后路枕骨髁螺钉技术研究进展

正枕骨、寰椎和枢椎共同构成了枕颈部活动的结构功能单位,即枕颈交界区~([1-2])。炎症、创伤、肿瘤及畸形等因素会导致枕颈交界区失稳,从而引起颈脊髓或神经根的损伤、麻痹及难以忍受的疼痛,甚至危及生命~([3-4])。后路内固定融合技术是治疗枕颈部失稳的重要手段,目前常用术式为枕骨螺钉技术,该技术较钢丝固定技术有更好的生物力学稳定     

颈腰综合征的诊断与治疗进展

椎管狭窄在解剖学上表现为椎管容积减少和神经卡压,按病理学分类可分为先天性和特发性[1].前者常因软骨发育不全导致椎弓根长度及间距过短而发生;后者又称为"获得性"椎管狭窄,通常由椎间盘、小关节和黄韧带退行性变导致.椎管狭窄好发于腰椎,其次为颈椎,但胸椎同样可受累,在某些情况下,所有区域可同时受到影响[2].颈腰综合征(串联性椎管狭窄症,TSS)是指颈椎、胸椎和腰椎之间2个及以上区域发生椎管狭窄,同时或先后出现椎管内神经、血管受压,并产生相应临床症状[3].由于TSS常发生上下神经元病变,患者临床症状、体征常与影像学表现不符,易造成漏诊与误诊[4].目前,国内外关于TSS的诊断标准及治疗策略尚未达成一致.如何提高TSS确诊率,哪些区域椎管狭窄需要优先治疗,以及单纯治疗一个区域的椎管狭窄是否能够缓解临床症状等问题目前仍存在争议.本文对近年来国内外TSS的相关研究进行分析,从发生率、临床表现与诊断、治疗方案等方面作如下综述.     

快速成型导向模板技术在枢椎椎板交叉螺钉置钉中的应用

 目的 验证在快速成型导向模板辅助下枢椎椎板交叉螺钉置钉的安全性、准确性及偏差因素分析。方法 选取正常颈椎标本18具,行螺旋CT扫描。扫描数据经Mimics软件三维重建后行枢椎椎板交叉螺钉最佳钉道的计算机辅助设计,建立与枢椎椎板及棘突后表面解剖结构互补的基板,组合形成导向模板。在激光快速成型机上进行导向模板实体化,利用导向模板辅助置钉。扫描置钉后的标本,分割重建螺钉钉道路径。将置钉前后的标本配对拟合,测量理想钉道与实际螺钉的进钉点及进钉角度。结果 上、下位椎板螺钉理想钉道长度分别为(29.12±1.39)、(29.62±1.40) mm;内倾角分别为56.20°±2.07°、56.02°±1.72°。下位椎板螺钉实际钉道内倾角和尾倾角分别为56.28°±1.54°、0.13°±0.65°;上位椎板分别为55.48°±1.75°、-0.19°±1.54°。下位椎板螺钉进钉点在X、Y、Z轴上的偏移分别为(0.69±1.79)、(2.54±4.86)、(0.63±1.37) mm;上位椎板分别为(0.64±1.61)、(2.36±4.85)、(0.62±1.38) mm。理想钉道与实际螺钉进钉点、钉道方向的差异无统计学差异。结论 利用数字化快速成型导向模板技术辅助枢椎椎板交叉螺钉置钉提高了置钉的安全性和准确性,理论上可降低椎动脉和脊髓损伤的风险。     

A comparative study on the accuracy of pedicle screw placement assisted by personalized rapid prototyping template between pre- and post-operation in patients with relatively normal mid-upper thoracic spine

Purpose

The aim of this study was to assess the accuracy of rapid prototyping drill template technique for placing pedicle screws in the mid-upper thoracic vertebrae in clinics.

Methods

151 consecutive patients underwent thoracic instrumentation and fusion for a total of 582 pedicle screws placed in the mid-upper thoracic vertebrae. Using computer software, the authors constructed drill templates that fit onto the posterior elements of the mid-upper thoracic vertebrae with drill guides designed to instrument the pedicles. The start point and three dimensional location of the planned and inserted screws were measured and compared.

Results

Grading of the CT scans revealed 559 (96.1 %) out of 582 screws completely within the desired pedicle. The direction of pedicle violation included 5 medial, 2 airball, and 16 lateral. The paired t test suggested that these results were statistically significant in more than half of the locations (T1-left-TA(P = 0.024), T2-left-SA(P = 0.031), T3-left-SA(P = 0.014), T4-left-TA(P = 0.004), T5-left-TA(P = 0.034), T7-left-TA(P = 0.000). T1-right-TA(P = 0.049), T2-right-TA(P = 0.044), T3-right-TA(P = 0.014), T5-right-TA(P = 0.013)). The paired t-test suggested that these results were statistically significant at several locations (T4-left-Δy(P = 0.041), T5-left-Δx(P = 0.016), T3-right-Δy(P = 0.015)).

Conclusion

Use of a rapid prototyping drill template to assist in the placement of mid and upper thoracic pedicle screws may lead to increased accuracy. This patient specific technology must be combined with an understanding of the patients’ anatomy and carefully secured to the posterior elements intraoperatively to avoid nerve or vascular complications.

     

上颈椎内固定技术的研究近况

正上颈椎包括寰椎和枢椎,构成寰枢关节,作为颅颈部的过渡区,头端承载颅脑,尾端连接下颈椎,具有重要的生理活动功能,尤其是旋转运动,占整个颈椎旋转功能的50%左右。寰枢关节因创伤、肿瘤、先天性畸形和炎症等因素引起疾病,常伴随上颈髓、神经根及椎动脉受压所引起的症状和体征。治疗上往往以减压及重建其稳定性为主要目的,由于上颈椎解剖结构的复杂性和生理活动功能的重要性,一直是脊柱外科手术治疗的高难度、高风险领     

枢椎后路峡部螺钉固定的相关影像学测量

目的：通过CT测量探讨枢椎峡部螺钉固定技术的安全性和可行性。方法：收集2016年1月至2019年12月进行全颈椎CT检查的137例结构完整的上颈椎CT数据,其中男71例,女66例;年龄22~65（41.8±17.4）岁。通过Mimics19.0软件测量峡部螺钉技术相关的解剖学数据,包括峡部宽度、峡部垂直长度、峡部垂直高度、峡部螺钉通道长度、峡部螺钉通道头倾角度。并分析各项指标之间的相关性。结果：枢椎峡部宽度（9.05±1.63） mm,垂直长度（11.21±1.43） mm,垂直高度（17.53±2.93） mm。螺钉通道长度为（19.07±3.20） mm。峡部螺钉通道长度>14 mm的占94.53%,14~16 mm的占82.12%,16~18 mm的占63.14%,18~20 mm的占39.78%。螺钉通道的头倾角度为30°~68°,平均（46.06±8.06）°。螺钉通道长度和头倾角度呈高度正相关（r=0.965,P=0.000）。峡部垂直长度和螺钉通道长度,峡部垂直长度和螺钉的头倾角度之间都呈轻度正相关（r=0.240,P=0.000;r=0.163,P=0.007）。峡部宽度和螺钉通道长度,峡部宽度和螺钉通道的头倾角度之间都呈中度负相关（r=-0.333,P=0.000;r=-0.380,P=0.000）。结论：进行枢椎后路峡部螺钉固定安全、可靠,比枢椎后路椎弓根螺钉固定具有更大的适用范围,可以作为椎弓根螺钉的替代选择。     

A comparative study of weight-bearing and non-weight-bearing 3-dimensional lower extremity alignment in knee osteoarthritis

BackgroundLower extremity alignment is an important variable with respect to the development and progression of knee osteoarthritis. It is very essential for the preoperative planning of realignment surgeries such as total knee arthroplasty and high tibial osteotomy. Nevertheless, there have been no reports comparing 3D lower extremity alignment between weight-bearing upright and non-weight-bearing horizontal states in osteoarthritic knees in the same subject. Therefore, we determined whether the alignment of the lower extremity in the weight-bearing upright state differed from that in the non-weight-bearing horizontal or supine position in patients with knee osteoarthritis.MethodsAdduction–abduction, flexion–extension, and rotational angle of osteoarthritic knees were assessed in weight-bearing upright and non-weight-bearing supine positions. Knee alignment in the supine position was determined from preoperative computed tomography data. In the weight-bearing upright state, alignment was determined using a technique that utilized 2D-3D image-matching with biplanar computed radiography and 3D bone models of the complete lower extremity rebuilt using computed tomography-based information.ResultsWe assessed 81 limbs from osteoarthritic knee patients (74 women, 7 men; mean age 75.3 years, range 59–86 years). In the coronal plane, there were varus deformities in both the supine and standing positions, while there was flexion in both the supine upright state and position at the sagittal plane. In the axial plane, the rotation of the tibia to the femur was neutral in the supine position and internal in the upright state.ConclusionPatient position significantly affects lower extremity alignment in osteoarthritic knees. This study provides important data regarding the preoperative evaluation of realignment surgery in total knee arthroplasty and high tibial osteotomy. We believe that these results are an important contribution to the knowledge regarding knee osteoarthritis.     

伤椎固定结合成形与跨伤椎固定结合伤椎成形治疗骨质疏松性胸腰椎爆裂骨折的疗效比较

目的:比较伤椎椎弓根固定结合伤椎成形与跨伤椎椎弓根固定结合伤椎成形在治疗骨质疏松性胸腰椎爆裂骨折的临床疗效。方法:收集2015年1月至2017年12月符合纳入标准的骨质疏松性胸腰椎爆裂骨折患者70例,其中35例采用伤椎椎弓根螺钉固定结合伤椎椎体成形术治疗(A组),男20例,女15例;年龄55～74 (64.03±7.82)岁;AO分型A3型26例,A4型9例。其余35例采用短节段跨伤椎椎弓根固定结合伤椎椎体成形术(B组),男18例,女17例;年龄54～72(62.78±6.40)岁;A3型28例,A4型7例。比较两组手术时间、术中出血量、并发症、临床疗效及影像学参数。结果:所有患者随访时间至少12个月;术前两组患者性别、年龄、损伤部位、术前疼痛视觉模拟评分(visual analogue scale,VAS)、Cobb角与伤椎前缘高度比例差异均无统计学意义。两组手术时间、术中出血差异无有统计学意义。术前、术后1周及末次随访时VAS评分:A组分别为(5.5±2.5)、(1.8±0.8)、(0.9±0.4)分,B组分别为(5.4±2.3)、(1.7±0.6)、(1.2±1.8)分;术前、术后1周及末次随访时伤椎前缘高度比例:A组分别为(40.4±8.8)%、(92.0±4.9)%、(87.1±3.8)%,B组分别为(41.2±6.6)%、(93.2±4.6)%、(80.0±4.3)%;术前、术后1周及末次随访时Cobb角:A组分别为(18.4±6.9)°、(2.8±2.2)°、(4.2±2.6)°,B组分别为(16.8±7.2)°、(2.7±2.5)°、(6.0±2.4)°。所有患者术前与末次随访3项评估结果差异均有统计学意义(P0.05);Cobb角和伤椎前缘高度比例术后1周与末次随访差异有统计学意义(P0.05)。A组末次随访伤椎前缘高度比例与B比较差异有统计学意义(P0.05)。A组术后出现2例内固定失败,B组出现4例内固定失败。两组均无神经并发症。结论:对骨质疏松性胸腰段椎体爆裂骨折,伤椎固定结合伤椎椎体成形与单纯结合伤椎成形均能取得良好临床疗效,但伤椎固定结合成形术更有利于维持术后伤椎高度和矢状位排列,减少内固定相关并发症,值得研究应用并推广。     

双开门揭盖式椎板分块切除治疗严重颈椎后纵韧带骨化伴颈脊髓损伤

目的:评价双开门揭盖式椎板分块切除治疗严重颈椎后纵韧带骨化症(ossification of posterior longitudinal ligament,OPLL)伴颈脊髓损伤的临床疗效。方法:回顾性分析2012年6月至2014年6月治疗严重颈椎OPLL合并颈脊髓损伤38例患者资料,所有患者接受后路双开门揭盖式椎板分块切除减压内固定术,男25例,女13例;年龄42~78岁,平均58.2岁;35例有明确颈部外伤史,3例仅受轻微暴力(与颈部突然过伸有关)。术前颈部功能障碍指数(Neck Disability Index,NDI)19.8±4.4,术前日本矫形外科协会评分(Japanese Orthopaedics Score,JOA)为8.1±1.7;术前CT重建显示骨化韧带均分布在3个节段以上,椎管占位50%~85%,平均70.7%。结果:所有患者获得随访,时间10~24个月,平均15.6个月。手术时间90~150 min,平均120 min;出血量300~800 ml,平均(480±80)ml。末次随访时颈椎NDI和JOA评分分别为7.5±2.5和13.5±2.0,均较术前明显改善(P0.05)。术前颈椎前凸Cobb角为(8.10±2.70)°,末次随访时为(15.60±1.80)°,差异有统计学意义(P0.05)。术后发生深部感染1例,硬膜外血肿1例,C5神经根麻痹症状3例,轴性症状(axial symptom,AS)8例。无椎动脉损伤、神经症状加重、脑脊液漏、内固定失败等并发症。结论:颈椎后路双开门揭盖式椎板分块切除减压技术治疗重度颈椎OPLL合并颈脊髓损伤患者疗效良好,安全、可行,临床值得推广应用。     

Modified one-stage posterior/anterior combined surgery with posterior pedicle instrumentation and anterior monosegmental reconstruction for unstable Denis type B thoracolumbar burst fracture

Purpose

This study aimed to evaluate the clinical and radiological results in patients with unstable Denis type B thoracolumbar burst fractures treated by modified one-stage posterior/anterior combined surgery.

Methods

Thirty-one patients with unstable Denis type B thoracolumbar burst fractures were enrolled in this study. The patients underwent one-stage posterior/anterior combined surgery with posterior instrumentation using pedicle screws and anterior monosegmental reconstruction utilizing titanium mesh cages. The mean follow-up period was 38.3 months. Clinical outcomes, radiological parameters, and treatment-related complications were assessed.

Results

The mean age of the patients was 36.4 years. The mean operative time and blood loss were 230 min and 645 ml, respectively. The VAS pain score was significantly improved after surgery, and the improvement was maintained until the final follow-up. In 23 patients with neurologic dysfunction, 20 (87 %) patients had improvement after surgery. By the final follow-up, 27 patients had returned to work; 18 of the 27 patients returned to a similar job. The mean sagittal kyphosis was corrected from 21.2° preoperatively to 2.5° postoperatively, which increased slightly to 4.3° at the final follow-up. Minimal subsidence and tilt of the titanium mesh cage were observed during the follow-up period. Solid bony fusion was achieved in all patients. One patient developed a posterior surgical site infection, which was resolved by antibiotic treatment and surgical debridement.

Conclusion

Modified one-stage posterior/anterior combined surgery for Denis type B unstable thoracolumbar burst fractures can produce good clinical and radiological outcomes.