导航辅助置入下颈椎椎弓根螺钉的误差分析

[目的]探讨导航辅助置入下颈椎椎弓根螺钉的准确性和产生误差的原因.[方法]25例下颈椎疾患手术病人,导航辅助下置入144枚颈椎(C3-7,)椎弓根螺钉,术后行X线、CT检查,横断位测量螺钉中线与椎弓根内壁的相对位置、与椎体中线的角度;矢状位测量螺钉中线与椎弓根上壁的相对位置、与椎体上缘的角度;并与导航图像的对应数据进行统计学分析.[结果]2枚螺钉穿出椎弓根上壁,3枚螺钉穿出椎弓根外壁入椎动脉孔,其它螺钉术后CT和术中导航图像所显示的位置角度无显著性差异,导航图像的显示是基于坚硬物体原则,颈椎手术本身特点不可能完全满足如此要求,两者偏差表现为"漂移"现象.[结论]导航辅助置入下颈椎椎弓根螺钉准确性显著提高,术中漂移是置钉偏差的原因.     

颈椎椎弓根螺钉误置的临床特征分析

目的:观察颈椎椎弓根置钉的准确性,分析螺钉误置的临床特征。方法:32例施行颈椎椎弓根置钉手术患者,男22例,女10例;年龄25~74岁(51.5±13.6岁)。颈椎骨折/脱位16例,颈椎后纵韧带骨化8例,颈椎多节段椎间盘突出1例,颈椎管内肿瘤7例(神经鞘瘤3例,脊膜瘤3例,室管膜瘤1例)。术前进行颈椎CT三维重建,确定椎弓根螺钉的进钉点,并测量椎弓根的内倾角、矢状面角度及直径、长度等参数;术中在C型臂X线机透视辅助下置入椎弓根螺钉;术后复查颈椎CT观察椎弓根螺钉位置,按照Lee等的方法判断椎弓根螺钉位置准确性:0级,螺钉未穿破椎弓根;1级,螺钉穿破椎弓根25%的螺钉直径;2级,螺钉穿破椎弓根25%,但50%的螺钉直径;3级,螺钉穿破椎弓根50%的螺钉直径。2级和3级判为螺钉误置,分析椎弓根螺钉误置的特点;观察血管神经损伤等并发症情况。结果:32例患者中因术中置钉困难更改为侧块螺钉3枚,改为寰椎椎板钩1枚,共置入颈椎椎弓根螺钉147枚(上颈椎40枚,中下颈椎107枚),椎弓根螺钉位置0级53枚,1级67枚,2级17枚(上颈椎2枚,下颈椎15枚),3级10枚(上颈椎1枚,下颈椎9枚)。椎弓根螺钉总误置率为18.3%(2级+3级);外侧壁穿破17枚,下壁5枚,上壁4枚,内侧壁1枚。上颈椎椎弓根螺钉的误置率(7.5%)显著低于中下颈椎(22.4%)(P0.05);椎弓根外侧壁穿破率(11.5%)高于上壁(2.7%)、下壁(3.4%,)及内侧壁(0.7%)(P均0.01)。5例患者6枚螺钉术中椎弓根钉道攻丝后活动性出血,予骨蜡封堵及置入螺钉后即止血,无血肿或脑缺血梗死并发症。3例患者术后出现上肢神经根刺激症状,予颈椎制动、神经营养治疗,分别于术后1个月、3个月、4个月好转。结论:颈椎椎弓根螺钉误置率较高,但相关并发症较少;穿破椎弓根外侧壁多于内侧壁、上壁或下壁;中下颈椎椎弓根螺钉的误置率高于上颈椎。     

导航系统辅助下颈椎椎弓根螺钉置钉准确性的实验研究

目的：评价导航系统辅助下颈椎（C3～C7）椎弓根螺钉内固定置钉的准确性.方法：将32具成人尸体颈椎标本随机分为4组,分别采用盲法、透视法、透视导航法和CT导航法进行下颈椎椎弓根螺钉置入.术后采用标本大体解剖观察的方法评价置钉准确性.分优（螺钉完全在椎弓根内）、可（仅有螺纹穿出,对周围组织无损伤）和差（螺钉明显穿出）进行统计.结果：共置入螺钉318枚.盲法80枚,平均手术时间27min,优29枚（36 3%）、可21枚（26.3%）、差30枚（37.5%）;透视法78枚（有1例C4、C5右侧椎弓根均细小,不能容纳3.5mm螺钉）,平均手术时间112min,优35枚（44.9%）、可29枚（37.2%）、差14枚（17.9%）;透视导航法80枚,平均手术时间69min,优34枚（42.5%）,可36枚（45%）,差10枚（12.5%）;CT导航法80枚,平均手术时间98min,优70枚（87.5%）、可10枚（12.5%）.各组间手术时间均有显著性差异（P＜0.05）,透视法与透视导航法的置钉准确率间无显著性差异,其余各组间均有显著性差异（P＜0.05）.结论：单纯根据术前影像结果盲法行下颈椎椎弓根螺钉内固定不安全.透视法和透视导航法可提高置钉准确性,但手术风险仍较大,透视导航法比透视法置钉的手术时间缩短.CT导航法并未比透视法增加手术时间,但置钉准确性显著提高.     

三维平板透视引导上颈椎椎弓根螺钉置入准确性及疗效分析

目的 评价在三维平板透视系统引导下应用上颈椎椎弓根螺钉内固定加植骨融合技术治疗上颈椎骨折的安全性和临床疗效。方法 回顾性分析自2012-06-2013-10我科收治的11例上颈椎骨折脱位病例,均在术中三维平板透视系统引导下采用上颈椎椎弓根螺钉短节段内固定加植骨融合技术进行手术治疗。结果 术后所有患者的颈椎稳定性均得到即刻恢复,44枚螺钉均在位良好,未发生脊髓及椎动脉损伤等任何与置钉相关的并发症,无螺钉断裂、松动。结论 在三维平板透视系统引导下经上颈椎椎弓根螺钉内固定加植骨融合技术治疗上颈椎骨折脱位,螺钉置入准确性高,有效防止置钉并发症,力学稳定性好,植骨融合率高,是上颈椎骨折后路固定术中理想的手术方式之一。     

应用颈椎椎弓根螺钉内固定治疗颈椎骨折脱位

目的探讨椎弓根螺钉系统在颈椎骨折脱位的临床应用。方法用形态学定位法对12例颈椎骨折脱位患者行复位椎弓根螺钉固定。定位：C3～C6为侧块外上象限的中点，C7位于关节突中垂线接近上关节面的下缘。方向水平面上，椎弓根螺钉向内侧倾斜C3～C5约为400，C6～C7约为350，矢状面上，C3-C4从后下向前上倾斜约100，C6-C7从后上向前下倾斜约100，C5与椎体后侧面垂直。结果置钉48枚，10枚穿破椎弓根，无神经血管损伤。骨折复位，术后平均随访7．3个月。神经功能恢复除2例A级无变化外，其余均有1—2级改善。结论经椎弓根螺钉固定对创伤性颈椎紊乱的重建是一种有效的方法，且被安全的实施。     

下颈椎经椎弓根螺钉置入技术的相关研究进展

研究表明[1、2],颈椎椎弓根螺钉的三柱固定能提供较以往一些固定方法更牢固的稳定性。但由于颈椎椎弓根特殊的解剖特点及毗邻关系,使颈椎经椎弓根螺钉置入手术难度大,具有一定风险。为了寻找一种安全、可靠的下颈椎经椎弓根螺钉置入技术,将置钉并发症降至最低,国内外学者进行了大量的解剖形态学、生物力学、影像学及临床应用方面的研究,综述如下。1下颈椎椎弓根解剖从解剖结构上看,椎弓根是椎骨中最强硬的部位,椎弓根皮质骨呈筒状,中间围有少量松质骨,这一结构对螺钉有很好的“把持力”。下颈椎椎弓根常用解剖参数包括:(1)椎弓根高度(pedicl…     

"钥匙孔式"开窗椎弓根探查结合盲置法在颈椎椎弓根固定术中的应用

目的探讨“钥匙孔式”开窗椎弓根探查结合盲置法行颈椎椎弓根固定术的临床应用价值。方法介绍“钥匙孔式”开窗椎弓根探查结合盲置法的置钉方法,对40例患者采用此法行颈椎椎弓根内固定术,术后X线和CT观察骨性愈合和椎弓根螺钉位置,螺钉穿透皮质率以及神经功能恢复情况。结果31例获随访,平均随访35个月,28例患者固定良好,并已达骨性融合;3例局部骨性愈合,无内固定松动,螺钉穿透皮质率仅为6．74％。29例脊髓损伤患者神经功能均有所恢复,仅有1例神经症状加重。结论“钥匙孔式”开窗椎弓根探查结合盲置法是一种良好的颈椎椎弓根固定方法,安全性高,有临床应用价值。     

颈椎椎弓根螺钉内固定术中并发症及其对策

目的：探讨颈椎椎弓根螺钉固定技术常见并发症及其处理方法。方法：应用Axis内固定系统（美国枢法模公司）对69例颈椎病患者进行经后路椎弓根内固定术，术中清晰显露颈椎侧块和突间关节，用直径3．2mm高速球形磨钻去除侧块外上象限处骨皮质，然后用直径2．0mm的手锥沿椎弓根事先确定的方向轻轻钻入，使其自然置入，深约2．0～2．5cm。确定无误后，则安置Axis钛板和置入长度合适的椎弓根螺钉，完毕后用C形臂X线机作双斜位透视。结果：从C3到C7，术中植入椎弓根螺钉314枚，其中21枚钉初次置入后感觉松动，经校正后二次置入成功，17枚钉道钻孔后出血较多，但及时处理后出血停止并无不良结果，其余螺钉置钉一次成功，未出现并发症。术后检查有28枚螺钉穿出椎弓根，6枚螺钉穿破椎弓根上侧皮质，3枚螺钉穿破椎弓根下侧皮质，12枚螺钉穿破椎弓根外侧皮质，7枚螺钉穿破椎弓根内侧皮质。随访未发现与螺钉置入穿破椎弓根皮质相关的神经血管损伤问题。结论：手术前充分了解每个患者颈椎椎弓根影像学解剖结构，术中仔细按原则操作，正确处理则会明显减少术中及术后并发症的发生。     

颈椎前路椎弓根螺钉置入的解剖学研究

[目的]分析颈椎前路椎弓根螺钉内固定的解剖学参数,研究其可行性;通过文献分析比较国内外相关数据。[方法]取42具成人正常干燥颈椎标本,分别用手工和三维CT测量C2^C7椎弓根高度和宽度,进钉点位置,进钉方向,前路椎弓根螺钉进钉轴线上的椎体长度、椎弓根长度及总长度,用统计学分析手工和CT测量差异。以"颈椎"、"前路"、"椎弓根"为关键词搜索CNKI、PubMed、Scopus,纳入含以上相关数据的文献进行比较分析。[结果]手工测量数据与CT数据无统计学差异。除6.4%的C3椎弓根宽度<4 mm外,C2C7椎弓根高度和宽度,进钉点位置,进钉方向,前路椎弓根螺钉进钉轴线上的椎体长度、椎弓根长度及总长度,用统计学分析手工和CT测量差异。以"颈椎"、"前路"、"椎弓根"为关键词搜索CNKI、PubMed、Scopus,纳入含以上相关数据的文献进行比较分析。[结果]手工测量数据与CT数据无统计学差异。除6.4%的C3椎弓根宽度<4 mm外,C2^C7椎体椎弓根平均高度和宽度均≥4 mm。进钉点位置:C3、C4位于椎体正中矢状面的对侧,距离正中为2C7椎体椎弓根平均高度和宽度均≥4 mm。进钉点位置:C3、C4位于椎体正中矢状面的对侧,距离正中为2³ mm;C53 mm;C5^C7位于同侧,距离正中C5:1.38 mm,C6、C7:4C7位于同侧,距离正中C5:1.38 mm,C6、C7:4⁵ mm。C35 mm。C3^C7距离椎体上终板的距离为5C7距离椎体上终板的距离为5⁸ mm。进钉点方向,与矢状面的夹角:C2、C5、C6为38°8 mm。进钉点方向,与矢状面的夹角:C2、C5、C6为38°⁴0°,C3、C4为43°40°,C3、C4为43°⁴7°;与横断面的夹角:C247°;与横断面的夹角:C2^C4角度为下倾,角度分别为19.43°,10.58°和5.93°;C5C4角度为下倾,角度分别为19.43°,10.58°和5.93°;C5^C7角度为头倾,分别为1.94°,6.29°和7.50°。各椎弓根轴线总长度为29C7角度为头倾,分别为1.94°,6.29°和7.50°。各椎弓根轴线总长度为29³2 mm,轴线上椎体长度约为14 mm。比较国内外文献中椎弓根宽度和高度以及进钉点位置显示:上述解剖学数据存在差异。[结论]该实验利用手工和三维CT进行大样本研究,为临床上应用颈椎前路椎弓根螺钉内固定提供了解剖学数据。同时针对国内外不同测量方法和测量对象得出的数据进行对比,为进一步研究其差异提供依据。     

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.     

A free‐hand technique for pedicle screw placement in the lower cervical spine

Objective: To describe a free‐hand method for pedicle screw placement in the lower cervical spine with no intraoperative imaging monitors, and to evaluate the safety of this technique. Methods: A study of the free‐hand technique of cervical pedicle screw placement was conducted by postoperative radiological review and follow‐up. Thirty‐six patients who had had cervical reconstruction with posterior plate utilizing pedicle screw fixation, and been followed for a minimum of 2 years, were studied. The position of the pedicle screw was evaluated by postoperative oblique radiographs and axial computed tomograms. Clinical outcomes were measured by Odem's criteria. Results: A total of 144 screws of diameter 3.5 or 4.0 mm were inserted into the cervical pedicles in 36 patients. Postoperative images showed that 16 (11.1%) of the screws had penetrated the pedicle walls. Among them, 10 (6.9%) screws had penetrated the lateral, 4 (2.8%) the superior and 2 (1.3%) the inferior walls. However, there were no neurological or vascular complications related to the malpositioned screws during a minimum of 2 years follow‐up. In addition, Odem's scores were applied postoperatively in all patients except one with complete neurological deficit. Conclusion: Based on 144 screw placements, cervical pedicle screw insertion utilizing a free‐hand technique without intraoperative imaging guidance seems to be safe and reliable. However, solid knowledge of the anatomy of the cervical pedicle and adjacent neurovascular bundles, and careful preoperative review of cervical images, are imperative for successful screw placement in the cervical spine.     

球形探针技术在椎弓根螺钉置钉术中的应用

 目的 通过与传统徒手置钉术的比较, 评价一种新的椎弓根螺钉置钉技术, 即应用椎弓根球形探针系统置入椎弓根螺钉的准确率。方法 自 2009年 5月至 2010年 6月, 对脊柱侧凸、腰椎滑 脱、脊柱骨折等疾病需行颈胸腰椎椎弓根钉内固定的患者, 术中应用椎弓根球形探针置入椎弓根螺钉。 该探针为医用不锈钢制成, 包括一个球端、杆和柄, 金属球端的直径分别有 1.5、2.5、3.0、3.5 mm四种, 其 中直径 1.5 mm的探针具有较强的硬度和一定的弹性。球形探针技术要点: 按标准椎弓根螺钉进钉点定 位, 高速磨钻去除皮质骨, 将椎弓根球形探针按直径从小到大±次缓慢敲入椎弓根内直至达到椎体前 方骨皮质。术后采用 CT扫描评价椎弓根螺钉钉道情况。并与采用传统徒手技术的病例资料进行对比。 结果采用球形探针技术共置入 312枚椎弓根螺钉, 传统徒手技术置入 276枚。术后 CT扫描显示球形 探针技术组颈椎、胸椎、腰椎椎弓根螺钉钉道准确率为 100%, 无一例穿出椎弓根骨皮质。传统徒手技术 组准确率为 78%, 共有 61枚螺钉(22%)位置不良, 23枚(8.3%)穿透椎弓根内侧骨皮质, 38枚(13.7%) 穿透外侧骨皮质。两组置钉准确率的差异具有统计学意义。所有患者术中和术后均未出现神经、血管和内脏损伤等并发症。结论 与传统徒手置钉技术相比, 椎弓根球形探针置钉技术, 可准确地置入椎弓根钉, 避免因螺钉误置所导致的术后并发症。     

Techniques and accuracy of thoracolumbar pedicle screw placement

Pedicle screw instrumentation has been used to stabilize the thoracolumbar spine for several decades. Although pedicle screws were originally placed via a free-hand technique, there has been a movement in favor of pedicle screw placement with the aid of imaging. Such assistive techniques include fluoroscopy guidance and stereotactic navigation. Imaging has the benefit of increased visualization of a pedicle’s trajectory, but can result in increased morbidity associated with radiation exposure, increased time expenditure, and possible workflow interruption. Many institutions have reported high accuracies with each of these three core techniques. However, due to differing definitions of accuracy and varying radiographic analyses, it is extremely difficult to compare studies side-by-side to determine which techniques are superior. From the literature, it can be concluded that pedicles of vertebrae within the mid-thoracic spine and vertebrae that have altered morphology due to scoliosis or other deformities are the most difficult to cannulate. Thus, spine surgeons would benefit the most from using assistive technologies in these circumstances. All other pedicles in the thoracolumbar spine should theoretically be cannulated with ease via a free-hand technique, given appropriate training and experience. Despite these global recommendations, appropriate techniques must be chosen at the surgeon’s discretion. Such determinations should be based on the surgeon’s experience and the specific pathology that will be treated.     

A new technique for anterior cervical pedicle screw implantation

Objective: To introduce and evaluate a new technique, anterior pedicle screw implantation, for anterior cervical reconstruction. Methods: Seven patients (five men and two women) with an average age of 65 years were included in this group. After carefully preparation, anterior pedicle screws were implanted under fluoroscopy in all patients. The position of the anterior pedicle screws was evaluated three days postoperatively by X‐ray and CT imaging. The mean recovery rate as assessed by the Japanese Orthopaedic Association (JOA) score was recorded at final follow‐up. Results: A total of fourteen anterior pedicle screws were implanted in our group. The average follow up period was 8 months. The mean JOA score was 12.5 preoperatively and 14.8 postoperatively. The mean improvement in the JOA score was 50.5% at final follow‐up. The average local alignment improved from 4.0 of kyphosis preoperatively to 6.5 of lordosis at final follow‐up. Early bony union was observed in four cases that were followed up for more than 3 months. There were no serious complications. No “pedicle perforation” was observed in any of the fourteen anterior pedicle screws, whereas one screw exposure occurred. Conclusion: Anterior cervical pedicle screw implantation is a feasible method for selected cases. It provides another choice for strong anterior cervical reconstruction.     

颈椎弓根置钉的影像不测量

目的：探索一种能指导颈椎弓根螺钉置钉手术操作的影像学测量方法。方法：随机取福尔马林浸泡的成人颈椎标本（Cl-Tl)共7具,保留完整的脊柱三柱结构及相关的韧带和椎旁肌。分别摄取颈椎标本的X线片及CT断层扫描,测量其颈椎弓根内、外径的高、宽、选择以颈椎侧块平面为参考平面,进行进钉点和进钉方向的测量,并将7具标本全部进行实体解剖肉眼观察,对比影像学测量结果的有效性。结果：影像学测量结果与实体解剖测量比较有效率为100%。结论：该影像学测量方法可为颈椎弓根螺钉的置钉提供参考。     

数字骨科技术在寰枢椎个体化置钉手术中的应用

目的 探讨数字骨科技术在寰枢椎椎弓根螺钉个性化置钉的应用价值.方法 将术前接受薄层CT扫描的30例上颈椎疾患患者(其中男16例,女14例)的数据输入Mimic和 Simpleware软件后,建立三维仿真模型,并设计最佳的椎弓根钉道,然后根据钉道设计导航模版.用激光快速成型机打印导航模版,用于手术时辅助寰枢椎椎弓根螺钉...     

颈椎椎弓根钉置钉技术的研究进展

由于创伤、结核、肿瘤、畸形矫正等原因造成脊柱不稳定,需要重建脊柱的稳定性,虽然有众多学者对此做了大量深入的研究,但目前治疗颈椎不稳定方法的选择仍然困扰着临床医生。考虑到更好的稳定性和安全性因素,越来越多的临床工作者选择椎弓根螺钉置入法治疗脊柱不稳。通过对国内外颈椎椎弓根螺钉置钉技术进行总结,现将颈椎椎弓根钉常用置钉方法及最新技术作一综述。