Establishment and validation of a risk nomograph model of residual back pain after percutaneous vertebroplasty for osteoporotic vertebral compression fractures
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摘要:目的
分析骨质疏松性椎体压缩性骨折(OVCF)经皮椎体成形术(PVP)后残余腰背痛的发生情况和影响因素，构建风险预测列线图模型并验证。
方法回顾性选取接受双侧PVP治疗的302例单节段OVCF患者作为研究对象，根据术后1个月时疼痛视觉模拟评分法(VAS)评分分为残余腰背痛组(≥4分)43例和无疼痛组(< 4分)259例。观察并比较2组患者的临床资料和治疗前后磁共振成像(MRI)参数变化。采用单因素和多因素Logistic回归分析筛选危险因素，绘制受试者工作特征(ROC)曲线并计算曲线下面积(AUC), 利用R软件构建列线图模型，绘制校准曲线和决策曲线。
结果单因素和多因素Logistic回归分析显示，椎管内真空裂隙征(IVC)(OR=2.680, 95%CI: 1.429~5.029, P < 0.001)、后筋膜水肿(OR=2.863, 95%CI: 1.584~5.175, P < 0.001)、椎旁肌变性Ⅱ级(OR=3.762, 95%CI: 1.477~9.582, P=0.004)、椎旁肌变性Ⅲ~Ⅳ级(OR=5.801, 95%CI: 2.098~16.042, P < 0.001)、块状骨水泥分布(OR=1.578, 95%CI: 1.064~2.340, P=0.012)是残余腰背痛的独立危险因素。根据回归分析结果构建列线图模型，总分最高为200分。ROC曲线显示，该模型预测残余腰背痛的AUC为0.845, 提示区分度较好。校准曲线和决策曲线显示，该模型具有较好的吻合度和净获益率。
结论OVCF患者PVP后仍有较高的残余腰背痛发生率, IVC、后筋膜水肿、严重椎旁肌变性和块状骨水泥分布是残余腰背痛的重要预测因素，由此构建的风险预测列线图模型在识别残余腰背痛高危患者方面具有较好的临床应用潜能。
Abstract:ObjectiveTo analyze the occurrence and influencing factors of residual back pain after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCF) patients, and to establish a risk predictive nomograph model to verify its efficacy.
MethodsA total of 302 patients with single segment OVCF who received bilateral PVP treatment were retrospectively selected as study objects. According to the pain Visual Analogue Scale (VAS) score one month after surgery, they were divided into residual back pain group (≥4 points, n=43) and non-pain group(< 4 points, n=259). The clinical data and changes of magnetic resonance imaging (MRI) parameters before and after treatment were compared between the two groups. Univariate and multivariate Logistic regression analysis was used to screen risk factors, the receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated, the nomogram model was constructed with R software, and the calibration curve and decision curve were plotted.
ResultsUnivariate and multivariate Logistic regression analysis showed that the intraspinal vacuum gap (IVC) (OR=2.680; 95%CI, 1.429 to 5.029; P < 0.001), posterior fascia edema (OR=2.863; 95%CI, 1.584 to 5.175; P < 0.001), paravertebral muscular degeneration grade Ⅱ (OR=3.762; 95%CI, 1.477 to 9.582; P=0.004), paravertebral muscular degeneration grade Ⅲ to Ⅳ (OR=5.801; 95%CI, 2.098 to 16.042; P < 0.001) and massive bone cement distribution (OR=1.578; 95%CI, 1.064 to 2.340; P=0.012) were independent risk factors for residual low back pain. A nomograph model based on the regression results was established, with the highest total score of 200 points. ROC curve showed that the area under the curve (AUC) of residual low back pain predicted by the model was 0.845, indicating a good discrimination. The calibration curve and decision curve showed that the model had a good fit and net benefit ratio.
ConclusionThere is still a high incidence of residual back pain in OVCF patients after PVP. IVC, posterior fascia edema, severe paraspinal muscle degeneration and blocky cement distribution are important predictors of residual back pain. The nomogram risk prediction model has a good potential to guide clinical identification of high-risk patients with residual back pain.
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图 1 压缩椎骨的放射学评估
A: AVHR评估，公式为压缩椎体前缘高度(b)/[上椎体前缘高度(a)+下椎体前缘高度(c)]×2; B: Cobb角评估, Cobb角为骨折椎体上端板(b线)与下端板(a线)形成的夹角。
表 1 2组患者临床资料比较(x±s)[n(%)]
临床资料 分类 无疼痛组(n=259) 残余腰背痛组(n=43) t/χ2 P 性别 男 152(58.7) 26(60.5) 0.048 0.826 女 107(41.3) 17(39.5) 年龄/岁 68.5±6.3 70.2±7.4 0.859 0.234 体质量指数/(kg/m2) 23.2±2.1 23.5±2.6 0.565 0.457 基础疾病 糖尿病 84(32.4) 10(23.3) 1.449 0.229 高血压病 106(40.9) 16(37.2) 0.212 0.645 病变节段 T11~L2 90(34.7) 19(44.2) 1.424 0.233 L3~L5 169(65.3) 24(55.8) 骨密度(T值) -3.3±0.5 -3.5±0.6 0.426 0.635 骨水泥注射量/mL 4.0±0.3 3.9±0.3 0.332 0.759 骨水泥渗漏 20(7.7) 3(7.0) 0.029 0.865 手术时间/min 53.4±9.7 55.6±9.8 1.023 0.268 抗骨质疏松治疗 233(90.0) 40(93.0) 0.398 0.528 
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表 2 2组治疗前MRI参数比较(x±s)[n(%)]
参数 分类 无疼痛组(n=259) 残余腰背痛组(n=43) t/χ2 P ODI评分/分 65.8±15.4 62.8±10.3 0.968 0.234 AVH/mm 15.5±3.2 14.8±2.6 0.564 0.502 AVHR/% 49.6±10.2 50.2±11.3 0.324 0.758 Cobb角/° 24.3±6.2 25.5±6.4 0.298 0.859 IVC 18(6.9) 9(20.9) 8.854 0.003 后筋膜水肿 21(8.1) 10(23.3) 9.186 0.002 椎旁肌变性分级 0~Ⅰ级 83(32.0) 11(25.6) 14.570 0.001 Ⅱ级 124(47.9) 12(27.9) Ⅲ~Ⅳ级 52(20.1) 20(46.5) ODI: Oswestry功能障碍指数; AVH: 椎体前缘高度; AVHR: 椎体前缘高度比; IVC: 椎管内真空裂隙征。
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表 3 2组治疗后MRI参数比较(x±s)[n(%)]
参数 分类 无疼痛组(n=259) 残余腰背痛组(n=43) t/χ2 P 骨水泥分布 块状 78(30.1) 23(53.5) 9.050 0.003 海绵状 181(69.9) 20(46.5) AVHRR/% 7.5±1.8 7.8±2.2 0.769 0.324 Cobb角变化/° 5.8±1.9 6.2±2.4 0.652 0.359 AVHRR: 椎体前缘高度恢复率。
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表 4 残余腰背痛危险因素的多因素Logistic回归
因素 β Wald P OR 95%CI IVC 0.986 9.435 < 0.001 2.680 1.429~5.029 后筋膜水肿 1.052 12.134 < 0.001 2.863 1.584~5.175 椎旁肌变性Ⅱ级 1.325 7.716 0.004 3.762 1.477~9.582 椎旁肌变性Ⅲ~Ⅳ级 1.758 11.474 < 0.001 5.801 2.098~16.042 块状骨水泥分布 0.456 5.147 0.012 1.578 1.064~2.340 常数项 -0.235 3.968 0.009 — —
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