【作者】 辛军；

【导师】 崔新刚；

【作者基本信息】 山东大学 ， 外科学（骨外科）（专业学位）， 2021， 硕士

【摘要】 目的:胸椎骨质疏松性骨折患者常有肋间神经痛。目前还不清楚为什么在MRI上没有任何神经压迫的椎体骨折患者会出现肋间神经痛。本研究的目的是调查胸椎骨质疏松性骨折患者产生肋间神经痛的原因。方法:回顾性研究分析单节段胸椎骨质疏松性骨折的患者100例,根据病史及病历记录,按照疼痛类型将患者分为两组。A组50例患者有肋间神经痛,B组50例患者无肋间神经痛。通过视觉模拟评分(VAS)和Oswestry功能障碍指数(ODI)来评估疼痛的严重程度。记录患者的性别、年龄、有无外伤、骨折时间、骨折节段及有无镇痛药物的应用情况。在CT上测量骨折椎体形态(高度、宽度、长度)变化、椎间孔形态(高度、宽度)变化、骨折椎体楔形变程度、局部后凸角等数据。通过磁共振成像(MRI)评估骨折水肿信号大小。通过以上参数进行多因素分析。结果:1.一般情况肋间神经痛组和无肋间神经痛组平均年龄分别为68.8±6.9岁和69.8±9.0岁。两组中,下胸段(T10-T12)是最常见的骨折部位。两组患者在有无外伤史、有无镇痛药物应用、视觉模拟评分(VAS)的差异均有统计学意义(P<0.05)。两组患者在骨折节段、磁共振水肿信号大小、骨折类型分类、疼痛症状持续时间、Oswestry功能障碍指数(ODI)的差异均无统计学意义(P>0.05)。2.椎体形态参数的比较两组患者骨折椎体的宽度、前、中高度变化差异均有统计学意义(P<0.05)。骨折椎体长度和后高度变化无显著性差异(P>0.05)。两组患者骨折椎体上方两侧侧椎间孔宽度变化差异有统计学意义(P<0.05)。两组患者骨折椎体椎间孔其他参数差异无统计学意义(P>0.05)。两组患者骨折椎体楔形变和局部后凸角差异无统计学意义(P>0.05)。3.两组有差异参数与肋间神经痛相关性独立样本T检验或卡方检验结果显示,两组患者在骨折椎体宽度、前、中高度变化、上方左右椎间孔宽度变化、有无外伤史、有无镇痛药物应用史、疼痛视觉模拟评分(VAS)等因素均有显著性差异。为进一步分析8个因素的相关性,进一步采用二元Logistic回归分析。通过二元Logistic回归分析显示,两组患者骨折椎体宽度的变化是肋间神经痛的一个恒定显著预测因子(P=0.00,Exp(B)=4.531E+50)。经二元Logistic回归分析,其余7个因素不再是肋间神经痛的预测因素(P>0.05)。也就是说,调整其他7个因素后结果显示,骨折椎体宽度增加的患者发生肋间神经痛的发生率更高。结论:1.有肋间神经痛的患者椎体宽度变化明显高于无肋间神经痛的患者(P<0.05)。胸椎骨质疏松性骨折患者的肋间神经痛发生率与骨折椎体宽度显著正相关。2.肋间神经痛在胸椎骨质疏松骨折患者中很常见。对于此类患者,骨折部位与疼痛部位可能并不一致。正确的诊断需要仔细的体格检查和完善的影像学分析。因此,对于疼痛沿肋间隙或向两侧或一侧胸部放射的老年患者,无论其在胸椎区域有无外伤,都应检查胸椎。意义:肋间神经痛和骨折形态之间的关系在以前的文献中没有报道过,我们相信我们对这种疼痛的研究有助于弄清楚疼痛来源,进而有助于这些患者的疼痛管理。我们也正在进行一项前瞻性研究,以进一步证实这一结论的可靠性。我们认为,本研究可能进一步阐明脊柱骨质疏松性骨折中非中线疼痛的机制。更多还原

【Abstract】 Objectives:The costal pain is common in thoracic osteoporotic fracture patients.It is unclear why vertebral fracture patients without any specific nerve impingement on MRI present with costal pain.The aim of this study was to investigate the potential causes of costal pain in patients with osteoporotic fracture of thoracic vertebra.Methods:In this retrospective study,100 patients with thoracic osteoporotic fracture were collected and assigned into two groups on the basis of pain patterns noted during medical history and physical examination.Group A comprised 50 patients with costal pain.Group B comprised 50 patients without costal pain.The Visual Analogue Scale(VAS)and Oswestry Disability Index(ODI)scores were recorded to assess the pattern and severity of pain.The sex,age,presence or absence of trauma,time of fracture,fracture segments,and analgesic application were recorded.CT data including changes in fracture vertebral body shape(height,width and length),changes in intervertebral foramen shape(height and width),wedge shape of fractured vertebral body and local kyphosis angle were recorded.The fracture edema signal was determined by magnetic resonance imaging(MRI).Multivariate analysis was performed for all the above parameters.Results:1.Genral conditionsThe average ages in the costal and non-costal groups were 68.8±6.9 and 69.8±9.0 years,respectively.In both groups,the lower thoracic segment(T10-T12)was the most common level of fracture site.There was significant difference in trauma or not,analgesic or not and Visual Analogue Scale between the two groups(P<0.05).No statistical significance in the fracture level,magnetic resonance edema signal size,classification of fracture types,symptom duration or Oswestry Disability Index(P>0.05)were observed between the two groups.2.Comparison of vertebral morphology parametersThere was significant difference in vertebral fracture width,anterior and middle height between the two groups(P<0.05).While there was no significant difference in vertebral length or posterior height(P>0.05).There was significant difference in width of left upper intervertebral foramen or width of right upper intervertebral foramen between the two groups(P<0.05).There was no significant difference in the other parameters of the intervertebral foramen between the two groups(P>0.05).No significant difference in the wedge angle and local kyphosis angle was observed between the two groups(P>0.05).3.The correlation between costal pain and different parameters between the two groupsOur T-test or Chi-square test results showed significant differences in the changes of the vertebral fracture width,anterior and middle height,the width of left and right upper intervertebral foramen,trauma or not,analgesic or not and Visual Analogue Scale(VAS)between the two groups.To further analyze the correlation of the eight factors,binary Logistic regression analysis was conducted.Binary Logistic regression analysis showed that the change of the vertebral body width was a constant significant predictor of costal pain for all patients(P=0.00,Exp(B)=4.531E+50).Following binary Logistic regression analysis,the other seven factors were no longer predictors of costal pain(P>0.05).The incidence of costal pain was higher in patients with increased fracture vertebral width after adjusting for the other seven factors in binary Logistic regression model.Conclusion:1.The vertebral width in patients with costal pain was significantly higher than that without costal pain(P<0.05).The incidence of costal pain is significantly and positively associated with the width of the fractured vertebra in patients with osteoporotic thoracic vertebrae fracture.2.The costal pain is common in patients with osteoporotic fracture of thoracic vertebra.For patients with thoracic osteoporotic fracture,pain location may not accurately reflect the fracture site.Both physical examination and radiological image analysis are required for correct diagnosis.Thus,for aged patients with the pain radiating to both or one side along the intercostal space or to the chest,their thoracic vertebra should be examined,regardless of their trauma history in this region.Significance:The relationship between costal pain and fracture morphology has not been previously reported,we believe that our classification of pain pattern may be useful in finding the pain sources from OVCFs,and hence facilitate in the pain management of these patients.We are also conducting a prospective study to further confirm the reliability of this conclusion.We believe that this study may further elucidate the mechanism of non-midline pain in osteoporotic fractures of the spine.更多还原