Vd㊁Vs㊁Vm㊁RI㊁PI变化绝对值及联合预测焦虑抑郁的AUC分别为0.603㊁0.728㊁0.802㊁0.805㊁0.756㊁0. 710㊁0.783㊁0.739㊁0.949,其中联合组最高,提示临床可通过TCD联合直立倾斜试验,以识别焦虑抑郁高危人群㊂焦虑抑郁患者普遍存在自主神经系统功能失衡现象,以交感神经兴奋增强或(和)副交感神经活性降低为主㊂HRV是指每次窦性心律心搏间心动周期的微小差异,是反映副交感神经与交感神经张力㊁平衡的重要指标,且可定量反映自主神经系统㊂本研究发现,病例组LF㊁HF㊁PNN50㊁RMSSD㊁SDNN比对照组低,且与DBP㊁HR㊁SV㊁Vd㊁Vs㊁Vm㊁RI㊁PI变化绝对值均呈负相关,可见焦虑抑郁患者存在自主神经失调现象,且TCD㊁直立倾斜试验可有效反映患者自主神经功能特征㊂综上所述,TCD联合直立倾斜试验可有效预测焦虑抑郁发生,且二者可反映患者自主神经功能特征㊂ʌ参考文献ɔ[1]㊀Werner-Seidler A,Perry Y,Calear AL,et al.School-baseddepression and anxiety prevention programs for young peo-ple:a systematic review and meta-analysis[J].Clin PsycholRev,2017(51):30-47.[2]㊀孙仙,张婷婷,王立群,等.宁夏回族自治区成人酒精使用障碍现况调查[J].中国心理卫生杂志,2023,37(12): 1017-1022.[3]㊀Choi KW,Kim YK,Jeon orbid anxiety and depres-sion:clinical and conceptual consideration and transdiagnos-tic treatment[J].Adv Exp Med Biol,2020(1191):219-235.[4]㊀Hu MX,Lamers F,de Geus EJ,et al.Differential autonomicnervous system reactivity in depression and anxiety during stress depending on type of stressor[J].Psychosom Med, 2016,78(5):562-572.[5]㊀苟显娜,赵丽莉,吴静悦,等.睡眠障碍伴发焦虑抑郁的脑血流自动调节功能的分析[J].河北医学,2021,27(1):37-41.[6]㊀Zhang W,Fu W,Yan,et al.Impaired dynamic cerebral auto-regulation in young adults with mild depression[J].Psycho-physiology,2022,59(1):e13949.[7]㊀中华医学会精神病学分会.中国精神障碍分类与诊断标准第三版(精神障碍分类)[J].中华精神科杂志,2001,34(3):184-188.[8]㊀Zhang HL,Guo ZN,Yang G,et promised cerebrovas-cular modulation in chronic anxiety:evidence from cerebral blood flow velocity measured by transcranial Doppler sonogra-phy[J].Neurosci Bull,2012,28(6):723-728. 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Rev,2020(116):154-161.ʌ文章编号ɔ1006-6233(2024)03-0499-07经皮椎体后凸成形术后脊柱-骨盆动态姿势与矢状面平衡参数联合预测相邻椎体继发骨折的价值吴海龙,㊀张㊀弛,㊀李一鹏,㊀张㊀帅,㊀周建伟,㊀郭洪涛,㊀商永伟(河北省石家庄市人民医院骨科,㊀河北㊀石家庄㊀050000)ʌ摘㊀要ɔ目的:探讨经皮椎体后凸成形(PKP)术后脊柱-骨盆动态姿势与矢状面平衡参数联合预测相邻椎体继发骨折的价值㊂方法:选取2021年1月至2022年6月106例骨质疏松性胸椎压缩骨折(OVCF)患者,均接受PKP手术治疗,术后3个月测量脊柱-骨盆的动态姿势参数(静态时脊柱旋转幅度㊁行走时脊柱侧倾幅度㊁前倾幅度)㊁矢状面平衡参数[脊柱矢状轴(SVA)㊁骶骨倾斜角(SS)㊁胸椎后凸角(TK)㊁骨盆入射角(PI)㊁腰椎前凸角(LL)㊁骨盆倾斜角(PT)㊁T1骨盆角(TPA)],随访1年,根据相邻椎体是否继发骨折分为继发组(37例)与未继发组(69例)㊂比较两组脊柱-骨盆的动态姿势㊁矢状面平衡参数,分析脊柱-骨盆的动态姿势与矢状面平衡参数相关性及预测价值㊂结果:继发组脊柱旋转幅度小于未继发组,侧倾幅度㊁前倾幅度大于未继发组(P<0.05);继发组SVA㊁TK大于未继发组,LL㊁SS㊁PI㊃994㊃ʌ基金项目ɔ2022年度河北省医学科学研究课题计划,(编号:20221698)小于未继发组(P<0.05);脊柱旋转幅度与SVA㊁TK呈负相关,与LL㊁SS㊁PI呈正相关,侧倾幅度㊁前倾幅度与SVA㊁TK呈正相关,与LL㊁SS㊁PI呈负相关(P<0.05);脊柱侧倾幅度㊁前倾幅度㊁SVA㊁TK高值㊁脊柱旋转幅度㊁LL㊁SS㊁PI低值会显著增加相邻椎体继发骨折风险(P<0.05);脊柱-骨盆动态姿势参数联合矢状面平衡参数预测相邻椎体继发骨折的AUC为0.920(95%CI:0.851~0.964),敏感度为89.19%,特异度为82.61%,优于脊柱-骨盆动态姿势参数联合预测㊁矢状面平衡参数联合预测及各参数单独预测㊂结论:OVCF患者PKP术后脊柱-骨盆动态姿势与矢状面平衡参数显著相关,均会增加相邻椎体继发骨折风险,联合预测价值可靠㊂ʌ关键词ɔ㊀骨质疏松性胸椎压缩骨折;㊀经皮椎体后凸成形术;㊀脊柱-骨盆动态姿势;㊀矢状面平衡参数;㊀相邻椎体继发骨折;㊀预测价值ʌ文献标识码ɔ㊀A㊀㊀㊀㊀㊀ʌdoiɔ10.3969/j.issn.1006-6233.2024.03.027Combined Prediction of Adjacent Vertebral Fracture Using Postoperative Spine-Pelvis Dynamic Posture and Sagittal Balance Parametersin Patients Undergoing Percutaneous KyphoplastyWU Hailong,ZHANG Chi,LI Yipeng,et al(Shijiazhuang People's Hospital,Hebei Shijiazhuang050000,China)ʌAbstractɔObjective:To investigate the value of combining postoperative spine-pelvis dynamic posture and sagittal balance parameters in predicting adjacent vertebral fractures following percutaneous kyphoplasty (PKP).Methods:A total of106patients with osteoporotic vertebral compression fracture(OVCF)from Jan-uary2021to June2022were selected,all of whom received PKP surgery.Dynamic spindle-pelvis postural parameters(spine rotation amplitude at rest,scoliosis amplitude during walking,and forward inclination am-plitude),sagittal plane balance parameters[Sagittal axis(SVA),sacral inclination Angle(SS),thoracic kyphosis Angle(TK),pelvic incidence Angle(PI),lumbar lordosis Angle(LL),pelvic inclination Angle (PT),and T1pelvic Angle(TPA)]were measured3months after surgery.Patients were followed up for one year and divided into the fracture group(37cases)and non-fracture group(69cases)based on the occur-rence of adjacent vertebral fractures.The dynamic posture and sagittal plane balance parameters of the spine and pelvis were compared between the two groups,and the correlation and predictive value of the dynamic posture and sagittal plane balance parameters were analyzed.Results:The rotation amplitude of the fracture group was smaller,while lateral and forward inclination amplitudes were larger than those of the non-fracture group(P<0.05).SVA and TK were greater in the fracture group,while LL,SS,and PI were smaller com-pared to the non-fracture group(P<0.05).Rotation amplitude showed a negative correlation with SVA and TK,and a positive correlation with LL,SS,and teral and forward inclination amplitudes were positively correlated with SVA and TK,and negatively correlated with LL,SS,and PI(P<0.05).High values of later-al and forward inclination,SVA,TK,and low values of rotation amplitude,LL,SS,PI significantly in-creased the risk of adjacent vertebral fractures(P<0.05).The combined prediction of spine-pelvis dynamic posture parameters and sagittal balance parameters for adjacent vertebral fractures had an AUC of0.920(95% CI:0.851–0.964),sensitivity of89.19%,and specificity of82.61%,outperforming predictions based solely on dynamic posture or sagittal balance parameters.Conclusion:Postoperative spine-pelvis dynamic posture and sagittal balance parameters are significantly correlated in OVCF patients undergoing PKP and are associated with an increased risk of adjacent vertebral fractures.The combined prediction of these parameters provides a reliable and superior method for predicting such fractures.ʌKey wordsɔ㊀Osteoporotic vertebral compression fracture;㊀Percutaneous kyphoplasty;㊀Spine-pelvic dynamic posture;㊀Sagittal balance parameters;㊀Adjacent vertebral fracture;㊀Predictive value㊃005㊃㊀㊀近年来,随着人口老龄化加剧,骨质疏松(Osteo-porosis,OP)发病率呈逐年升高趋势,其中55~70岁男性OP发病率在30%左右,女性OP发病率则高达70%,骨质疏松性胸椎压缩骨折(Osteoporosis thoracic vertebral compression fracture,OVCF)是OP最严重类型之一,防治形势严峻[1-2]㊂目前,经皮椎体后凸成形术(Percutaneous kyphoplasty,PKP)是治疗OVCF的最有效方式,但临床实践证实PKP术后伴有较高的相邻椎体继发骨折风险,需及早识别高危患者,以便早期开展科学的防治措施[3-4]㊂有研究显示,PKP术无法完全改善椎体楔形改变,可能会导致患者术后脊柱-骨盆矢状面力线及动态姿势发生变化[5]㊂既往临床忽视了脊柱-骨盆的动态姿势的影响㊂鉴于此,本研究尝试探讨PKP术后脊柱-骨盆动态姿势与矢状面平衡参数联合预测相邻椎体继发骨折的价值,旨在为临床及早开展防治工作提供理论佐证㊂报告如下㊂1㊀资料与方法1.1㊀一般资料:选取2021年1月至2022年6月106例骨质疏松性胸椎压缩骨折(OVCF)患者作为研究对象,纳入标准:符合OVCF诊断标准[6];单节段OVCF;影像资料完整;无自发性腰痛及脊髓压迫综合征;具备KPK术适应证;随访时间ȡ1年;患者与家属均知情患者病情及研究方案,签订知情同意书㊂排除标准:有脊柱骨折或手术史的患者;多节段OVCF的患者;合并腰椎退变性侧凸的患者;伴有脊柱转移瘤的患者;存在严重心血管疾病㊁神经血管损伤的患者;病理性OVCF的患者;感染新型冠状肺炎或受疫情影响无法配合研究实施及数据统计的患者;难以完成随访的患者㊂106例OVCF患者中,男36例,女70例;年龄55~78岁,平均(65.28ʃ3.17)岁;体质量指数18~28kg/m2,平均(22.46ʃ1.35)kg/m2;骨密度T值-3.82~-2.12SD,平均(-3.03ʃ0.25)SD;骨折部位:T12区41例,T11区16例,L1区20例,L2区21例,T12~L1区3例,L1 ~L2区5例㊂1.2㊀方法:所有患者均接受PKP手术治疗㊂①术后3个月于患者自然站立位时采用PLX8600动态DR全脊柱X光检测仪(购自普爱医疗设备有限公司)行脊柱全长X线检查,在X线片上采用Image J软件测量[脊柱矢状轴(SVA)㊁骶骨倾斜角(SS)㊁胸椎后凸角(TK)㊁骨盆入射角(PI)㊁腰椎前凸角(LL)㊁骨盆倾斜角(PT)㊁T1骨盆角(TPA)]㊂②术后3个月采用三维动态脊柱测量仪(芙索特公司的FT07W型三维电子脊柱测量仪)进行检查,患者均穿由医院提供的统一的紧身衣,粘贴26个体表标志点,叮嘱患者以自己习惯的㊁自然的走路姿势,在确保疼痛耐受且身体平衡的状态下以最快速度步行,拍摄行走图像,实时捕捉标志点空间三维位置,测算静态时脊柱旋转幅度㊁行走时脊柱侧倾幅度㊁前倾幅度㊂所有参数均由具有5年以上工作经验的2名影像科医生以双盲法测量3次,取平均值表示最终结果㊂1.3㊀随访:经过定期门诊复查㊁微信平台㊁电话等途径随访1年,根据相邻椎体是否继发骨折分为继发组(37例)与未继发组(69例)㊂两组一般资料均衡可比(P>0.05),见表1㊂表1㊀两组一般资料资料继发组(n=37)未继发组(n=69)t/χ2P 性别0.6700.413男11(29.73)26(37.68)女26(70.27)43(62.32)年龄(岁)65.76ʃ3.0565.02ʃ3.11 1.1760.243 BMI(kg/m2)22.63ʃ1.2722.37ʃ1.300.9890.325骨密度T值(SD)-3.06ʃ0.21-3.01ʃ0.24 1.0670.289骨折部位0.2790.780 T12区15(40.54)26(37.68)T11区5(13.51)11(15.94)L1区8(21.62)12(17.39)㊃105㊃L2区6(16.22)15(21.74)T12~L1区1(2.70)2(2.90)L1~L2区2(5.41)3(4.35)1.4㊀统计学处理:在SPSS 27.0版本中进行统计学处理㊂计量资料以( xʃs)表示,t 检验;计数资料以n (%)表示,χ2检验;相关性采用Pearson 相关系数分析;危险度采用相对危险度(RR )分析;预测价值采用受试者工作特征(ROC )曲线分析㊂P <0.05表示差异有统计学意义㊂2㊀结㊀果2.1㊀两组脊柱-骨盆动态姿势参数:继发组脊柱旋转幅度小于未继发组,侧倾幅度㊁前倾幅度大于未继发组(P<0.05),见表2㊂典型病例脊柱-骨盆动态姿势见图1~2㊂2.2㊀两组脊柱-骨盆矢状面平衡参数:继发组SVA ㊁TK 大于未继发组,LL ㊁SS ㊁PI 小于未继发组(P <0.05);两组PT ㊁TPA 差异无统计学意义(P>0.05),见表3㊂典型病例脊柱-骨盆矢状面平衡见图3㊁4㊂表2㊀两组脊柱-骨盆动态姿势参数( xʃs ,度)组别例数脊柱旋转幅度脊柱侧倾幅度脊柱前倾幅度继发组379.26ʃ2.34 5.21ʃ1.47 5.78ʃ0.62未继发组6912.85ʃ3.77 3.76ʃ1.03 5.24ʃ0.40t 151.987 5.927 5.436P<0.001<0.001<0.001表3㊀两组脊柱-骨盆矢状面平衡参数( xʃs)组别例数SVA (mm )TK (度)LL (度)SS (度)PI (度)PT (度)TPA (度)继发组3726.51ʃ8.2348.02ʃ9.2735.26ʃ6.0422.71ʃ4.3645.55ʃ6.1122.80ʃ5.4921.06ʃ4.93未继发组6915.28ʃ6.3941.16ʃ6.6541.72ʃ8.5327.40ʃ5.8851.29ʃ8.2423.42ʃ6.1320.37ʃ6.04t7.7834.3964.0864.2603.7210.5140.596P <0.001<0.001<0.001<0.001<0.0010.6080.552图1㊀术后相邻椎体继发骨折患者脊柱-骨盆动态姿势图㊀图2㊀术后相邻椎体未继发骨折患者脊柱-骨盆动态姿势图㊀图3㊀术后相邻椎体继发骨折患者脊柱-骨盆矢状面平衡图㊀图4㊀术后相邻椎体继发骨折患者脊柱-骨盆矢状面平衡图㊃205㊃2.3㊀脊柱-骨盆动态姿势与矢状面平衡参数的相关性:Pearson相关性分析,脊柱旋转幅度与SVA㊁TK呈负相关,与LL㊁SS㊁PI呈正相关,侧倾幅度㊁前倾幅度与SVA㊁TK呈正相关,与LL㊁SS㊁PI呈负相关(P<0.05);静态时脊柱旋转幅度㊁行走时脊柱侧倾幅度㊁前倾幅度与PT㊁TPA无明显相关性(P>0.05),见表4㊂表4㊀脊柱-骨盆动态姿势与矢状面平衡参数的相关性指标脊柱旋转幅度r㊀㊀㊀㊀㊀㊀㊀㊀㊀P脊柱侧倾幅度r㊀㊀㊀㊀㊀㊀㊀㊀㊀P脊柱前倾幅度r㊀㊀㊀㊀㊀㊀㊀㊀㊀PSVA-0.482<0.0010.538<0.0010.477<0.001 TK-0.511<0.0010.559<0.0010.463<0.001 LL0.503<0.001-0.514<0.001-0.512<0.001 SS0.465<0.001-0.493<0.001-0.509<0.001 PI0.471<0.001-0.505<0.001-0.522<0.001 PT0.112>0.050.108>0.050.121>0.05 TPA0.104>0.050.119>0.050.115>0.052.4㊀脊柱-骨盆动态姿势㊁矢状面平衡参数对相邻椎体继发骨折的影响:以两组脊柱-骨盆动态姿势㊁矢状面平衡参数的平均值为界,分为高值与低值㊂相对危险度分析,脊柱侧倾幅度㊁前倾幅度㊁SVA㊁TK高值㊁脊柱旋转幅度㊁LL㊁SS㊁PI低值会显著增加相邻椎体继发骨折风险,RR值分别为2.072㊁2.020㊁1.954㊁2.238㊁2.304㊁2.119㊁1.787㊁3.357(P<0.05),见表5㊂表5㊀脊柱-骨盆动态姿势矢状面平衡参数对相邻椎体继发骨折的影响指标继发组(n=37)非继发组(n=69)RR(95%CI)U P脊柱旋转幅度低值2018 2.072(1.262~3.403) 2.2920.022高值1751脊柱侧倾幅度高值2624 2.020(1.375~2.969) 2.5360.011低值1145脊柱前倾幅度高值2221 1.954(1.252~3.049) 2.2360.025低值1548SVA高值2420 2.238(1.443~3.471) 2.7330.006低值1349TK高值2117 2.304(1.398~3.796) 2.6330.009低值1652LL低值2522 2.119(1.405~3.195) 2.6300.009高值1247㊃305㊃SS 低值2324 1.787(1.187~2.691) 2.0180.044高值1445PI低值2715 3.357(2.059~5.472)3.995<0.001高值1054㊀㊀注:脊柱旋转幅度㊁侧倾幅度㊁前倾幅度㊁SVA ㊁TK ㊁LL ㊁SS ㊁PI 平均值分别为11.60度㊁4.27度㊁5.43度㊁19.20mm ㊁43.55度㊁24.87度㊁39.47度㊁25.76度㊁49.29度2.5㊀脊柱-骨盆动态姿势㊁矢状面平衡参数对相邻椎体继发骨折的预测价值:ROC 曲线分析,脊柱旋转幅度㊁侧倾幅度㊁前倾幅度㊁SVA ㊁TK ㊁LL ㊁SS ㊁PI 预测相邻椎体继发骨折的AUC 分别为0.812(95%CI :0.724~0.881)㊁0.786(95%CI :0.696~0.860)㊁0.796(95%CI :0.707~0.868)㊁0.795(95%CI :0.706~0.867)㊁0.721(95%CI :0.625~0.803)㊁0.765(95%CI :0.672~0.842)㊁0.746(95%CI :0.652~0.825)㊁0.704(95%CI :0.607~0.788),见图5㊂图5㊀脊柱-骨盆动态姿势㊁矢状面平衡参数对相邻椎体继发骨折的预测价值2.6㊀脊柱-骨盆动态姿势㊁矢状面平衡参数联合预测价值:ROC 曲线分析,脊柱-骨盆动态姿势参数脊柱旋转幅度㊁侧倾幅度㊁前倾幅度联合预测相邻椎体继发骨折的AUC 为0.887(95%CI :0.811~0.940),敏感度为91.89%,特异度为71.01%,大于各参数单独预测;矢状面平衡参数SVA ㊁TK ㊁LL ㊁SS ㊁PI 联合预测相邻椎体继发骨折的AUC 为0.867(95%CI :0.788~0.925),敏感度为72.97%,特异度为84.06%,大于各参数单独预测;脊柱-骨盆动态姿势参数联合矢状面平衡参数预测相邻椎体继发骨折的AUC 为0.920(95%CI :0.851~0.964),敏感度为89.19%,特异度为82.61%,价值最优,见图6㊂图6㊀脊柱-骨盆动态姿势㊁矢状面平衡参数联合预测价值3㊀讨㊀论近年来,随着临床不断深入研究发现除了上述因素之外,脊柱-骨盆结构与运动学改变可能与PKP 术后相邻椎体继发骨折有关㊂三维动态脊柱测量仪是一种利用运动学和生物力学手段对脊柱-骨盆的活动轨迹进行动力学分析的系统,能提供脊柱-骨盆的动态姿势及力学㊁几何㊁时间等一系列参数和曲线,从而为判定脊柱-骨盆动态活动㊁评估脊柱功能提供详细的数据支持[7]㊂本研究数据显示,继发组脊柱旋转幅度小于未继发组,侧倾幅度㊁前倾幅度大于未继发组,提示OVCF 患者PKP 术后早期脊柱-骨盆动态姿势存在明显异常,与相邻椎体继发骨折有关㊂分析原因,PKP 术虽然解除了OVCF 患者的骨折情况,但因OP 所致的腰背肌肉韧带力量减退及压缩椎体后凸畸形均无法经由手术纠正,会导致患者术后早期行走时出现脊柱不稳定㊁前后左右摆动明显的现象,从而导致行走时脊柱侧倾幅度㊁前倾幅度呈增大趋势;而静止状态脊柱旋转幅度显著减小与术后脊柱活动度及椎体周围肌力下降有关[8-9]㊂相对危险度分析表明,脊柱旋转幅度低值㊁侧倾幅度㊁前倾幅度高值会显著增加相邻椎体继发骨折风险㊂且ROC 曲线分析,脊柱旋转幅度㊁侧倾幅度㊁前倾幅度单独及联合预测PKP 术后相邻椎体继发骨折㊃405㊃的AUC均接近0.8或在0.8以上,预测价值良好㊂脊柱-骨盆矢状面在维持脊柱生物力学中发挥重要作用,当脊柱矢状面失衡时,骨盆矢状面序列会出现相应的代偿性改变[10]㊂有研究认为,脊柱-骨盆矢状面失衡与PKP术后继发骨折有关[11]㊂本研究显示,继发组SVA㊁TK大于未继发组,LL㊁SS㊁PI小于未继发组,与李伟等[12]报道中的结果一致㊂正常情况下,LL丢失引起的躯干前倾可经由减小TK使得躯干后仰,两者形成代偿作用,保持SVA正平衡㊂PKP术后患者腰背肌肉韧带力量减退㊁压缩椎体后凸畸形导致TK增加,致使其代偿LL丢失的能力下降,从而造成SVA的平衡失常[13]㊂同时,在骨盆代偿躯干前倾能力减弱的状态下,PT角恒定,PI角和SS增大时,会明显增加骨盆后旋引起躯干后倾的幅度,进一步增加矢状面失衡程度[14-15]㊂进一步研究发现,SVA㊁TK高值㊁LL㊁SS㊁PI低值会导致相邻椎体继发骨折风险显著增加,可预测PKP术后相邻椎体继发骨折㊂相关性分析,脊柱旋转幅度与SVA㊁TK呈负相关,与LL㊁SS㊁PI呈正相关,侧倾幅度㊁前倾幅度与SVA㊁TK呈正相关,与LL㊁SS㊁PI呈负相关,说明OVCF患者PKP术后患者脊柱-骨盆动态姿势与矢状面力线二者之间联系紧密,可在相互影响㊁相互作用下呈进行性加重,最终增加术后相邻椎体继发骨折风险㊂本研究结果还显示,两类参数联合预测相邻椎体继发骨折的AUC高达0.920优于脊柱-骨盆动态姿势参数联合预测㊁矢状面平衡参数联合预测及各参数单独预测,提示临床在预测OVCF患者PKP术后相邻椎体继发骨折时应同时关注脊柱-骨盆动态姿势与矢状面参数改变情况,最好是利用这两类参数进行共同预测㊂不足之处在于未详细探讨OVCF患者PKP术后脊柱-骨盆动态姿势与矢状面平衡参数对其他预后情况的影响,今后需做进一步探讨㊂综上可知,OVCF患者PKP术后脊柱-骨盆动态姿势与矢状面平衡参数显著相关,均会增加相邻椎体继发骨折风险,联合预测价值可靠,能为临床开展防治工作提供可靠的指导信息㊂ʌ参考文献ɔ[1]㊀Yu T,Zheng S,Cheng XL,et al.Osteoporotic vertebral frac-ture misdiagnosed as metastatic vertebral 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