第6节 经皮椎体成形术的并发症及其预防
一、 并发症
骨质疏松椎体成形术并发症的发生率为1%～ 2%，多为神经并发症，且持续时间短暂。恶性肿瘤由于椎体外壳的破坏，并发症发生率为3%～6%，可出现神经并发症，但大多数神经并发症可通过应用激素、消炎治疗而得到缓解，仅2%～3%需要手术减压。
图37-3 椎体成形术骨水泥渗漏
A. 骨水泥渗入椎旁血管；B. 骨水泥渗入颈椎前间隙；C. 骨水泥渗入椎间隙
骨水泥外溢为主要的并发症，占所有并发症的30%～67%（图37-3）。骨水泥外溢有三种情况：① 骨水泥溢入椎旁静脉或硬膜静脉。② 溢入脊柱旁软组织或椎管内硬膜外。③ 溢入椎间盘。骨水泥外溢产生的急性临床症状主要有神经根痛和脊髓受压。发生神经根痛的主要机制为骨水泥通过不完整的椎体后壁、骨折线、骨质破坏区或硬膜外静脉进入椎间孔，压迫神经根而产生神经根症状。在胸椎可致肋间神经痛，可用无水酒精局部浸润治疗；在腰椎则需要神经减压，应用经椎弓根入路可避免骨水泥进入椎间盘；骨水泥溢入椎间盘多无太大的临床意义；骨水泥溢入椎旁多无临床症状。在透视监视下出现溢入椎旁征象时应立即停止注射，以防止动脉栓塞发生。
对脊柱转移瘤行PVP后，可能出现局部疼痛加重，其机制与骨水泥注入后在体内聚合过程的热反应对周围组织与神经根的热损伤有关，一般经2～3天抗炎治疗后症状即可缓解。
其他并发症有：肋骨骨折，多见于严重骨质疏松患者；肺动脉栓塞罕见，即使出现栓子，通常进入血管中的脂肪或者骨髓物质的量较少，并不具有很大的临床意义，文献仅有2例报道，经抗凝治疗后未引起严重临床后果。然而，肺动脉栓塞这一并发症仍不可忽视，特别是针对术前具有慢性阻塞性肺疾病（COPD）的患者，发生肺动脉栓塞的概率可能升高。
Anne用PMMA对37例患者40个肿瘤椎体（30个恶性肿瘤和10个骨髓瘤）行椎体成形术，其泄露情况为：21例至椎旁组织、15例至硬膜外、8例至椎间孔、8例至椎间盘、2例为穿刺孔漏出。其中1例泄露至腰大肌引起股神经刺激症状，术后出现下肢疼痛，但3天后即缓解；1例泄露至椎间孔引起神经根痛，后来予以手术减压。Alain的33例椎体恶性肿瘤椎体成形术资料也显示无严重的并发症发生，虽有多例椎管内泄露，但未引起神经系统症状，1例泄露至椎间孔引起神经根痛，后来予以手术减压，2例PMMA椎体成形术后反而疼痛加重，认为是PMMA引起化学性炎症，予口服地塞米松数日后缓解。
二、 并发症的预防
通过导管经椎弓根至椎体前部，不充盈椎体后缘部。尽量避免不穿破椎弓根内壁，椎弓根内壁破坏后骨水泥可沿针道外溢至椎管内。对于椎体后壁严重破坏的，骨水泥易向椎管内泄露，压迫椎管内结构，应慎用。骨水泥中加入硫酸钡等使其在X线下可显示，及时发现骨水泥的溢出。全过程在X线监视下操作，一旦发现灌注剂随静脉回流迅速扩散或向硬膜外、椎间孔渗漏，应立即暂停，待其黏稠度稍增加后再注射。骨水泥黏度要适度，推注的压力不可太大。避免注射针插入静脉丛，必要时操作前做静脉造影。
术前造影剂的应用仍有待于探讨，因为造影剂的流动性与骨水泥明显不一样，实际应用中，难以根据造影剂的泄露情况操作。为避免泄露，最根本、有效的措施是实时的双平面监视，一旦发现泄露即停止注射，不仅侧位监视以防泄露至椎管，也要前后位监视以防向两侧泄露至椎间孔。
（魏海峰 吴志鹏 彭东宇）
【参考文献】
［1］ Lane J M, Riley E H, Wirgbanowizc P Z. et al. Osteoporosis: Diagnosis and treatment[J]. J Bone Jiont Surg(Am), 1996, 11: 565-567.
［2］ John M M, Michelle P, Neal N. Percutaneous vertebroplasty treatment of steroid-induced osteoporotic compression fractures[J]. Arthritis and Rheumatism, 1998, 41(1): 171-175.
［3］ Alain W M, Jacques C, Jean M S. et al. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement[J]. Radiology, 1996, 199: 241-247.
［4］ Anne C, Florence D, Bernard C. et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: Effects of the
percentage of lesion filling and the leakage of
methyl methacrylate at clinical follow-up[J]. Radiology, 1996, 200: 525-530.
［5］ Mermelstein L E, Mclain R E, Yerby S A. et al. Reinforcement of thoracolumbar burst fractures with calcium phosphate cement[J]. Spine, 1998, 23: 664-671.
［6］ Bo B, Laith M J, Frederick J K. The use of an injectable, biodegradable calcium phosphate bone substitute for the prophylactic augmengtation of osteoporotic vertebrae and the management of vertebral compression fractures[J]. Spine, 1999, 24: 1521-1526.(https://www.daowen.com)
［7］ Kelkott S M, Mathis J M, Deramond H, et al. An ex vivo biomechanical evaluation of a hydroxyapatite cement for use with kyphoplasty[J]. AJNR Am J Neuroradiol, 2001, 22(6): 1212.
［8］ Hamanishi C, Kitamoto K, Ohura K, et al. Self-setting, bioactive, and biodegradable TTCP-DCPD apatite cement[J]. J Biomed Mater Res, 1996, 32(3): 383-389.
［9］ 贾连顺，李家顺.脊柱创伤外科学[M].上海：上海远东出版社，2000：284-291.
［10］ Knobc, Fabian H F, Bastian L, et al. Late results of thoracolumbar fractures after posterior instrumentation and transpedicular bone grafting[J]. Spine, 2001, 26(1): 88-99.
［11］ Kopylor P, Jonsson K, Thorngren K G, et al. Injectable calcuim phosphate in the treatment of distal radial fractrues[J]. J Hand Surg, 1996, 21B: 768-770.
［12］ Gauthier, Bouler J M, Weiss P, et al. Shortterm effects of mineral particle sizes on celluar degradation activity after implantation of injectable calcium phosphate biomaterials and the consequence for bone substitution[J]. Bone, 1999, 25(2S): 71S-74S.
［13］ Goodman S B, Bauer T W, Carter D, et al. Norian SRS cement augmentation in hip fracture treatment. Laboratory and initial clinical results[J]. Clin Orthop, 1998, 348(3): 42-50.
［14］ Yoshikawa T, Suwa Y, Ohgashi, et al. Selfsetting hydroxyapatite cement as a carrier for bone-forming cells[J]. Bio-Med Mater Eng, 1996, 6(5): 345.
［15］ Hamanishi C, Kitanoto K, Tanaka S, et al. A self-setting TTCP-DCPD apatite cement for release of vanocmycin[J]. J Biomed Mater Res, 1996, 33(3): 139.
［16］ Lieberman I H, Dudeney S, Reinhardt M K, et al. Initial outcome and efficacy of “kyphoplasty” in the treatment of painful osteoporotic vertebral compression fractures[J]. Spine, 2001, 26(14): 1631-1638.
［17］ Jensen M E, Evans A J, Mathis J M, et al. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects[J]. Am J Neuroradiol, 1997, 18(10): 1897-1904.
［18］ Cyteval C, Sarrabere M P B, Roux J O, et al. Acute osteoporotic vertebral collapse: open study on percutaneous injection of acrylic surgical cement in 20 patients[J]. Am J Roentgenol, 1999, 173(6): 1685-1690.
［19］ McGraw J K, Lippert J A, Minkus K D, et al. Prospective evaluation of pain relief in 100 patients undergoing percutaneous vertebroplasty: results and follow-up[J]. J Vasc Intervent Radiol, 2002, 13(9 Pt 1): 883-886.
［20］ Evans A J, Jensen M E, Kip K E, et al. Vertebral compression fractures: pain reduction and improvement in functional mobility after percutaneous-polymethylmethacrylate vertebroplasty-retrospective report of 245 cases[J]. Radiology, 2003, 226(2): 366- 372.
［21］ Grados F, Depriester C, Cayrolle G, et al. Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty[J]. Rheumatology, 2000, 39: 1410-1414.
［22］ Peh W C G, Gilula L A, Peck D D. Percutaneous vertebroplasty for severe osteoporotic vertebral body compression fractures[J]. Radiology, 2002, 223(1): 121-126.
［23］ Peh W C G, Gelbart M S, Gilula L A, et al. Percutaneous vertebroplasty: treatment of painful vertebral compression fractures with intraosseous vacuum phenomena[J]. Am J Roentgenol, 2003, 180(5): 1411-1417.
［24］ Weill A, Chiras J, Simon J M, et al. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement[J]. Radiology, 1996, 199(1): 241-247.
［25］ Cotten A, Duquesnoy B. Vertebroplasty: current data and future potential[J]. Rev Rhum Engl Ed, 1997, 64(11): 645-649.
［26］ Alvarez L, Perez-Higueras A, Quinones D, et al. Vertebroplasty in the treatment of vertebral tumors: postprocedural outcome and quality of life[J]. Eur Spine J, 2003, 12(4): 356-360.
［27］ Fourney D R, Schomer D F, Nader R, et al. Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients[J]. J Neurosurg, 2003, 98(Suppl 1): 21-30.
［28］ Cotten A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up[J]. Radiology, 1996, 200(2): 525-530.