| Objective1.To evaluate the effect of different fixed segments in patients with osteoporotic lumbar degenerative diseases.Based on the theories of stability differentiation of stability and immobilization in Chinese Orhtopedic and modern advanced imaging technique,to determine the risk factors related to screws loosing after lumar fusion surgery,enriching the theory of stability differentiation in Chinese Orthopedics.2.To explore the necessity of cement augmented pedicle screw fixation in osteoporotic spine for patients with single-segment lumbar degenerative disease.3.To explore the necessity of cement augmented pedicle screw fixation in osteoporotic spine for patients with two-segment lumbar degenerative disease.4.To evaluate the effect and safety of cement-augmented sacral screw used in osteoporotic spine with lumbosacral degenerative disease.Based on the theories of stability differentiation of stability and immobilization in Chinese Orhtopedic and modern advanced imaging technique,to determine the risk factors related to S1 screw loosing after lumar fusion surgery,enriching the theory of stability differentiation in Chinese Orthopedics.5.To evaluate the incidence,type and risk factors of cement leakage with cement-augmented pedicle screw instrumentation lumbosacral(CAPSI)in the treatment of degenerative disease.Methods1.The first part,from January 2011 to December 2014,80 patients including two males and seventy-eight females,aging from 69.96±6.55 years old with T scores of bone mineral density at-3.13±0.62SD,underwent posterior fixation with pedicle screws at lumbosacral segments and followed up by 19.98±10.42 months were enrolled.All patients were divided into 3 groups,single segment fixation group(group A,29 cases),double segmental fixation group(group B,25 cases)and multisegmental segmental fixation(group C,26 cases).The gender?age?bone mineral density(BMD)?body mass index(BMI)?operation time?blood loss?hospital stay?complications of surgery?screw loosening rate and bone fusion rate were also recorded.Besides,the Visual Analogue Scale(VAS)and Oswestry Disability Index(ODI)pre-Op and at the last follow up were assessed.2.The second part,74 cases followed up for a minimum of 2 years with single-segment degenerative lumbar disease in osteoporotic spine receiving posterior lumbar fusion and Regular anti-osteoporosis treatment were reviewed retrospectively.36 cases(3 males and 33 females,70.61±6.37 years old on average,average bone density-3.38±0.77SD,surgical segment:L4/5 32 cases and L5/S1 4 cases)were in the Polymethylmethacrylate-augmented pedicle screw group(PMMA-PS)and the other 38 cases(2 males and 36 females,69.79±5.90 years old on average,average bone density-3.32±0.57SD,surgical segment:L4/5 32 cases and L5/S1 6 cases)in the Conventional pedicle screw group(CPS).Surgical datas including the operation time,intra-operative blood loss,hospitalization day and surgical complications were recorded,as well as the radiological parameters measured from postoperative X-rays and CT scans containing the raes of fusion and screw loosening.In addition,the visual analogue scores(VAS)and Oswestry disability index(ODI)were evaluated preoperatively,at 6 months and the final follow-up postoperatively.3.The third part,58 patients followed up at least 2 years,who diagnosed as degenerative lumber diseases with osteoporosis,and received two-segments TLIF with pedicle screw,fixation system,were enrolled in our institute were retrospectively reviewed.The patients,that the fusion segment were L4-S1 and L3-L5,were divided into polymethylmethacrylate-augmented pedicle screw(PMMA-PS)group and conventional pedicle screw(CPS)group.The clinical outcome was evaluated by comparing demographics,surgical date,VAS value?ODI value?non-fusion rate and pedicle screw loosening rate.4.The fourth part,61 patients including six males and fifty-five females,aging from 60-80 years old with T scores of bone mineral density at-3.37±0.69SD,underwent posterior fixation with pedicle screws at lumbosacral segments were enrolled.All patients received cement-augmented pedicle screw at L5,and were divided into 3 groups,bone cement augmentation group(group A,17 cases),bicortical pedicle screw group(group B,20 cases)and three cortical pedicle screw group(group C,24 cases)according to the different patterns of S1 pedicle screws.The Visual Analogue Scale(VAS)and Oswestry Disability Index(ODI)pre-op and at the last follow up were assessed.Besides,the complications of surgery?screw loosening rate and bone fusion rate were also recorded.5.The fifth part,This study included 202 consecutive patients who underwent posterior lumbar interbody fusion using a total of 950 cement-augmented screws.Cement leakage was classified according to the anatomical localization:Type B:leakage to the spinal canal via basivertebral veins;Type S:leakage to segmental veins;Type I:leakage via pedicle screw internal fixation to paravertebral tissue(include leakage via cortical defect and fenestrated screws).The age,gender,operation stage(earlier or later stage),BMD,BMI,the number and the type of augmented screws,the position of screw tip(lateral or internal of the vertebra bodies),the position of screw(left or right),the doses of bone cement,augmented vertebra(lumbar or sacrum),the type of cement leakage and complications were recorded.Binary logistic regression correlation was used to analysis risk factors of veins leakage(Type S and Type B).Results1.Part I clinical study,All patients were completed surgery successfully.In group A,the average operation time was 184.45±35.66 min,the blood loss was 230.24± 154.88ml,and the average hospital stay was 9.48± 1.68 d.There were 2 patients had perioperative complications,2 patients with three tailing screw were happened screws loosening,loosening rate was 6.90%and fusion rate was 96.550%(28 cases).In group B,the average operation time was 260.44±58.02 min,the blood loss was 358.00±202.42ml,and the average hospital stay was 15.28±4.15 d.There were 4 patients had perioperative complications,8 patients with fourteen head and tail screw were happened screws loosening,loosening rate was 32%and fusion rate was 84%.In group C,the average operation time was 288.46±72.11 min,the blood loss was 811.54±495.44ml,and the average hospital stay was 20.23±7.44 d.There were 7 patients had perioperative complications,13 patients with twenty-nine head and tail screw were happened screws loosening,loosening rate was 50%and fusion rate was 70%.Group A with lowest operation time?blood loss?hospital stay?loosening rate?VAS and ODI scores at last follow up.Furthermore,high BMI,large pre and post-op PI-LL,and large post-op PI were found as risks related to screw loosening.However,gender?BMD?whether it's lumbosacral fixation?pre and post-op LL?SS?PI?the change of LL and pre-op PT attaching less importance on it(P>0.05).2.Part II clinical study,In CPS group,the average operation time was 147.21 ± 17.llmin,the blood loss was 138.03±42.45ml,and the average hospital stay was 8.82±1.07d;The PMMA-PS was 185.75±18.37min,142.64±35.08ml,8.82+1.07d,respectively.Compared with PMMA-PS group,operation times in the CPS group decreased significantly(P<0.05).While no statistical difference for the average hospital stay or blood loss between 2 groups(P>0.05).The VAS scores of CPS group and PMMA-PS group on pre-operative,at 6 months after operation and last follow-up were 7.16±0.82,6.93±10.88;1.74±0.49,1.92±0.47;1.76±0.43,1.81±0.40;The ODI were51.84±4.41%,52,50±4.71%;18.03±2.74%,18.89±3.61%;17.24±2.77%,16.67±2.67%;respectively.After surgeries,VAS and ODI at 6 months and last follow-up improved significantly in two groups(P<0.05).There were no significant differences of VAS and ODI preoperatively and postoperatively between 2 groups(P>0.05).In PMMA-PS group,no screw loosening occurred,and the fusion rate was 100%;In the CPS group,2 screws loosened(1.3%,2/152)in 1 patient(2.7%,1/36),and the fusion rate was(97.3%,37/38),however,no significant difference were found for both items between 2 groups(P>0.05).Besides,27(18.7%,27/144)asymptomatic trajectory PMMA leakages were detected.3.Part III clinical study,All the patients,which include 31 patients in PMMA-PS group and 27 patients in CPS group,were successfully complete operation.The intraoperative blood loss of PMMA-PS group was more than CPS group,and it had statistical difference.The two groups VAS value and ODI value of pre-operation were more than post-operation one month and the final follow-up(P<0.05),and the VAS value of PMMA-PS group less than CPS group in the final follow-up(P<0.05).The pedicle screw loosening rate of the CPS group were more than PMMA-PS group(P<0.05).The non-fusion rate of the CPS group were more than PMMA-PS group,but no statistical difference(P>0.05).Furthermore,large pre and post-op PI-LL,and large post-op PI were found as risks related to screw loosening.However,gender?BMD?whether it's lumbosacral fixation?pre and post-op LL?SS?PI?the change of LL and pre-op PT attaching less importance on it(P>0.05).4.Part IV clinical study,All patients were completed surgery successfully and followed up by 19.98±10.42 months.The scores of VAS and ODI at the last follow up significantly improved compared to the pre-op scores in all groups,in addition,group A with lowest VAS and ODI scores at last follow up,meanwhile,no significant difference detected between group B and C.In group A,the leakage rate of bone cement in lumbar and sacrum was 23.68%and 23.53%,respectively,with other complications including dural tear(1 case),shallow wound infection(1 case)and lateral plantar flextion weakness(1 case)observed and,no screw loosening and unfusion occurred.;In group B,leakage rate was 41.25%,with contralateral limb numbness and weakness in 2 cases,and S1 screw loosening rate of 30%;In group C,leakage rate was 24.46%,dural tear in 2 patients,wound infection in 1 patient,contralateral limb numbness and weakness in 1 patient and S1 screw loosening rate of 25%were found.Furthermore,older age,longer fusion segments and large post-op PI-LL were found as risks related to S1 screw loosening without cement-augmentation,however,gender?BMD?BMI?surgical approach?pre and post-Op LL?SS?PT?PI?the change of LL and pre-op PI-LL attaching less importance on it(P>0.05).5.Part V clinical study,Cement leakage was observed in 165 patients(81.68%)and 335 screws(35.26%),the numbel of type S/type B/type I were 255 screws(76.12%),77 screws(22.99%),and 30 screws(8.96%),besides,27 screws showed leakage to more than one site.The number of augmented screws was a risk factor to veins leakage(P=0.000).Furthermore,the position of screw(P=0.000),the doses of bone cement(P=0.019),augmented vertebra(P=0,006)was a risk factor to type S and the position of screw(P=0.000)and the doses of bone cement(P-0.000)was a risk factor to type B.Conclusions1.With the increase of the fixed segment(?2 segments),the operation time,blood loss,hospital stay and the head/tail of the screw loosening rate were increased significantly and lead poor clinical efficacy in patients with osteoporotic lumbar degenerative disease.For patients with large BMI,PI-LL and PT,we suggests to use internal fixations with higher holding force at head/tail to reduce screw loosening.2.It is not recommended conventional application of PMMA augmented screw in osteoporotic spine with single-segment lumbar degenerative disease due to the similar clinical efficacy and fusion rate achieved on the basis of regular anti-osteoporosis treatment with or without augmentation,besides,less operative time needed in CPS.3.Cement-augmented pedicle screw technique is effective and safe in osteoporotic spine with lumbar degenerative diseases,with better fusion rates and less screw loosening incidence,compared with CPS group.For patients with large BMI and PI-LL,we suggests to use internal fixations with higher holding force at head/tail to reduce screw loosening.4.Sacral screw cement augmentation was able to achieve better stability with less screw loosening in osteoporotic spine with lumbosacral degenerative diseases,especially recommended in patients with old age,long segment fixation and large post-operation PI-LL.5.It seem that cement leakage in CAPSI was ineluctability and type S and type B was the most common leakage type.More augmented screws and larger doses of cement was a risk factor to veins leakage(type S and type B)and the internal position of screw tip in vertebra bodies was a risk factor to type B leakage.This indicate that the leakage of screws can be reduced by optimizing operative techniques and procedures.6.It seems that large BMI,large post-operation PI-LL and PT,old age,and long segment fixation are related with the“stability”of the stability differentiation in osteoporotic lumbar degenerative disease receiving posterior lumbar fusion,especially in large post-operation PI-LL. |
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