骨科手术导航系统在椎弓根螺钉固定术中的应用

目的: 探讨骨科导航系统在脊柱椎弓根螺钉固定术的应用价值。方法: 同期行椎弓根螺钉固定术患者 44例 (男 26例,女 18例, 共 230枚椎弓根螺钉), 其中应用骨科手术导航系统及未应用该系统各 22例, 术后均进行置入螺钉节段的X线平片确定螺钉置入情况。结果: 应用骨科手术导航系统置入椎弓根螺钉无 1例出现早期并发症, 107 /116枚螺钉置入位置准确, 与对照组相比有显著性差异 (X2 =9. 17,P<0. 01)。结论: 应用骨科手术导航系统可保证螺钉置入位置的准确性, 降低手术相关并发症及避免放射线损害, 特别是对于椎弓根变异如脊柱侧凸、后凸畸形及严重脊柱退变有明显优越性。     

透视及导航下颈椎椎弓根螺钉内固定术的临床应用经验

目的　报告使用透视下及无线主动式红外诱导计算机导航引导下进行颈椎椎弓根钉固定手术的经验 ,分析手术成功的要素。方法　自 2 0 0 1年 10月至 2 0 0 2年 12月共行颈椎椎弓根螺钉 -AXIS钛板内固定 2 9例 ,男性 18例 ,女性 11例。年龄 2 6岁～ 76岁 ,平均年龄 4 9.4岁。使用C形臂X线透视下螺钉置入 2 5例 ,无线主动式红外诱导计算机导航下椎弓根内固定 4例。共置入椎弓根螺钉 174枚。结果　 174枚螺钉中有 15 5枚 (89% )位置正确。 19枚螺钉存在不同程度的偏差 ,均为内倾不够 ,1例出现一过性神经根合并症。计算机导航置入螺钉 2 4枚 ,位置正确率 10 0 %。术前颈椎后凸者固定节段曲度平均- 12 .1°术后平均 - 0 .6° ,明显得到纠正。术后 3个月和 6个月的随诊 ,颈椎曲度和固定节段椎体高度均维持 ,没有出现内固定物松动 ,螺钉断裂等情况。结论　颈椎椎弓根钉固定手术是颈椎获得牢固固定的方法 ,为颈椎后路手术提供了更广的操作空间 ,免去部分同时前路手术的需要 ,而且可以用于颈椎后凸的矫正。但是结构的复杂性和变异性及周围的神经血管使手术难度加大 ,在透视下可以比较安全地置入螺钉 ,更好的方法是使用计算机导航技术。这一技术具有良好的临床应用前景。     

颈椎弓根螺钉内固定的解剖学研究

目的探讨颈椎弓根螺钉内固定的定位定向方法。方法设计椎体平面固定架,用游标卡尺、角度计和标本涂钡X线片对40具成人颈椎干燥标本进行解剖学观测。内容包括:椎弓根高度、宽度、轴线长度、轴线角度,上下关节突间侧凹的深度及存在率,椎弓根上下切迹、关节面、椎弓后上缘与椎体上平面的垂直高度及关节突后平面角度。结果C2~C7上下关节突间侧凹的存在率为100%。颈椎弓根完全可以接受直径3.5mm、长28mm的螺钉内固定;椎弓根在椎体平面上的外展角C1为20°,C2上为25°、下为44°,C3~C5为45°~47°,C6、C7为40°。除寰枢椎外,颈椎弓根后结构、关节突间侧凹对应椎弓根轴线。椎弓根的指向与关节突后平面角度密切相关:椎弓后上缘高度线、关节突后平面和椎体上平面三者之间形成前后两个180°互补角,前角大于90°时椎弓根指向前下方,小于90°时指向上终板。关节突后平面的平均角度C3 为-2.30°±1.82°,C4为2.32°±1.98°,C5为2.42°±1.87°,C6为2.36°±1.56°,C7为15.22°±2.68°。进钉点在C1为后弓缘与上关节突后突尖中垂线的交点,C2为上椎弓根外缘矢状线与下关节突上缘水平线交点,C3~C7为垂直于关节突后平面的椎弓后上缘水平线与关节突间侧凹外缘的矢状线交点。结论关节突间侧凹、侧块后平面及椎弓后上缘,三者     

颈椎椎弓根钉内固定治疗颈椎骨折脱位

[目的]探讨颈椎椎弓根钉内固定治疗颈椎骨折脱位的临床效果及影响因素。[方法]采用Axis系统经椎弓根内固定治疗颈椎骨折脱位41例。所有病例术前均行X线、CT及MRI检查并根据测量结果对每一椎弓根钉实施个体化置入。[结果]41例全部获得6～12个月随访，切口均Ⅰ期愈合，无1例近期死亡。共置入螺钉218枚，有196枚（90％）位置正确，22枚存在不同程度偏差，其中1l枚造成神经根损伤，1枚疑有血管损伤。有38例获得满意复位并骨性愈合，有3例因系陈旧骨折脱位术中未完全复位，术后出现神经根刺激症状，其中1例术后因退钉而改行前路手术。在25例脊髓及神经根损伤病例中，有6例系脊髓完全损伤，术后均无恢复；其余19例为脊髓和神经根不全损伤，术后神经功能均获明显改善甚至恢复正常。[结论]颈椎椎弓根钉内固定是治疗颈椎骨折脱位的安全有效方法之一。合理选择手术适应证，熟悉颈椎解剖结构。术中规范操作以及置钉个体化等是手术成功的关键。     

胸腰椎经皮椎弓根螺钉置钉的准确性分析

目的:分析胸腰椎经皮椎弓根螺钉固定术的置钉准确性.方法:回顾分析2010年7月～2012年12月我院53例胸腰椎经皮椎弓根螺钉固定术患者,男31例,女22例;年龄18～73岁,平均51.2岁.腰椎退变性疾病24例,胸腰椎骨折29例.置钉节段为T8～S1.根据术后CT轴位扫描图像以及患者是否出现椎弓根螺钉相关并发症,将椎弓根螺钉位置分级:0级,螺钉位于椎弓根皮质内;1级,螺钉突破椎弓根骨壁但≤2mm;2级,螺钉突破椎弓根骨壁＞2mm,但无神经受压等症状;3级,出现螺钉相关并发症.结果:共置入椎弓根螺钉212枚,平均4.0枚/例.212枚螺钉中,0级175枚(82.5％);1级32枚(15.1％);2级4枚(1.9％);3级1枚(0.5％),患者出现神经受压症状,行翻修术.37枚位置不佳的螺钉中,24枚向内侧切出椎弓根,13枚向外侧切出.结论:胸腰椎经皮椎弓根螺钉固定技术虽置钉位置欠佳率较高,但很少发生2级以上置钉位置不佳者.     

下颈椎椎弓根内固定术的个体化设计及临床应用探讨

[目的]探讨下颈椎椎弓根螺钉内固定术的个体化设计及临床应用.[方法]应用64排CT采集图像、Fast VR软件立体重建、PACS软件存储和传输、SYNAPSE软件三维测量.对103例下颈椎骨折脱位患者进行了临床治疗,其中9例病人各置入椎弓根螺钉8枚,计72枚;27例病人各置入椎弓根螺钉6枚;计162枚,67例病人各置入椎弓根螺钉4枚;计268枚,共计502枚.[结果]术后87例患者获12 ～73个月随访,平均随访时间18.16个月.采用JOA评分标准[1],优41例,良33例,可8例,差3例,术后并发症死亡3例,优良率85.06％.椎弓根螺钉以Andrew CT位置分级标准进行评估,Ⅰ级476枚,Ⅱ级23枚,Ⅲ级3枚,螺钉Ⅰ级率94.82％.25例患者26枚椎弓根螺钉术后X线片示位置不理想,3枚Ⅲ级螺钉行二次手术调整,无脊髓及椎动脉损伤.无钢板、螺钉脱落及断裂,融合率为98.32％.[结论]应用下颈椎椎弓根螺钉内固定置钉技术治疗颈椎疾患可以获得即刻三维稳定,融合率高,是一种值得推广的方法.     

Complications of pedicle screw fixation in reconstructive surgery of the cervical spine

STUDY DESIGN: Retrospective evaluation of complications in 180 consecutive patients with cervical disorders who had been treated by using pedicle screw fixation systems. OBJECTIVES: To determine the risks associated with pedicle screw fixation in the cervical spine and to emphasize the importance of preoperative planning and surgical techniques in reducing the risks of this procedure. SUMMARY OF BACKGROUND DATA: Generally, pedicle screw fixation in the cervical spine has been considered too risky for the neurovascular structures. There have been several reports describing the complications of lateral mass screw-plate fixation. However, no studies have examined in detail the complications associated with cervical pedicle screw fixation. METHODS: One hundred eighty patients who underwent cervical reconstructive surgery using cervical pedicle screw fixation were reviewed to clarify the complications associated with the pedicle screw fixation procedure. Cervical disorders were spinal injuries in 70 patients and nontraumatic lesions in 110 patients. Seven hundred twelve screws were inserted into the cervical pedicles, and the locations of 669 screws were radiologically evaluated. RESULTS: Injury of the vertebral artery occurred in one patient. The bleeding was stopped by bone wax, and no neurologic complication developed after surgery. On computed tomographic (CT) scan, 45 screws (6.7%) were found to penetrate the pedicle, and 2 of 45 screws caused radiculopathy. Besides these three neurovascular complications directly attributed to screw insertion, radiculopathy caused by iatrogenic foraminal stenosis from excessive reduction of the translational deformity was observed in one patient. CONCLUSIONS: The incidence of the clinically significant complications caused by pedicle screw insertion was low. Complications associated with cervical pedicle screw fixation can be minimized by sufficient preoperative imaging studies of the pedicles and strict control of screw insertion. Pedicle screw fixation is a useful procedure for reconstruction of the cervical spine in various kinds of disorders and can be performed safely.     

Spine update: cervical spine internal fixation using screw and screw-plate constructs

Screw and screw-plate constructs have been used successfully in fixation of the cervical spine. This update focuses on the indications, complications, and nuances in the technique used for odontoid screws, transarticular C1-C2 screws, occipitocervical plating, posterior lateral mass screws, pedicle screws, and anterior plating.     

改良脊柱截骨治疗重度驼背畸形32例随访观察

[目的]研究重度驼背畸形安全有效的矫正和内固定方法,探索其早、晚期严重并发症的预防。[方法]后路横形多节段后、中柱截骨经椎弓根钉棒系统长节段三维内固定。[结果]最大矫正64°,最少矫正50,°站立身高最多增加30 cm,最少增加22 cm,无死亡、截瘫及不完全瘫。2例术后并发肠系膜上动脉综合征者经及时有效处理,相应症状5 d内消失。平均随访5年8个月,全部病例脊柱长期稳定性良好,矫正度未见明显丢失,外观畸形明显改善,能平卧,双目能平视前方,生活质量大大提高。[结论]改良脊柱后路截骨经椎弓根钉棒系统三维内固定,增加了脊柱截骨后的稳定和融合点,加强了内固定钉棒两端的集体抓握力,对脊柱的良好融合、长期稳定和矫正度数少丢失或不丢失起到重要作用,是治疗重度驼背畸形的一种安全可靠的方法。     

颈椎前路椎弓根螺钉在颈椎不稳疾病应用的研究进展

颈椎不稳疾病需要手术来重建其稳定性。以往而言,手术方式可分为前路与后路两种,但各自有各自的缺点。前路椎体螺钉的失败率较高,有时需要再次手术;而后路椎弓根螺钉、侧块螺钉、关节突关节螺钉的创伤较大,导致患者住院时间较长。一般的颈椎不稳疾病,根据疾病所在的位置,单用前路或者后路就可以达到稳定的效果。但是,对于单节段的三柱损伤、需要多节段的椎体次全切除术和椎间盘摘除术的疾病,单一的前路或后路往往不能达到预期的牢固稳定效果。同时,联合应用前后路又有其更突出的缺点:如手术时间延长、手术损伤更大、感染风险增加等等。近些年来,颈椎前路椎弓根螺钉作为一种新近提出的颈椎固定技术。它的生物力学特性、形态学的可行性、抗拔出力的强度、影像学特点及新兴置钉技术已经有了相关的实验室及临床研究。因其重建的牢固稳定性、良好的力学特性和患者的满意疗效得到了较多学者的认可。虽然颈椎前路椎弓根螺钉技术已经被运用于临床上,但它的长期临床效果还需待进一步明确。尽管如此,其创新性的提出,将为广大医师同仁为治疗颈椎不稳疾病提供新的解决思路。     

Correction of cervical kyphosis using pedicle screw fixation systems

STUDY DESIGN: This retrospective study was conducted to analyze the clinical results in 30 patients with cervical kyphosis that had been treated using cervical pedicle screw fixation systems. OBJECTIVES: To evaluate the effectiveness of a pedicle screw fixation procedure in correction of cervical kyphosis. SUMMARY OF BACKGROUND DATA: Correction of cervical kyphosis is a challenging problem in the field of spinal surgery. There have been several reports regarding surgical correction of cervical kyphosis; however, there have been no detailed reports on correction of cervical kyphosis using a pedicle screw fixation procedure. METHODS: Thirty patients with cervical kyphosis underwent correction and fusion using cervical pedicle screw fixation. Seventeen of 30 patients with flexible kyphosis (Group I) were managed by a posterior procedure alone. The remaining 13 patients with rigid or fixed kyphosis (Group II) had a combined anterior and posterior procedure. RESULTS: The average preoperative cervical kyphosis of 29.4 degrees improved to 2.3 degrees after surgery and was 2.8 degrees at the final follow-up. In Group I patients, preoperative kyphosis of 28.4 degrees improved to 5.1 degrees at the final follow-up. In contrast, preoperative kyphosis of 30.8 degrees in Group II patients improved to 0.5 degree at the final follow-up. Solid fusion was achieved in all patients. There were two patients with transient nerve root complications related to pedicle screw instrumentation. CONCLUSION: Cervical kyphosis in 30 patients was effectively corrected using a pedicle screw fixation procedure with no serious complications. Flexible kyphosis with segmental motion can be satisfactorily corrected by a single posterior procedure using pedicle screw fixation. However, circumferential osteotomies combined with a posterior shortening procedure involving a pedicle screw system are required to achieve the best correction of fixed kyphosis by bony union. Cervical pedicle screw fixation is the most advantageous instrumentation in the correction of cervical kyphosis.     

Accuracy of upper thoracic pedicle screw placement using three-dimensional image guidance

Background contextPedicle screw malposition rates using conventional techniques have been reported to occur with a frequency of 6% to 41%. The upper thoracic spine (T1–T3) is a challenging area for pedicle screw placement secondary to the small size of the pedicles, the inability to visualize this area with lateral fluoroscopy, and significant consequences for malpositioned screws. We describe our experience placing 150 pedicle screws in the T1–T3 levels using three-dimensional (3D) image guidance.PurposeThe aim of this study was to assess the accuracy of 3D image guidance for placing pedicle screws in the first three thoracic vertebrae.Study designThe accuracy of pedicle screw placement in the first three thoracic vertebrae was evaluated using postoperative thin-section computed tomography (CT) scans of the cervicothoracic region.Patient sampleThirty-four patients who underwent cervicothoracic fusion were included.Outcome measuresRadiological investigation with CT scans was performed during the postoperative period.MethodsThirty-four consecutive patients underwent cervicothoracic instrumentation and fusion for a total of 150 pedicle screws placed in the first three thoracic vertebrae. All screws were placed using 3D image guidance. Medical records and postoperative imaging of the cervicothoracic junction for each patient were retrospectively reviewed. An independent radiologist reviewed the placement of the pedicle screws and assessed for pedicle breach. All cortical violations were reported as Grade 1, 0 to 2 mm; Grade 2, 2 to 4 mm; and Grade 3, greater than 4 mm.ResultsOverall, 140 (93.3%) out of 150 screws were contained solely in the desired pedicle. All 10 pedicle violations were Grade 1. The direction of pedicle violation included three medial, four inferior, two superior, and one minor anterolateral vertebral body. No complication occurred as a result of screw placement or the use of image guidance.ConclusionsUpper thoracic pedicle screw placement is technically demanding as a result of variable pedicle anatomy and difficulty with two-dimensional visualization. This study demonstrates the accuracy and reliability of 3D image guidance when placing pedicle screws in this region. Advantages of this technology in our practice include safe and accurate placement of spinal instrumentation with little to no radiation exposure to the surgeon and operating room staff.     

Pedicle screw fixation in the cervical spine

Pedicle screw fixation of the lower cervical spine is a new technique that provides an alternative to posterior lateral mass plating. Although biomechanical studies support the use of pedicle screws to reconstruct the cervical spine, placing screws into the small cervical pedicle poses a technical challenge. Penetration of the pedicle is the primary complication associated with screw insertion in the lower cervical spine. Pedicle screw fixation at the C2 and C7 pedicles in conjunction with use of plates for occipitocervical or cervicothoracic plating is becoming an accepted technique; however, pedicle screw fixation should not be routinely used at the C3-C6 levels. It may be indicated in patients who have osteoporotic bone or when rigid internal fixation cannot be achieved by conventional techniques.     

颈椎椎弓根螺钉内固定技术有关问题探讨

目的　探讨经颈椎椎弓根内固定治疗颈椎病变临床常见问题及其处理方法。方法　采用AXIS内固定系统 ,经颈椎椎弓根螺钉固定技术对 4 0例颈椎病患者进行了手术治疗 ,对手术中常遇到的问题及处理方法进行总结。结果　 4 0例手术中 ,有 13例在置钉后感觉松动 ,9例在打椎弓根孔道时出血较多 ,术中正确处理后未发现神经血管症状。结论　经颈椎弓根内固定固定牢固 ,康复快 ,效果好 ,但手术中风险较大 ,处理不好 ,会出现严重的并发症。故熟悉解剖及手术操作技巧、冷静处理手术中遇到的问题非常重要。     

Accuracy of cervical pedicle screw placement using the funnel technique.

STUDY DESIGN: This was a cadaver study assessing the accuracy of cervical pedicle screw placement. OBJECTIVE: To evaluate the accuracy of the funnel technique of screw placement. SUMMARY OF BACKGROUND DATA: Although excellent results have been reported in clinical studies, with no major neurovascular injuries, several cadaveric studies have shown a high pedicle perforation rate during screw placement. METHODS: Ten fresh frozen cervical spines (C2-C7) were used (120 pedicles, 20 pedicles per level). The average specimen age was 79.6 years (range 65-97); the average height was 159 cm (range 155-175). The male-to-female ratio was 3:7. Pedicle width and angulation were measured on preoperative axial computed tomography (1-mm slices). By use of four bony landmarks and the funnel technique, screws were placed under direct vision. Critical perforations (documented contact of a screw with, or an injury to, a spinal cord, nerve root, or vertebral artery) and noncritical perforations (a perforation with no critical contact) were recorded. RESULTS: In seven pedicles (5.8%) the procedure was aborted because of a small or nonexistent pedicle medullary canal. Ninety-four pedicle screws (83.2%) were placed correctly, whereas 11 pedicles (9.7%) had noncritical perforations and 8 pedicles (7.1%) had critical perforations. The majority of the critical and noncritical perforations were at C3, C4, and C5. CONCLUSIONS: Axial computed tomography is necessary for the preoperative planning. Because of the small diameter and steep angulation of cervical pedicles, every spine surgeon who intends to use pedicle screws should first master the technique on cadavers.