非影像监视下行脊柱侧凸胸椎椎弓根螺钉置入的临床应用

目的:探讨脊柱侧凸胸椎椎弓根螺钉非影像监视下徒手置入的方法及可行性。方法:57例脊柱侧凸患者行后路椎弓根螺钉系统矫形手术,徒手法置入胸椎椎弓根螺钉。术后常规拍摄脊柱全长X线片,随机选取10例患者行CT扫描观察,了解螺钉置入的准确性。结果:共置入胸椎椎弓根螺钉362枚。术后X线片观察到10枚螺钉偏外,4枚螺钉偏下,其中2枚螺钉引起轻微肋间神经痛,3周后完全缓解。CT观察47枚螺钉有2枚螺钉导致椎弓根内壁膨胀内移,没有相应神经症状。主弯Cobb角术前平均60.4°(32°～121°),术后平均18.3°(1°～70°),平均矫正率71.9%(38.1%～98.0%)。结论:徒手法置入脊柱侧凸胸椎椎弓根螺钉是可行的。     

胸椎椎弓根螺钉固定矫治青少年脊柱侧凸

目的 :探讨青少年胸椎椎弓根螺钉的固定方法及注意事项。方法 :测量 2 0例正常青少年胸椎椎弓根影像学参数 ,并在此基础上采用自行设计的胸椎椎弓根螺钉固定器械 (Scofix器械 ) ,对 32例青少年脊柱侧凸进行了矫正治疗。结果 :正常青少年T4椎弓根横径最小 ( 3 9± 0 6 6mm) ,胸椎椎弓根中点均位于横突根部上缘与中点之间 ,椎弓根与矢状面夹角在T11、T12为负角 ,T10以上为正角 ,T1最大 ( 35 8°± 0 84°)。 2 7例患者术后平均随访 11个月 ,特发性和先天性侧凸的矫正率分别为 5 7 8%和 46 4% ,无严重并发症。结论 :根据测量结果 ,如选择好进钉点、方向及深度 ,Scofix器械对青少年脊柱侧凸的矫正可获得更好的稳定性和固定强度     

青少年脊柱侧凸患者胸椎椎弓根螺钉置入的准确性和安全性评价

目的：探讨青少年脊柱侧凸患者胸椎椎弓根螺钉置入的准确性和安全性，以减少相关手术并发症。方法：32例青少年脊柱侧凸患者术前均对畸形脊柱进行标准俯卧位CT加密扫描，测量进钉点至椎体前缘的深度、进针角度、椎弓根直径和椎体的旋转角度，根据测得数据确定椎弓根螺钉置入的深度和方向，置入螺钉后再行脊柱全长X线片及CT扫描评价置钉的准确性和安全性。结果：32例共置入226枚胸椎椎弓根螺钉，术后CT加密和X线片观察到205枚螺钉（90．7％）完全在椎弓根皮质骨内。10例21枚螺钉（9.3％）发生错置，7枚螺钉（3．1％）偏外，5枚螺钉（2．2％）偏前外侧（其中2枚螺钉靠近节段血管），4枚螺钉（1．8％）偏下，4枚螺钉（1．8％）直径过大导致椎弓根内壁膨胀内移，1枚螺钉（0．4％）误入椎管导致完全性脊髓损伤。T1～T4错置12枚（18．2％），T5～T12错置9枚（6．1％）；凸侧椎根螺钉置入的准确率为93．8％，凹侧为83．1％。结论：脊柱畸形患者术前应常规采用标准俯卧位CT加密扫描，根据扫描图像测得的相关数据可为术中准确置入椎弓根螺钉提供重要参考依据。在青少年脊柱侧凸患者胸椎椎弓根螺钉置入有一定的误置率，螺钉发生错置多见于上胸椎和凹侧．术中应高度重视。     

胸椎椎弓根螺钉在脊柱侧凸矫形术中的应用效果评价

[目的]评价胸椎椎弓根螺钉在脊柱侧凸矫形术中的应用效果。[方法]2008～2010年采用后路胸椎椎弓根螺钉技术治疗特发性和先天性脊柱侧凸患者26例。根据术后临床表现、矫正率和术后X线片判定胸椎椎弓根螺钉置钉情况,对胸椎椎弓根螺钉在脊柱侧凸矫形术中的应用效果进行评价。[结果]本组病例术后平均矫正率为63.81%,术后患者脊柱长度平均增加6.2 cm;术后X线片判定置入的308枚胸椎椎弓根螺钉中,置钉不良率为16.9%;所有患者术后均无胸部脏器及神经系统损伤表现。[结论]在脊柱侧凸临床治疗中,采用胸椎椎弓根螺钉进行侧凸矫形是有效、安全的方式。     

徒手胸椎椎弓根螺钉置入技术治疗青少年特发性脊柱侧凸的安全性评价

目的 评价徒手胸椎椎弓根螺钉置入技术治疗青少年特发性脊柱侧凸的安全性。方法从2002年7月～2004年6月对38例青少年特发性脊柱侧凸患者，徒手应用胸椎椎弓根螺钉进行后路矫形内固定，所有患者术中进行神经电生理监测及X线透视确认，术后进行X线成像、CAT扫描评估螺钉位置，并对其中35例进行随访，从而评价本技术的安全性。结果共置入胸椎椎弓根螺钉326个，每一水平置入的螺钉数如下：T1,n=2；T2，n=10;T3，n=19；T4，n=27；L，n=28；T6，n=24；T7，n=23；TB，n=25；T9，n=29；T10,n=34；T11,n=48；T12，n=57。通过胸椎CT扫描评价326枚置入畸形胸椎的螺钉位置。共有19枚螺钉（5．8％）有中等程度的皮质穿破，即螺钉的中线在椎弓根壁皮质之外，其中6枚螺钉（1．8％）穿破椎弓根内侧壁。对35例患者进行术后跟踪随访，平均随访时间2年，未发现任何与置入的胸椎椎弓根螺钉（全部326枚螺钉）相关的神经、血管或内脏并发症。结论遵循严格步骤，逐步置入胸椎椎弓根螺钉的徒手技术在治疗青少年特发性脊柱侧凸中具有可靠的安全性。     

胸椎椎弓根螺钉置入位置的CT评价

目的:探讨胸椎椎弓根螺钉置入的准确性和安全性。方法:对37例胸椎椎弓根螺钉内固定患者术后行CT断层扫描,观察螺钉在椎弓根内的位置,记录螺钉穿透骨壁的位置、数目和距离。结果:37例患者共置入405枚胸椎椎弓根螺钉,124枚螺钉(30.61%)穿透骨壁,其中76枚(18.77%)穿透椎弓根外侧壁,32枚(7.90%)穿透椎弓根内侧壁,16枚(3.95%)穿透椎体前壁。66枚(16.30%)穿透距离<2mm,37枚(9.14%)穿透距离在2mm~4mm之间,21枚(5.9%)穿透距离>4mm。结论:胸椎椎弓根螺钉骨壁穿透率较高,应严格按照胸椎椎弓根螺钉置入方法,仔细操作,避免出现因螺钉置入不当造成神经、血管或内脏损伤等并发症。     

万向椎弓根螺钉在重度脊柱侧后凸中的应用

[目的]分析和总结万向椎弓根螺钉在治疗重度脊柱侧凸患者手术矫形中的疗效.[方法]回顾性分析了2008年3月～2009年4月期间本科使用万向椎弓根内手术矫形的66例重度脊柱侧凸病人的临床资料,其中男性25例,女性41例;平均18.2岁.侧凸主弯Cobb角平均113.4°(80°～165°),后凸角度平均90.5°(49°～165°),旋转Ⅱ-Ⅳ度.手术行后路矫形38例,截骨矫形28例,其中二期手术矫形13例.[结果]全部病例均安全完成矫形手术,手术时间3.5～6.5 h,平均5.6 h,出血450～3 300 ml,平均1 577 ml.术后出现一过性单侧下肢不全瘫1例,给予甲强龙冲击、神经营养治疗3个月后完全恢复.术后侧凸Cobb角平均42.9°,矫形率62.1%,后凸角度平均32.3°,矫形率64.3%,身高平均增长8.9 cm.[结论]万向椎弓根螺钉是治疗重度脊柱侧凸的安全有效的方法,具有良好的矫形率.     

术中三维影像脊柱导航引导半椎体切除及椎弓根螺钉置入矫治儿童先天性脊柱侧后凸畸形

目的:探讨术中实时三维影像脊柱导航引导下后路椎弓根螺钉置入及半椎体切除矫治儿童先天性脊柱侧后凸畸形的临床疗效。方法:自2010年5月~2013年4月,对18例儿童先天性半椎体脊柱侧后凸畸形患者进行术中实时三维影像脊柱导航引导下进行脊柱矫形手术。其中,男7例,女11例,年龄7.6±2.9岁。术中在实时三维影像脊柱导航引导下经后路置入椎弓根螺钉并切除半椎体后进行矫形。术后通过CT评价椎弓根螺钉位置及半椎体切除情况,术前、术后摄脊柱正侧位X线片,评价矫形效果。结果:手术时间216±55min,术中出血量732±378ml。18例患者共置入椎弓根螺钉127枚(4~12枚/例)。术后CT证实124枚椎弓根螺钉位置准确,置钉准确率97.6%;1枚椎弓根螺钉穿破椎弓根内侧皮质,2枚椎弓根螺钉穿破椎弓根外侧皮质。1例出现椎弓根螺钉切割,1例出现血气胸,置入胸腔闭式引流。无神经损伤并发症病例,无螺钉误置而引起的并发症。术后CT证实18例患者半椎体均完整切除。18例中有16例获得随访,随访时间18.5±8.0个月。16例术前测量冠状面节段性侧凸Cobb角44.5°±11.4°,术后为9.3°±4.7°,末次随访时为9.7°±5.0°,矫正率为(78.2±7.8)%。节段性后凸Cobb角术前测量为32.2°±7.3°,术后为7.2°±3.5°,末次随访节时为7.7°±3.9°,矫正率为(76±9.4)%。侧凸及后凸矫正与术前相比均有统计学意义(P0.01)。末次随访时16例患者均获得骨性融合。结论:术中实时三维影像脊柱导航引导经后路矫治先天性脊柱侧后凸畸形半椎体切除完整,置入椎弓根螺钉准确率高,安全性高,畸形矫正效果满意。     

青少年脊柱侧凸矫正术中胸椎椎弓根螺钉植入技术

[目的]探讨在青少年脊柱侧凸矫正术中胸椎椎弓根螺钉植入的力学基础及解剖学基础,并总结胸椎椎弓根螺钉植入的临床经验。[方法]应用胸腰椎椎弓根螺钉系统治疗青少年脊柱侧凸,通过比较手术前后冠状面矢状面Cobb′s角、顶椎移位、顶椎旋转的变化进行疗效评价。[结果]本组57例,随诊12~41个月,术前冠状面Cobb′s角平均67·8°,术后平均21·2°;矢状面畸形胸后突术前Cobb′s角平均51°,术后31·7°,平背畸形术前Cobb′s角平均10°,术后26·7°;顶椎旋转术前平均3·4°,术后1·7°;顶椎移位术前平均47mm,术后14·5mm。[结论]胸椎椎弓根螺钉贯穿脊柱三柱,能有效地控制整个椎体,具有三维固定和矫正功能,是一项矫正力强且安全可靠的技术,有利于对僵硬侧凸的矫正和控制。     

脊柱侧凸外科治疗中的胸椎椎弓根螺钉置入技术

在脊柱侧凸的外科治疗中,胸椎椎弓根螺钉固定技术经过10余年的不断完善,目前正在逐渐受到重视。椎弓根螺钉可同时固定畸形椎体的三柱,增加了把持力,便于去旋转、撑开、加压等矫形操作。通过对正常和畸形胸椎椎弓根形态及椎弓根螺钉置入技术的研究和改进,目前已经提出了几种相对成熟的胸椎椎弓根螺钉置入技术,在脊柱侧凸的矫形实践中验证是可行的,综述如下。1胸椎椎弓根螺钉技术的发展Roy-Camille(1986年)首先将椎弓根螺钉技术用于治疗胸椎骨折,并总结了技术要点。此方法得到了普遍接受,也带来了一些问题。该方法相对简单,其进钉点为通过下…     

漏斗技术结合探针技术置入胸椎椎弓根螺钉在脊椎畸形矫形术中的应用

目的 探讨应用漏斗技术结合探针技术置入胸椎椎弓根螺钉在脊椎畸形矫形术中的实用性和安全性。方法 12例脊椎畸形患者接受了后路矫形固定术,在手术矫形过程中,胸椎椎弓根螺钉的置入均采用“漏斗技术结合探针技术”,记录术中和术后并发症;术后常规复查X线片和CT,记录穿出骨皮质螺钉数目及距离。结果 采用“漏斗技术结合探针技术”共置入胸椎椎弓根螺钉129枚,术后复查CT见129枚螺钉中2枚穿透椎弓根内侧壁,3枚螺钉穿破外侧壁;1枚螺钉穿透椎体前壁。Heary分级,其置钉准确性达96.12%。结论 在脊椎畸形矫形术中,应用“漏斗技术结合探针技术”置入胸椎椎弓根螺钉的方法是实用的、安全的。     

Accuracy of pedicle screw placement for upper and middle thoracic pathologies without coronal plane spinal deformity using conventional methods

There is a growing interest in the implantation of pedicle screws into the middle and upper thoracic spine. However, usage of the technique is still under debate for these levels because the pedicles in these regions are small and exhibit a high degree of inter- and intraspecimen variability. Twenty-four consecutive patients treated for upper and middle thoracic pathologies by pedicle screw instrumentation under biplanar or uniplanar fluoroscopy were evaluated retrospectively. The rate of screw misplacement on postoperative computerized tomography and complications caused by misplaced screws were determined. In 24 cases, a total of 113 upper-middle thoracic pedicle screws were inserted. Fifty-one of them were inserted between T2 and T5 with guidance of biplanar fluoroscopy, and 62 were inserted between T6 and T8 with uniplanar fluoroscopy. The rate of misplacement was 20.3% for 113 screws (27.4% for T2 to T5 screws, and 14.5% for 62 T6 to T8 screws). Four screws were incorrectly inserted which could have clinical significance (3.5%), and 1 of them required revision. The difference between the upper and middle thoracic screws was not statistically significant (P=0.089). Screw insertion with laminectomy did not cause significant difference in both upper and middle thoracic regions. Only 2 complications were seen because of screw insertion. Pedicle screw insertion with guidance of fluoroscopy may be a reliable and safe method for upper and middle thoracic pathologies.     

Accuracy and safety of thoracic pedicle screw placement in spinal deformities

OBJECTIVES: To determine the safety of pedicle screw fixation in thoracic spine deformity correction. METHODS: One hundred twelve pedicle screws were surgically placed in 25 patients with degenerative, posttraumatic, and Scheuermann kyphosis and idiopathic and neuromuscular scoliosis. Screw position was evaluated using intraoperative and postoperative radiographs and thin-slice computed tomography. RESULTS: Of the total 112 thoracic pedicle screws that were inserted, 98 screws (87.5%) were fully contained within the cortical boundaries of the pedicle. When comparing proximal screws (T1-T8) with distal screws (T9-T12) and convex placed screws with concave ones, a statistically significant difference in screw placement was evident (P < 0.05). More misplaced screws were seen proximally and on the concave side. Of the 14 malpositioned screws, 2 (1.8%) demonstrated aortic abutment. There were no neurologic deficits, vascular injuries, or mechanical failures recorded. CONCLUSIONS: Placement of thoracic pedicle screws is both feasible and safe.     

Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosis

Pedicle screw fixation is a challenging procedure in thoracic spine, as inadvertently misplaced screws have high risk of complications. The accuracy of pedicle screws is typically defined as the screws axis being fully contained within the cortices of the pedicle. One hundred and eighty-five thoracic pedicle screws in 19 patients that were drawn from a total of 1.797 screws in 148 scoliosis patients being suspicious of medial and lateral malpositioning were investigated, retrospectively. Screw containment and the rate of misplacement were determined by postoperative axial CT sections. Medial screw malposition was measured between medial pedicle wall and medial margin of the pedicle screw. The distance between lateral margin of the pedicle screw and lateral vertebral corpus was measured in lateral malpositions. A screw that violated medially greater than 2 mm, while lateral violation greater than 6 mm was rated as an “unacceptable screw”. The malpositions were medial in 20 (10.8%) and lateral in 34 (18.3%) screws. Medially, nine screws were rated as acceptable. Of the 29 acceptable lateral misplacement, 13 showed significant risk; five to aorta, six to pleura, one to azygos vein and one to trachea. The acceptability of medial pedicle breach may change in each level with different canal width and a different amount of cord shift. In lateral acceptable malpositions, the aorta is always at a risk by concave-sided screws. This CT-based study demonstrated that T4–T9 concave segments have a smaller safe zone with respect to both cord-aorta injury in medial and lateral malpositions. In these segments, screws should be accurate and screw malposition is to be unacceptable.     

低龄儿童脊柱侧凸矫正术中椎弓根螺钉置入的精确性和安全性评估

目的:评估10岁及以下脊柱侧凸患儿侧凸矫正术中椎弓根螺钉置入的精确性及安全性,并分析其相关影响因素。方法:回顾性分析2008年2月~2008年7月我院收治的行后路椎弓根螺钉固定的10岁及以下脊柱侧凸41例患儿的临床资料,所有患者术前、术后均行CT检查,男26例,女15例,年龄2~10岁,平均5.4岁。先天性脊柱侧凸36例,特发性脊柱侧凸2例,神经肌肉源性脊柱侧凸2例,先天性软骨发育不全伴脊柱侧凸1例。术中根据解剖标志徒手置入椎弓根螺钉。在PACS系统上通过Pacs Client软件测量螺钉尖距椎弓根内壁、外壁、上壁、下壁以及椎体前缘的距离。若左侧椎弓根螺钉穿破椎弓根外壁或椎体前缘,测量钉尖与主动脉的距离。根据椎弓根螺钉所在位置(节段、凹凸侧、脊椎发育是否异常)分析其破壁率差别。不良置钉定义为椎弓根螺钉穿破椎弓根内、外壁或椎体前缘的距离超过2mm,和椎弓根螺钉进入椎间孔或穿破终板进入椎间盘。结果:本组病例共置入242枚椎弓根螺钉,胸椎128枚,腰椎114枚,平均每例患者置入5.8枚螺钉。螺钉完全在椎弓根内208枚,占86.0%。破壁34枚(占14.0%),其中不良置钉18枚(占7.4%),18枚中有5枚穿破外壁,8枚穿破内壁,5枚穿破椎体前缘。形态异常椎和凹侧的椎弓根螺钉的破壁率较高(分别为24.1%和17.9%)。术中一枚螺钉拔出,未出现其他螺钉置入相关并发症。穿破椎体前缘螺钉距离主动脉距离平均2.3mm。结论:10岁及以下儿童椎弓根螺钉的徒手置入有较高的精确性和安全性,但在发育不良椎体及凹侧置钉时应谨慎。     

Prospective evaluation of thoracic pedicle screw placement using fluoroscopic imaging

BACKGROUND: In this prospective 18-month study, 29 patients underwent posterior thoracic instrumentation with placement of 209 transpedicular screws guided by intraoperative fluoroscopic imaging and anatomic landmarks. We assessed the safety, accuracy, complications, and early stability of this technique. METHODS: Pedicle and pedicle-rib units were measured, and screw cortical penetrations were graded on anatomy and depth of penetration. All 29 patients underwent preoperative computed tomographic (CT) imaging, and 28 underwent postoperative CT imaging (199/209 screws). RESULTS: From T2 to T12, screw diameters were >or=5 mm with mean medial screw angulation measuring 20-25 degree. Of the 209 screws placed from T1 to T12, 111 had diameters greater than or equal to the pedicle width. From T3 to T9, the mean diameter of the pedicle screws exceeded the mean pedicle width. Lateral pedicle wall penetration occurred significantly more often than superior, inferior, and medial pedicle wall penetrations and anterolateral vertebral body penetration. Five of six high-risk screw penetrations occurred in one patient when intraoperative technique was compromised. We observed no new postoperative neurologic deficits, visceral injuries, or pedicle screw instrumentation failures. The three high-risk anterolateral vertebral body penetrations at T1 and T2 were associated with a significantly decreased mean screw transverse angle; the three high-risk medial pedicle wall penetrations occurring from T3 to T9 were associated with a significantly increased mean screw transverse angle. Among all 26 patients available at postoperative follow-up (mean 11.9 months), the mean loss of kyphosis correction was 2.0 degree. CONCLUSIONS: Guided by intraoperative fluoroscopic imaging and anatomic landmarks, thoracic pedicle screws can be placed safely. Early clinical follow-up reveals excellent results with minimal loss of kyphosis correction.     

胸椎椎弓根置钉技术研究进展

胸椎椎弓根螺钉固定系统具有良好的三柱固定效果,近年在脊柱矫形及重建方面得到广泛运用。胸椎椎弓根解剖结构特殊,且毗邻重要血管神经,其置钉安全性一直备受关注。最早由Roy-Camille提出的徒手法置钉技术及后来出现的经椎弓根-肋骨间置钉技术、漏斗置钉技术,都存在不同程度的椎弓根壁穿透率。随着近年计算机辅助导航技术的发展,提高置钉准确性显得尤为重要。该文就胸椎椎弓根解剖特点及置钉技术方法,作一综述。     

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.     

3D打印定位导航模板辅助置钉在脊柱畸形矫形术中的应用

目的　探讨3D打印定位导航模板辅助置钉在脊柱畸形矫形术中应用的可行性,并评估置钉的准确性与安全性。方法 回顾性分析2020年4月—2021年4月北京大学深圳医院收治的因脊柱畸形接受3D定位导航模板辅助置钉矫形术治疗的9例患者临床资料。通过术前规划确定钉道和螺钉尺寸,所有患者术中均使用3D打印定位导航模板辅助置钉,术后复查CT平扫及三维重建,采用Mobbs-Raley分级对螺钉位置进行评估,并分析置钉相关并发症发生情况。结果 所有手术顺利完成。共置入椎弓根螺钉118枚,其中34枚穿破椎弓根皮质,9枚穿破椎体外缘。0级螺钉75枚,1级螺钉24枚,2级螺钉19枚,置钉准确率为63.6%,置钉安全率为83.9%。所有患者均未发生神经、血管损伤等相关并发症,无患者行翻修手术。结论 3D打印定位导航模板辅助置钉在脊柱畸形矫形术中有良好的应用价值,置钉准确性和安全性较高。