Bula P, Lein T, Strassberger C, Bonnaire F
Klinik für Unfall-, Wiederherstellungs- und Handchirurgie, Städtisches Klinikum Dresden-Friedrichstadt, Dresden.
Z Orthop Unfall. 2010 Dec;148(6):646-56. doi: 10.1055/s-0030-1250379. Epub 2010 Nov 15.
Considering the demographic changes in the populations of Germany and Europe as a whole, the field of geriatric traumatology is gaining more and more importance within the specialty of orthopedic and trauma surgery. The high prevalence of osteoporosis in this specific group of patients poses a special challenge, with vertebral compression fractures being the by far most common osteoporosis-related fractures. These fractures present with acute as well as chronic back pain leading to severe consequences for the affected patients. Mobility and quality of life are often heavily impaired. Furthermore, higher morbidity and mortality as well as higher risk for further fractures have been proven in these patients.
Balloon kyphoplasty has become a more frequently used therapy and is now offered broadly. This treatment addresses stable fractures not involving the posterior margin of the vertebrae. With increasing application of this surgical procedure the number of complication reports is also rising. The following article gives an overview of the technique, indications and the possible complications by giving several examples from the daily practice and reviewing the relevant literature.
Cement leakage of the treated vertebrae is the most common complication associated with balloon kyphoplasty. In almost all cases this occurs due to too early application of the cement, not having reached its optimum in viscosity. Literature research shows a percentage rate of about 9% for cement leakage. Thus, balloon kyphoplasty provides more safety for the patient than vertebroplasty, for which cement leakage rates of up to 41% are reported. Other studies report cement leakage ratios of 4-10% for kyphoplasty versus 20-70% for vertebroplasty. Overall the percentage of cement leakage is clearly increased in osteoporotic fractures compared to non-osteoporotic fractures, with the cement leaking mainly into the spinal disc space. So far, valid data in order to further explore the consequences of intradiscal cements are lacking. Most relevant for everyday practice are cement leakages that have become symptomatic. Depending on the localisation they present with dysaesthesia culminating in radicular pain or even paraplegia. Cement leakage into vessels can, depending on the amount of cement, lead to embolism of pulmonary arteries. Complications due to the surgical technique, postoperative infections, bleeding or cardiovascular complications are rare with less than 1%. The probability for symptomatic cement leakage averages about 1.3% for balloon kyphoplasty. Another discussion, for which at present there is no evidence-based verification, is concerned with the higher risk for adjacent vertebral fractures after cement augmentation of an osteoporotic vertebral compression fracture. At present the degree of osteoporosis and more important the number of osteoporosis-related fractures must be the relevant predictor for adjacent fractures of neighbouring vertebrae.
Balloon kyphoplasty is a highly standardised and widely used minimally invasive procedure for stabilising and augmenting painful osteoporotic fractures of the vertebral body. When surgery is indicated carefully and is carried out subtly, the risk of complications is reasonable and the outcome is promising. Viscosity of the used cement has to be adequate and it must not be inserted with too high a pressure. A causal connection between cement viscosity and risk of cement leakage has been proven in experimental studies. During application of PMMA cement a thorough fluoroscopic monitoring must take place in order to detect cement leakage at an early stage and if necessary stop application. These procedures should be reserved for clinical centres and surgeons who are able to surgically handle possible complications such as compression of the spinal cord. On the basis of our own experience we also recommend treatment in a hospital with an integrated osteoporosis centre and consecutive treatment in specialised outpatient care. Standards in primary care as well as after treatment can be introduced thereby. Also communication with practitioner concerned with outpatient care is simplified, which leads to enduring therapeutic outcome.
鉴于德国及整个欧洲人口结构的变化，老年创伤学领域在骨科与创伤外科专业中愈发重要。该特定患者群体中骨质疏松症的高患病率带来了特殊挑战，其中椎体压缩骨折是迄今为止最常见的与骨质疏松相关的骨折。这些骨折会引发急性和慢性背痛，给患者带来严重后果。患者的活动能力和生活质量常常受到严重损害。此外，已证实这些患者的发病率和死亡率更高，且再次骨折的风险也更高。
球囊后凸成形术已成为一种更常用的治疗方法，目前广泛应用。该治疗针对不涉及椎体后缘的稳定骨折。随着这种外科手术应用的增加，并发症报告数量也在上升。以下文章通过列举日常实践中的几个例子并回顾相关文献，对该技术、适应症及可能的并发症进行概述。
治疗椎体的骨水泥渗漏是球囊后凸成形术最常见的并发症。几乎在所有情况下，这都是由于骨水泥应用过早，其粘度尚未达到最佳状态所致。文献研究表明骨水泥渗漏率约为9%。因此，与椎体成形术相比，球囊后凸成形术为患者提供了更高的安全性，据报道椎体成形术的骨水泥渗漏率高达41%。其他研究报告后凸成形术的骨水泥渗漏率为4 - 10%，而椎体成形术为20 - 70%。总体而言，与非骨质疏松性骨折相比，骨质疏松性骨折的骨水泥渗漏百分比明显增加，骨水泥主要渗漏到椎间盘间隙。到目前为止，缺乏进一步探究椎间盘内骨水泥后果的有效数据。对日常实践最相关的是出现症状的骨水泥渗漏。根据其位置不同，会出现感觉异常，最终导致神经根性疼痛甚至截瘫。骨水泥渗漏到血管中，根据骨水泥量的不同，可能导致肺动脉栓塞。手术技术、术后感染、出血或心血管并发症等并发症很少见，发生率低于1%。球囊后凸成形术出现症状性骨水泥渗漏的概率平均约为1.3%。另一个目前尚无循证验证的讨论内容是，骨质疏松性椎体压缩骨折进行骨水泥强化后，相邻椎体骨折的风险更高。目前，骨质疏松程度以及更重要的与骨质疏松相关的骨折数量必定是相邻椎体骨折的相关预测因素。
球囊后凸成形术是一种高度标准化且广泛应用的微创手术，用于稳定和强化椎体疼痛性骨质疏松性骨折。当谨慎选择手术适应症并精细操作时，并发症风险合理且预后良好。所用骨水泥的粘度必须合适，且不得在过高压力下注入。实验研究已证实骨水泥粘度与骨水泥渗漏风险之间存在因果关系。在应用聚甲基丙烯酸甲酯骨水泥过程中，必须进行全面的荧光透视监测，以便早期发现骨水泥渗漏并在必要时停止应用。这些手术应仅由能够手术处理诸如脊髓受压等可能并发症的临床中心和外科医生进行。基于我们自己的经验，我们还建议在设有综合骨质疏松中心的医院进行治疗，并在专科门诊进行后续治疗。由此可引入初级护理及治疗后的标准。同时也简化了与门诊护理相关从业者的沟通，从而带来持久的治疗效果。
