背景:下腰椎急性骨质疏松性椎体骨折(OVFs)后下肢神经根病在老年患者中并不常见。此外,对于对保守治疗无反应的患者,通常建议进行手术干预。考虑到该人群的一般状况较差,确定最佳手术策略具有挑战性。因此,在这里,我们建立了一种手术管理这种临床场景的算法,希望为手术决策提供参考。
方法:我们回顾性研究了下腰椎急性单级OVFs后新发的下肢神经根病患者,并最终在我们部门接受了手术干预。关于人口统计的信息,骨质量,椎体骨折的AO脊柱分类,预先存在的退行性变化,包括椎间孔狭窄和腰椎间盘突出,并收集手术干预类型。此外,临床结果,包括术前和术后背部和腿部疼痛的视觉模拟量表(VAS)评分,Oswestry残疾指数(ODI),和对手术反应的MacNab标准,进行了评估。
结果:从2019年9月至2021年12月,共分析了22例患者,平均年龄为68.59±9.74岁。受累最多的椎骨是L5(54.5%),其次是L4(27.3%)和L3(18.2%)。在22名患者中,15例(68.2%)被诊断为AO分类的A1型骨折,其中,11(73.3%)的特征是下端板(IEP)的塌陷。3例(13.6%)患有A2型骨折,而4例患者(18.2%)患有A3型骨折。在12例患者(54.5%)中观察到预先存在的退行性改变。共有16例(72.7%)患者接受经皮椎体后凸成形术(PKP)治疗。此外,三名患者接受了后路器械和融合,两名患者接受了二次内镜椎间孔成形术,1例患者接受了二次射频消融.平均随访时间为17.42±9.62个月。术后腰腿痛和ODI的平均VAS评分明显下降(P<0.05)。根据Macnab标准,最后一次随访的总满意率为90.9%。
结论:IEP中OVF患者易患下肢神经根病。PKP单独或与其他微创手术策略联合治疗稳定性骨折是安全有效的。此外,对于不稳定骨折或椎间孔严重侵犯的患者,应考虑积极的手术干预。
BACKGROUND: Radiculopathy of the lower limb after acute osteoporotic vertebral fractures (OVFs) in the lower lumbar spine is uncommon in geriatric patients. Moreover, surgical intervention is generally recommended in patients who are irresponsive to conservative treatment. Determining an optimum surgical strategy is challenging considering the poor general condition of this population. Thus, herein, we established an algorithm for surgically managing this clinical scenario, hoping to provide a reference for making a surgical decision.
METHODS: We retrospectively studied patients who suffered from new-onset radiculopathy of the lower limb after acute single-level OVFs in the lower lumbar spine and eventually underwent surgical intervention at our department. Information on the demographics, bone quality, AO spine classification of the vertebral fracture, pre-existing degenerative changes, including foraminal stenosis and lumbar disc herniation, and surgical intervention type was collected. Additionally, clinical outcomes, including preoperative and postoperative visual analog scale (VAS) scores for back and leg pain, Oswestry disability index (ODI), and MacNab criterion for response to surgery, were evaluated.
RESULTS: From September 2019 to December 2021, a total of 22 patients with a mean age of 68.59 ± 9.74 years were analyzed. The most involved vertebra was L5 (54.5%), followed by L4 (27.3%) and L3 (18.2%). Among the 22 patients, 15 (68.2%) were diagnosed with the A1 type fracture of AO classification, and among them, 11 (73.3%) were characterized by the collapse of the inferior end plate (IEP). Three patients (13.6%) suffered from A2-type fractures, whereas four patients (18.2%) suffered from A3-type fractures. Pre-existing degenerative changes were observed in 12 patients (54.5%) of the patients. A total of 16 patients (72.7%) were treated by percutaneous kyphoplasty (PKP). Additionally, three patients underwent posterior instrumentation and fusion, two patients underwent a secondary endoscopic foraminoplasty, and one patient underwent a secondary radiofrequency ablation. The mean follow-up period was 17.42 ± 9.62 months. The mean VAS scores for leg and back pain and ODI decreased significantly after the surgery (P < 0.05). The total satisfaction rate at the last follow-up was 90.9% per the Macnab criterion.
CONCLUSIONS: Patients with OVFs in the IEP are predisposed to suffer from radiculopathy of the lower limb. PKP alone or in combination with other minimally invasive surgical strategies is safe and effective in treating stable fractures. Additionally, aggressive surgical intervention should be considered in patients with unstable fractures or severe foraminal encroachment.