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。     

组合枢椎椎板螺钉及经枢椎椎板关节突螺钉固定技术的临床应用

目的探讨组合枢椎椎板螺钉及经枢椎椎板关节突螺钉(TLFS)固定技术治疗颈椎损伤的可行性和应用价值。方法自2005年10月～2008年10月,采用枢椎椎板螺钉及经枢椎TLFS固定技术治疗颈椎损伤36例。结果本组获随访13~32个月,平均18个月。30例行自体髂骨植骨,6例行异体骨植骨,获得了良好的骨性愈合。术后CT示枢椎椎板螺钉及经枢椎TLFS位置良好,未侵犯椎管和脊髓。结论枢椎椎板螺钉及经枢椎TLFS固定技术不受C2横突孔中椎动脉的位置和C2椎弓根大小限制,避免了螺钉置入过程中损伤椎动脉的风险,所以该方法可作为传统枢椎后路螺钉固定技术的补充。     

经后路顶椎椎弓根全椎体截骨矫正胸腰椎后凸畸形

目的探讨经后路顶椎椎弓根三柱截骨治疗脊柱后凸的临床疗效。方法2003年6月－2006年6月,采用经后路顶椎椎弓根三柱截骨治疗42例脊柱后凸患者,其中陈旧胸腰椎骨折20例、椎体发育不良8例、结核性10例、强直性脊柱炎4例。评定脊柱后凸矫正情况、植骨融合情况、内固定位置、手术并发症、腰痛及Oswestry功能评分的变化。结果术后随访6—21个月,平均15个月。植骨融合满意,无延迟愈合或不愈合。术前后凸Cobb角度平均为霹8．5°术后为20．6°,平均矫正角度为35．3°。术前患者腰痛VAS评分平均为7．5分,术后3．6分。术前ODI平均为57．6％,术后31.7％。结论经后路顶椎椎弓根截骨、椎弓根螺钉固定治疗胸腰椎后凸畸形,矫正角度大,手术视野开阔,手术相对安全,可获得满意的放射学矫形效果和临床疗效。     

下颈椎侧块螺钉结合棘突椎板螺钉在颈椎管扩大单开门成形术中的应用

颈椎椎板成形术于20世纪70年代作为椎板切除术的一种替代方式得到发展,用于治疗颈椎脊髓病并预防椎板切除术后颈椎失稳和后凸畸形[1].本文主要介绍一种新型的颈后路内固定技术在椎板成形术中的应用.     

不稳性寰椎骨折的外科治疗策略

目的 探讨枕颈或寰枢椎内固定融合技术治疗不稳性寰椎骨折的临床疗效和应用价值.方法 对2004年10月-2009年3月收治的不稳性寰椎骨折38例进行回顾性分析,其中6例寰椎爆裂性骨折合并寰枕关节不稳(5例行C0～C2固定融合术,其中1例同时合并有C7椎体压缩性骨折行C0～C3固定融合术),7例典型的Jefferson骨折,3例半环骨折,8例寰椎骨折合并Ⅱ型齿状突骨折,3例寰椎骨折合并Hangman骨折(其中2例Levine-Edwards Ⅲ型行C0～C3固定融合术,1例Ⅱ型行C1～C2固定融合术),3例寰椎骨折合并下颈椎损伤,6例寰椎横韧带断裂(Dickman Ⅰ型)伴寰枢关节不稳,2例寰椎粉碎性骨折合并寰椎侧块内侧骨性结构附着处横韧带撕裂(DickmanⅡ型).5例行C0～C2固定融合术,3例行C0～C3固定融合术,30例行C1～C2固定术并行自体髂骨植骨融合.结果 所有患者术后均获得随访,平均随访时间为28个月(12～46个月).临床症状均得到不同程度的改善.平均手术时间135 min(80～190 min),平均失血量460ml(200～3 300 ml),平均透视时间60 s.38例患者术中均未发生神经、椎动脉和其他手术相关并发症.全部患者均于术后3 d颈托固定后下地行走;术后脊髓损伤症状无加重.3例因电刀灼伤C1～C2间血管静脉丛导致出血,行止血纱布、脑棉片填塞止血,未出现颅脑缺血症状.复查X线片和CT未发现上颈椎失稳或复位丢失,螺钉位置良好,无松动、断钉,寰枢椎或枕颈部均获骨性融合.在晚期随访中,4例(11%)有颈部疼痛和僵硬感,1例枕神经痛.结论 对具有不稳定性寰椎骨折或合并寰椎横韧带损伤的患者,采用枕颈或寰枢椎内固定融合技术及短期外固定对于重建上颈椎永久稳定性是较好的手术方式,并且能阻止神经和脊髓功能的进一步损伤.

Abstract：

Objective To evaluate the clinical effect and safety of the occiput-cervicle or C1-C2 internal fixation and bone graft fusion in treatment of the unstable atlas fracture.Methods A retrospective study was performed in 38 patients with unstable atlas fractures treated by the occiput-cervicle or C1-C2 internal fixation and bone graft fusion from October 2004 to March 2009.Six patients with comminuted atlas fracture combined with instability of the occipito-atlantoid articulations were treated with occiput-C2 fusion(five patients)and with occiput-C3 fusion(one patient).There were seven patients with typical Jefferson fractures,three with semiring fractures,eight with atlas fractures combined with Anderson type Ⅱ odontoid process fractures,three with atlas fractures combined with Hangman's fractures (two patients with Levine and Edwards type Ⅲ Hangman's fractures were treated with occiput-C3 fusion and one patient Levine and Edwards type Ⅱ Hangman's fracture was treated with C1-C2 fusion),three with atlas fracture combined with lower cervicle injury,six with rupture of transverse ligament combined with instability of atlanto-axial joint(Dickman transverse ligament type Ⅰ injury)and two with comminuted fracture of the lateral mass associated with bony avulsion of the medial tubercle and transverse ligament(Dickman transverse ligament type Ⅱ injury).Of all,five patients were treated with occiput-C2 fusion,three treated with occiput-C3 fusion and 30 treated with C1-C2 fusion.Results All the patients were followed up for a range of 12-46 months(average 28 months),which showed improvement of clinical symptoms in some extent postoperatively.The operation time ranged from 80 to 190 min ates(average 135 minates),with intraoperative blood loss for 200-3 300 ml(average 460 ml)and average fluoroscopic time for 60 seconds.There were no neurological deficits,vertebral artery related complications or other complications in all the patients during the surgical operation.No neurological deficit was aggravated after the patient's mobilization with brace three days after operation.The enous plexus of blood vessel at C1-C2 rupture induced by the use of electrocautery was found in three patients who showed no cerebral hemodynamic deficit after hemostasis with hemostatic sponge and cotton piece.The follow-up X-ray and CT manifested osseous fusion in all the patients,with no looseness or breakage of the screws.The late follow-up showed pain associated with movement and limited range of motion in four patients(11%)and occipital neuralgia in one.Conclusions An occiput-cervicle fixation fusion or a C1-C2 fixation fusion combined with short external fixation can reestablish the upper cervical stability and prevent further injury of the spinal cord and nerve function and hence is an ideal option for C1 burst fracture with or without rupture of the transverse ligament.     

枢椎前路椎弓根螺钉固定通道的安全因素分析

目的 探讨枢椎前路椎弓根螺钉通道的安全性和可行性,为经前路枢椎椎弓根螺钉固定提供理论依据.方法 对32具干燥枢椎标本行前路椎弓根螺钉置入,测量枢椎前路椎弓根螺钉的钉道长度.行加密薄层螺旋CT扫描和重建,然后在重建后的横断面和矢状面图像上运用软件测量枢椎前路椎弓根螺钉的外倾角度及尾倾角度.结果 枢椎椎弓根螺钉均位于椎弓根内.枢椎前路椎弓根螺钉的进钉点选择在枢椎椎体与上关节突之间凹陷的顶点,螺钉长度为(28.4±2.5)mm,外倾角度为(28.5±2.3)°,尾倾角度为(15.5±2.0)°.结论 枢椎前路椎弓根螺钉不仅具有可行性,而且可以避开横突孔、椎动脉沟、椎管等重要解剖结构,安全空间较大.

Abstract：

Objective To investigate feasibility and safety of anterior pedicle screw fixation tunnel in the axis so as to provide theoretic evidence for further clinical application.Methods Thirty-two dry axis specimens were used for anterior pedicle screw placement,and the length of pedicle crews tunnel was measured by a digital caliper.The extraversion angle and the downslope angle were determined by CT cross-sectional scanning and reconstruction.Results All the anterior pedicle screws were positioned well,with no perforation of the pedicle.The anchoring point was at the vertex between the vertebral body and the superior articular process,with axis pedicle length of(28.4 ± 2.5)mm,the extraversion angle of (28.5 ±2.3)°and the downslope angle of(15.5 ±2.0)°.Conclusions Anterior pedicle screw fixation tunnel is feasible in the axis and can keep away from some important anatomy structures including transverse foramen,vertebral artery groove and vertebral canal to provide large safety space.     

下颈椎经关节螺钉联合侧块或椎弓根螺钉固定的效果

Objective To discuss the effect of transarticular screws combined with lateral mass screws or pedicle screws through posterior approach in the lower cervical spine. Methods From February 2003 to October 2007, 22 patients were treated using transarticular screws internal fixation combined with lateral mass screws or pedicle screws in Axis plating system and Vertex system. There were cervical fracture and dislocation in 13 patients, ossification of the posterior longitudinal ligament in 4, cervical canal stenosis associated with dentoid process fracture in 1, and cervical disc herniation associated with cervical stenosis in 4 patients. Lamina or facet bone grafting were used to achieve a long-term stability, with decompression and anterior approach or not. The starting point for screw insertion was located 1 mm medial to the midpoint of the lateral mass and the direction of the screw was 40° caudally in the sagittal plane and 20° laterally in the axial plane. Results All screws insertion was successful. A total of 45 transarticular screws were inserted, with 2 in C4,5, 39 in C5,6 and 4 in C6,7. A total of 12 lateral mass screws were inserted, with 6 in C3 and 6 in C4. A total of 41 pedicle screws were inserted, with 4 in C2, 2 in C3 and 6 in C4, 21 in C7 and 8 in T1. There was no complication related to screw insertion, such as injury to the vertebral artery, nerve roots or spine cord. The follow-up period ranged from 10 months to 3 years and 8 months (mean 17 months). All cases got bone fusion. Only one instance of screw partial backout was identified, but fusion was achieved in all pa-tients. In the follow-up period, only one instance of screw partial backout was identified, but fusion was achieved in all patients. Conclusion The combined use of transarticular screws and lateral mass screws or pedicle screws fixation in the lower cervical spine can enlarge the advantages of strong stability,relatively simple, and reduce operating risk when performed appropriately.     

经皮内镜下腰椎间盘切除术

近年来,经皮内镜下腰椎间盘切除术(PELD)已由非直视下切除椎间盘中央髓核的间接减压术,发展为内镜直视下切除压迫神经根髓核的直接减压术.PELD适应证与腰椎板开窗髓核切除术适应证相似,随着外科技术和设备的发展,也适用于椎间孔狭窄、侧隐窝狭窄和高髂嵴的L5～S1中央型椎间盘突出症患者.PELD设备种类很多,但外科技术基本一致.手术中可能会受到高髂嵴或L5横突的阻挡,但近来报道显示L5～S1经皮入路其实并不十分困难.PELD术后满意率与腰椎板开窗髓核切除术相当,且具有创伤小、并发症少、术后复发率低等优点,是治疗部分腰椎间盘突出症的理想选择.     

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。     

下颈椎经关节螺钉联合侧块或椎弓根螺钉固定的效果

Objective To discuss the effect of transarticular screws combined with lateral mass screws or pedicle screws through posterior approach in the lower cervical spine. Methods From February 2003 to October 2007, 22 patients were treated using transarticular screws internal fixation combined with lateral mass screws or pedicle screws in Axis plating system and Vertex system. There were cervical fracture and dislocation in 13 patients, ossification of the posterior longitudinal ligament in 4, cervical canal stenosis associated with dentoid process fracture in 1, and cervical disc herniation associated with cervical stenosis in 4 patients. Lamina or facet bone grafting were used to achieve a long-term stability, with decompression and anterior approach or not. The starting point for screw insertion was located 1 mm medial to the midpoint of the lateral mass and the direction of the screw was 40° caudally in the sagittal plane and 20° laterally in the axial plane. Results All screws insertion was successful. A total of 45 transarticular screws were inserted, with 2 in C4,5, 39 in C5,6 and 4 in C6,7. A total of 12 lateral mass screws were inserted, with 6 in C3 and 6 in C4. A total of 41 pedicle screws were inserted, with 4 in C2, 2 in C3 and 6 in C4, 21 in C7 and 8 in T1. There was no complication related to screw insertion, such as injury to the vertebral artery, nerve roots or spine cord. The follow-up period ranged from 10 months to 3 years and 8 months (mean 17 months). All cases got bone fusion. Only one instance of screw partial backout was identified, but fusion was achieved in all pa-tients. In the follow-up period, only one instance of screw partial backout was identified, but fusion was achieved in all patients. Conclusion The combined use of transarticular screws and lateral mass screws or pedicle screws fixation in the lower cervical spine can enlarge the advantages of strong stability,relatively simple, and reduce operating risk when performed appropriately.