【作者】 郑永佳；

【导师】 梁德；

【作者基本信息】 广州中医药大学 ， 中医骨伤科学， 2012， 硕士

【摘要】 目的探讨对骨质疏松性椎体压缩性骨折老年患者行经皮椎体强化术时采用不同术式及骨水泥注入量对凝血功能的影响及临床意义。方法2010年10月至2012年3月对确诊为骨质疏松性椎体压缩骨折,年龄大于60岁的患者行椎体强化术,共28例,32个椎体。采用C型臂X线机透视引导下穿刺注射聚甲基丙烯酸甲酯骨水泥(PMMA),并在注入骨水泥前10分钟、注入后5分钟、30分钟、1小时检测患者APTT、PT、 FIB和D-Dmier,记录单次骨水泥注入量,分析骨水泥注入前后患者凝血功能的变化,并对比分析PKP组与PVP组,小剂量组(胸椎≤3ml,腰椎≤5ml)和大剂量组(胸椎>3ml,腰椎>5ml)患者凝血功能变化的异同。结果所有患者的D-Dmier均值在注入骨水泥前10分钟略高于参考值,在注入骨水泥后逐渐升高,除在注入骨水泥后30分钟和1小时对比无统计学上的差异(P>0.05)外,其余各时间点相互对比均有统计学上的差异(P<0.05)：余指标数值均在参考值范围内,且在注入骨水泥前后各时间点对比无统计学上的差异(P>0.05)。PKP组和PVP组患者的D-Dmier均值在注入骨水泥前10分钟略高于参考值,在注入骨水泥后逐渐升高,PVP组在注入后1小时较注入后30分钟均值略低,但所有数值均高于参考值,两组在注入骨水泥后各时间点与注入骨水泥前对比均有统计学差异(P<0.05),PKP组在注入骨水泥后30分钟与注入骨水泥后5分钟、1小时对比均有统计学上的差异(P<0.05),PVP组则对比无统计学上的差异(P>0.05),余指标均值均在参考值范围内,PKP组APTT在注入骨水泥后30分钟与注入前10分钟及注入后5分钟对比均有统计学差异(P<0.05)。小剂量组与大剂量组患者的D-Dmier均值在注入骨水泥前10分钟略高于参考值,在注入骨水泥后逐渐升高,小剂量组在注入骨水泥后30分钟与1小时对比有统计学差异(P<0.05),其余各时间点对比均无统计学差异(P>0.05),大剂量组则在注入骨水泥后30分钟与1小时对比无统计学差异(P>0.05),其余各时间点对比有统计学差异(P<0.05)。结论经皮椎体强化术注入PMMA后1小时内会使患者血液趋于高凝状态,建议在术后给予预防血栓形成、改善微循环、中药活血化瘀等治疗。PKP与PVP在注入骨水泥后均会对患者凝血功能产生影响,但两者的影响无明显差异,故可根据患者具体情况选择合适术式。单次注入过多PMMA可能是使患者血液趋于高凝状态的危险因素,手术时在保证疗效的基础上应适当减少PMMA的注入量。更多还原

【Abstract】 ObjectiveTo evaluate the effects of different surgical approach and bone cement (i.e. polymethylmethacrylate, PMMA) dose on coagulation functions during percutaneous vertebral augmentation in old patients with osteoporotic veterbral compression fractures (OVCF) and it’s clinical significance.MethodsTwenty-eight patients who were diagnosed OVCF, with32vertebrae underwent percutaneous vertebral augmentation in our section betweent the October2010to March2012. Under the guidance of C-arm f luoroscogy, PMMA was injected into the fractured vertebrae percutaneously via transpedicular. Activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen (FIB), D-Dimer concentration (D-D-Dmier) were measured lOmin before and5min,30min, lh after bone cement implantation. The bone cement does in one operation was also recorded afer operarion. The change on coagulation functions before and after bone cement implantation was analyzed, and the differences between group of PKP and group of PVP, group of small dose (thoracical vertebrae^3ml, lumber vertebrae^5ml) and group of large does (thoracical vertebrae>3ml, lumber vertebrae>5ml)were also assessed.Results1. The mean D-Dmier of all patients was a little higher than normal scale and rose gradually after bone cement implantation. There were significant differences among the various moments before and after bone cement implantation (P<0.05), excluding the compartion between the moment of30min and lh after bone cement implantation (P>0.05). Other magnitudes were normal, and there were not statistic differences among them (P>0.05).2.In PKP and PVP, The mean D-Dmier of both groups were a little higher than normal scale and rose gradually after bone cement implantation. The mean D-Dmier of PVP groups was a little lower in the moment Ih afer bone cement implantation than30min afer, but both were higher than normal scale. There were statistic differences between the moment of l0min before bone cement implantation and each moment after in both groups (P<0.05), such as the moment of30min after bone cement implantation and the moment of5min and lh after in PKP group (P<0.05), but not in PVP group (P>0.05). Other magnitudes were normal.In PKP group, APTT demonstrated significant differences between the moment of30min after bone cement implantation and the moment l0min before and5min after (P>0.05).3. The mean D-Dmier of small dose group and large dose group were both a little higher than normal scale and rose gradually after bone cement implantation. In small dose group, There were no significant differences among the various moments before and after bone cement implantation (P>0.05), excluding the compartion between the moment of30min and Ih after bone cement implantation (P<0.05). But in large dose group, it was opposite. There were significant differences among the various moments before and after bone cement implantation (P<0.05), excluding the compartion between the moment of30min and lh after bone cement implantation (P>0.05). Other magnitudes were normal.ConclusionsIt can cause hypercoagulabale state in lh after PMMA implantation in percutaneous vertebral augmentation in elderly patients. We propose taking treatment like prevention of thrombosis, improvement of microcirculation, and traditional Chinese medicine after operation. PKP and PVP can both impact on coagulabale function in patients, but it showed no significant different between PKP and PVP, thus we shoukd select the appropriate procedure in accordance with the specific circumstances of the patients. Injecting PMMA too much in one operation may be the risk factors to cause hypercoagu1able state and we should be appropriate on the basis of ensuring the efficacy of surgery to reduce the PMMA injection更多还原