Andresen Reimer, Radmer Sebastian, Wollny Mathias, Andresen Julian Ramin, Nissen Urs, Schober Hans-Christof
Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Esmarchstraße 50, 25746, Heide, Germany.
Centre for Orthopaedics, Berlin, Germany.
Eur J Orthop Surg Traumatol. 2017 Dec;27(8):1045-1050. doi: 10.1007/s00590-017-2001-1. Epub 2017 Jun 26.
In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically associated with severe disabling pain. The objective of the present study was to examine the feasibility of cement augmentation by CSP, to determine post-interventional leakages and other complications, and to present the outcome of pain over the course of 18 months.
In 23 patients (20 women and 3 men) with an average age of 81.3 (71-92) years, a total of 41 sacral fractures were detected by MRI, 5 of them unilateral and 18 bilateral. Conservative treatment initially performed over a period of 3 weeks did not bring any satisfactory reduction in the severe disabling pain. The indication for intervention was established after an interdisciplinary case conference. The intervention was performed under intubation anaesthesia. Single-shot antibiotic prophylaxis was given routinely immediately prior to the intervention. Under sterile conditions, a Jamshidi needle was then advanced into the respective fracture zone in the sacrum from dorsal to ventral (short axis) or from lateral to medial transiliac (transiliac axis). After removing the inner needle, a flexible osteotome was inserted through the positioned hollow needle and used to extend the spongious space in the fracture zone and thus prepare a cavity for the cement filling. High-viscosity PMMA cement was then inserted discontinuously with the aid of a pressure gauge under low-dose CT control. Cement leakages were determined in the CT image on the day after the intervention, all cement outside of the cortical boundary being rated as a leakage. Pain was documented on a visual analogue scale (VAS) on the day before the intervention, on the second day, and 6, 12, and 18 months after the intervention. Additionally occurring complications were recorded, and the patients were asked to rate their satisfaction after 6 and 18 months.
CSP was technically feasible in all patients. In the control CT scan, sufficient cement distribution and interlocking with vital bone were found along the course of the fracture in the sacrum. An average of 6.0 ± 0.83 ml of cement was inserted per fracture. Leakage was found in 5 of 41 (12.2%) of the fractures treated, although none were symptomatic. The mean pain score on the VAS was 8.8 ± 0.59 before the intervention, a significant pain reduction (p < 0.0005) was seen on the second post-operative day, with an average value of 2.1 ± 0.36, and this was stable at 2.2 ± 0.28 after 6, 2.3 ± 0.31 after 12, and 2.2 ± 0.41 after 18 months. Now that they no longer experienced disabling pain, all of the patients were fully remobilised and discharged back home. A high level of patient satisfaction was found after 6 and 18 months.
As a minimally invasive procedure, CSP is an effective treatment method for rapid, significant, and sustained pain reduction.
在骨质质量下降的老年患者中，骶骨不全骨折相对常见，通常伴有严重的致残性疼痛。本研究的目的是探讨经皮骶骨成形术（CSP）进行骨水泥强化的可行性，确定介入后的渗漏及其他并发症，并展示18个月期间的疼痛结果。
23例患者（20例女性，3例男性），平均年龄81.3（71 - 92）岁，通过MRI共检测到41处骶骨骨折，其中5处为单侧骨折，18处为双侧骨折。最初进行了为期3周的保守治疗，但严重的致残性疼痛并未得到任何令人满意的缓解。经多学科病例讨论后确定了干预指征。干预在插管麻醉下进行。干预前常规单次给予抗生素预防。在无菌条件下，将Jamshidi针从背侧至腹侧（短轴）或从外侧至内侧经髂骨（经髂骨轴）插入骶骨的相应骨折区域。取出内针后，通过定位的空心针插入柔性骨刀，用于扩大骨折区域的松质间隙，从而为骨水泥填充准备一个腔隙。然后在低剂量CT控制下借助压力计间断插入高粘度聚甲基丙烯酸甲酯（PMMA）骨水泥。在干预后第二天的CT图像上确定骨水泥渗漏情况，皮质边界以外的所有骨水泥均被视为渗漏。在干预前一天、第二天以及干预后6、12和18个月，采用视觉模拟评分法（VAS）记录疼痛情况。记录额外出现的并发症，并在6个月和18个月后询问患者的满意度。
CSP在所有患者中技术上都是可行的。在对照CT扫描中，沿骶骨骨折线发现骨水泥分布充分且与活性骨相互嵌合。每个骨折平均注入骨水泥6.0 ± 0.83 ml。在治疗的41处骨折中有5处（12.2%）发现渗漏，但均无症状。干预前VAS平均疼痛评分为8.8 ± 0.59，术后第二天疼痛显著减轻（p < 0.0005），平均值为2.1 ± 0.36，6个月后稳定在2.2 ± 0.28，12个月后为2.3 ± 0.31，18个月后为2.2 ± 0.41。由于不再经历致残性疼痛，所有患者均完全恢复活动并出院回家。在6个月和18个月后患者满意度较高。
作为一种微创手术，CSP是一种有效减轻疼痛的治疗方法，能快速、显著且持续地缓解疼痛。
