vertebroplasty6,Preparetheplasticmaterialtobeinjected.MixthePMMApowderwithtungstenpowderorbariumsulfatetomakeitvisibleonX-ray.AddtheliquidtothepowderandmixedtoathickyetpourableconsistencysimilartohoneySurgi

35、cal Procedure of Vertebroplasty7,LoadthePMMAintoseveralsmallsyringes.Thesyringeisconnectedtothebonebiopsyneedleandinjectedunderfluoroscopicguidancetobesurethatthematerialdoesnotrunoffintotheveins.ThePMMAhardensafterinjectedtosupportthevertebra(Axialandsagittalanimations)ComplicationsComplications oc

36、cur in1.approximately3%ofosteoporoticpatients2.approximately5%ofpatientswithhemagiomas3.approximately10%ofpatientswithcancertothevertebraComplicationsThe most common complications are1.Ribfractureduetothedownwardonthebackneededtoinserttheneedleinthebonyvertebra2.Irritationofanadjacentnerveroot3.Thes

37、ecomplicationsusuallyresolveontheirowninafewmonthsPneumothorax(puncturedlung)ComplicationsPneumothorax(punctured lung)Fracture of the pediclePMMA pulmonary embolus-the PMMA enters the veins through the bone and is taken to the lungCompression of the spinal cord with paralysis or loss of feelingCompl

38、icationsIncreased back painPMMA may go outside the bone into the soft tissuesWound InfectionPneumoniaFollow Up Care1.Pain medications-usually tapered over several days after procedure2.Muscle relaxants 3.Adjust medications to prevent further mineral lossVertebroplasty Statistics1.80%moderatetomarked

39、painrelief2.5%inducedfracturesfromprocedure3.1%symptomaticembolismorinfectionExperiences of Our Hospital04.2001 08.200358 patients，65 vertebra L1 16，L2 12，L3 7 ，L4 5 T4 1,T8 2，T9 4，T10 4 T11 6，T12 8.Case 1 Female68yrs Case 1 Female68yrs L L1 1fracture before operationfracture before operationBack pa

40、in after falling on the Back pain after falling on the groundgroundCase 1 female 68yrs Case 1 female 68yrs L L1 1fracture postoperationfracture postoperationTo walk at the first day after To walk at the first day after operation operation Case 1 female 68yrs L1fracture postoperation CTCase 2Case3 T1

41、2CompressionVertebra FractureDuring operationCase3 T12 CompressionVertebra FracturePost-operationCase 4 PostoperationCervical Spine Fractures and OsteoporosisFractures of the cervical spine usually result from major trauma(traffic accidents,falls from great heights or dives into shallow water).In el

42、derly patients severe cervical spine injuries may already result from simple falls.little information available on treatment and outcome of cervical spine injuries in the elderly,especially regarding the subaxial spineCervical Spine Fractures and OsteoporosisIn the general population,about 50%of fra

43、ctures involve the C5-6 and C6-7 level,with dens fractures being the second most frequent localization.The incidence of lower cervical spine injuries continuously declines with age.In contrast,the incidence of upper cervical spine injuries rises in the elderly.Fractures of the dens are the most comm

44、on location in patients above theage of 70 yearsCervical Spine Fractures and OsteoporosisA 68-year-old patient,presenting with incomplete tetraplegia after falling from a tree.a.The lateral radiograph shows no apparent fracture,but there is advanced multilevel degeneration,b.MRI confirms severe spin

45、al canal stenosis,mainly at levels C4-5 to C6-7.The patient died a few days later due to pulmonary complications.Cervical Spine Fractures and OsteoporosisA 62-year-old patient presenting with cervical myelopathy 2 years after an initially missed dens fracture.MRI shows the pseudarthrosis and a bulgi

46、ng tissue mass posterior to the dens.Cervical Spine Fractures and OsteoporosisFractures of the Dens AxisOwn Material of Anterior Screw Fixation of Dens FracturesThoracic and Lumbar Spine FracturesIndications for surgery:devastating neurological compromise orincreasingly unstable kyphosis at the frac

47、ture site.Thoracic and Lumbar Spine FracturesLate Neurological Compromise after OsteoporoticFracturesThoracic and Lumbar Spine FracturesPosture and ApproachThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesRec

48、onstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral CollapseThoracic and Lumbar Spine FracturesReconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral Collapse Reconstructive Surgery ofOsteoporotic-Post-traumatic Vertebral Collapse