C2/3经关节突经椎弓根螺钉固定的影像学测量及可行性分析

目的 测量C_2/3经关节突经椎弓根螺钉相关影像学指标,并分析该置钉技术的可行性。方法 收集120例全颈椎CT薄层扫描数据,其中男性75例,女性45例。设定C_2/3经关节突经椎弓根螺钉的进钉点,即进钉点在枢椎侧块的水平中线与中外1/3垂线交点处,螺钉自枢椎侧块穿C_2/3关节突关节、C₃侧块止于C₃椎弓根下缘。测量C_2/3经关节突经椎弓根螺钉相关影像学数据,包括C₃椎弓根宽度与高度,螺钉通道长度,内倾角度,头倾角度,最狭窄处宽度。并分析各项测量结果之间的关系。结果 C₃椎弓根平均宽度5.48 mm,平均高度6.82 mm,螺钉通道平均长度18.68 mm,平均内倾角度20.46°,平均头倾角度50.1°,最狭窄处平均宽度2.80 mm。C₃椎弓根宽度与高度呈正相关(P=0.000),螺钉通道长度与C₃椎弓根宽度、高度呈正相关(P=0.000;P=0.000),螺钉通道最狭窄...     

枢椎椎弓根内固定的解剖学研究

目的通过标本测量,研究以下关节突中心点为入钉点,枢椎椎弓根螺钉的进钉方法及要点。方法50枚人尸体骨干骨标本,以下关节突中心点A为进针点,在枢椎腹侧测量椎弓根的内倾角α;在椎弓背侧,选择上关节突内缘C点为标志点,测量AC连线的冠状面内倾角β,探讨α与β的相关性。结果枢椎腹侧测量的椎弓根冠状面内倾角为43°±4°(左侧),45°±5°(右侧),均值44°±6°;枢椎背侧测量的下关节突中心点A与上关节面内缘点C的连线内倾角β为39°±5°(左侧),37°±6°(右侧),均值38°±7°;α,β差值平均为5°±2°。结论①椎椎弓根部的解剖特点决定了其椎弓根螺钉的进入方向必须非常精确,否则很容易穿出椎弓根内外壁,造成椎动脉或脊髓的损伤;②枢椎下关节中心点与上关节面内缘点的连线对于确定合理的钉道方向具有较好的参考价值。     

腰椎弓根延长术截骨部位与神经根关系的解剖学研究

目的　观察腰椎弓根延长术截骨部位与其毗邻神经根的解剖关系,为腰椎弓根延长术离断椎弓根提供解剖数据。  方法　16例成人防腐脊柱标本, 自T12~S1去除软组织、棘突、椎板、关节突关节、横突, 充分暴露硬膜囊、神经根和腰椎弓根, 精细磨削椎弓根至椎弓根-椎体连接处,测量该部位椎弓根上缘至上位神经根下缘的间距(PSRD),椎弓根下缘至下位神经根上缘的间距(PIRD),椎弓根内缘至硬膜囊外缘或内侧神经根外缘的间距(PMRD),椎弓根外缘至外位神经根内缘的间距(PLRD),所有解剖参数都做双侧测量。  结果　腰椎弓根至上、下、内、外神经根的间距范围分别是4.9~8.6 mm,1.0~2.5 mm,0~1.6 mm,0.7~11.5 mm,左、右两侧数据无显著性差异(P>0.05),男、女之间数据无显著性差异(P>0.05)。  结论　腰椎弓根截骨延长时,截骨部位的内缘和下缘毗邻的神经根相对于上缘和外缘损伤可能性大,透视下对椎弓根内缘和下缘截骨时要十分小心。     

CT测定胸腰椎椎弓根进钉点与TSA及其在术中的应用

目的：通过术前CT测定胸腰椎椎弓根进钉点及水平椎弓根钉植入角（transverse screw angle,TSA），为术中椎弓根置钉操作提供一参照数据。方法：本组22例病人术前均行CT扫描，以关节突下缘为参照物，测定椎弓根进钉点的横线；以关节突外侧缘为参照物，测定椎弓根进钉点的纵线，从而确定了椎弓根进钉点，并测定TSA。结果：22例病人共置钉88枚，最高为T80，最低为L1，术后X光片及CT复查螺钉位置准确。结论：以关节突为参照物，通过术前CT测定椎弓根进钉点为TSA指导中置钉操作，有简便，直观及可靠的优点。     

上中胸椎椎弓根-肋单位的CT测量及临床意义

目的:通过对上、中胸椎椎弓根—肋单位的CT测量,探索胸椎弓根外螺钉技术的安全性和可行性。方法:选择20例阴性结果的胸椎CT扫描图像,男16例,女4例,平均年龄48.8岁,对T1～T8测量下列解剖指标:椎弓根横径,椎弓根钉道长度,椎弓根—肋单位横径,椎弓根外螺钉钉道长度,椎弓根外螺钉内倾角,椎弓根外螺钉最大内倾角,椎弓根外螺钉最小内倾角。结果:胸椎弓根—肋单位横径(12.97～18.88)mm明显大于胸椎弓根横径(5.03～8.67)mm,胸椎弓根外螺钉钉道长度(46.05～61.47)mm明显长于胸椎弓根螺钉钉道长度(36.92～41.74)mm,椎弓根外螺钉内倾角从T1～T8有递减趋势,且均有一个相对安全的误差区间。结论:胸椎弓根外螺钉技术安全性高于胸椎弓根螺钉技术,使用是安全可行的。     

青少年胸腰椎关节突形态研究及意义

目的:为临床提供青少年关节突及椎管相关的解剖学测量数据.方法:年龄在14～19岁(平均16.5岁)25例原配完整的胸腰椎(T1～L5)标本,分别测量卜关节突内缘中点间距、下关节突内缘中点间距、下关节突根部外缘宽度、椎弓根内缘间距和椎管前后径,并与成人数据比较.结果:上、下关节突间距、椎弓根内缘间距和上关节突内缘间距/椎弓根内缘间距由上到下都旱两边高中间低的"马鞍形"变化趋势而椎孔前后径呈逐渐上升的趋势;上关节突内缘中点间距与下关节突内缘间距相关系数为0.92,下关节突内缘间距与下关节突根部外缘间宽度相关系数为0.83.结论:14～19岁青少年以上测量数据与成人数据均无显著性差异,并有一定的变化规律,为临床青少年脊柱椎管狭窄的诊断和治疗提供一定参考;上关节突内缘中点间距总是小于椎弓根内缘间距,中、下胸段椎弓根螺钉间距要小于上胸段和腰段.     

经胸椎肋横突结合区椎弓根外螺钉固定的解剖学研究

目的:为经胸椎肋横突结合区椎弓根外螺钉固定手术提供影像解剖学参数.方法:对50个正常成人的T1～10肋横突结合区进行CT扫描,测量肋横突结合区人路的长度、宽度、高度、内倾角度及下倾角度,并与椎弓根入路对比,数据经统计学处理.根据测量结果设置各椎体入路穿钉参数,在3具成人防腐尸体标本T1～10共30个胸椎体上进行模拟手术,穿钉后CT扫描.结果:肋横突结合区入路进钉长度(59.05±0.83)mm、宽度(15.03±0.73)mm、高度(10.36±1.28)mm、内倾角度(34.53±0.21)°及下倾角度(12.95±1.58)°均大于椎弓根入路进钉长度(45.51±0.56)mm、宽度(5.98±0.78)mm、高度(5.35±0.61)mm、内倾角度(12.31±2.05)°及下倾角度(2.85±1.07)°,差异有统计学意义(P<0.05);根据测量结果设置进钉入路参数,30个胸椎体60枚螺钉均位于肋横突结合区,未见穿入椎管、椎间孔和胸腔.结论:胸椎肋横突结合区螺钉内固定,在解剖学上是可行的,尤其对椎弓根发育畸形和狭窄者,具有安全、可靠、容易定位等优点,为胸椎后路螺钉固定的选位提供参考.     

枢椎椎弓根及峡部的临床解剖学观察

目的:明确枢椎椎弓根及峡部的解剖部位,指导枢椎后路螺钉的临床应用。方法:成人C2干燥骨标本30具,C3干燥骨标本10具,以横突孔周围结构为重点,进行枢椎形态比较学观察;测量枢椎椎弓根轴线在下关节突背侧的坐标点。结果:C2的下方结构与C3下方的表面解剖结构接近,枢椎上方结构与C3相比较,上关节突移向齿突的外下方,并使峡部拉长前移,其轴向角度为11.1°±2.4°;枢椎椎弓根轴向角度为42.6°±4.9°,椎弓根轴线-下关节突背侧关节突上缘的交点坐标O与下关节突上缘-中垂线交点O’基本重合。结论:枢椎上下关节突之间的部分,应为峡部和椎弓根的复合体,复合体的上部较为扁平的部分为峡部,其中下部分位于横突孔内后侧的半管柱状结构为椎弓根部,连接着椎体和下关节突。     

12～14岁青少年第1～10胸椎经椎弓根和肋椎单元固定相关解剖学指标测量及临床意义

目的：探讨12～14 岁青少年经“椎弓根- 肋椎单元”螺钉固定、经“椎弓根”螺钉内固定在解剖学上置钉 的可行性。方法：选取12～14 岁青少年胸椎行螺旋CT扫描后三维重建,观测经肋椎单元固定和经椎弓根固定的 形态结构,测量其横径、长度、内倾角、置钉安全角度范围,并进行统计分析。结果：胸椎经“椎弓根固定”相 关指标如下：横径随椎序的增加呈先减少后增加趋势,左右两侧无显著性差异;螺钉钉道长度随椎序的增加呈逐 渐增大的趋势,左右两侧无显著性差异;螺钉内倾角随椎序的增加呈逐渐减小的趋势,左右两侧无显著性差异; 置钉最小和最大内倾角得出安全角度范围为17°～42°,其中置钉安全范围最大位于第1 胸椎,左右两侧无显著性 差异。胸椎经“椎弓根- 肋椎单元固定”相关指标如下：横径随椎序的增加呈先减少后增加趋势,左右两侧无显 著性差异;钉道长度随椎序的增加呈逐渐增大的趋势,左右两侧无显著性差异;内倾角随椎序的增加呈逐渐减小 的趋势,左右无显著差异;最小和最大内倾角得出安全角度范围为28°～50°,其中置钉安全范围最大位于第1 胸椎, 左右两侧无显著性差异。胸椎经“椎弓根固定”和胸椎经“椎弓根- 肋椎单元固定”2 种方式测量的各项数据均 有显著性差异,且胸椎经“椎弓根- 肋椎单元固定”的各项测量数据明显宽于胸椎经“椎弓根固定”的各项测量 数据。结论：在手术前置钉时,应根据患者术前CT结果,优先选择胸椎经“椎弓根- 肋椎单元固定”。     

椎弓根螺钉入点定位及双侧入点间距的应用测量

目的提供椎弓根螺钉入点定位法及双入点间距的解剖学资料.方法观测螺钉入点并测量双入点间距.结果①螺钉入点分4组,第1组,C2为横突下缘水平线与中外1/4垂线交点处;第2组C3～L1,除C5外均在横突中上水平线与关节突中垂线及中外1/4垂线限定的四边形内.第3组L2～L4在横突中水平线与外缘垂线交点处;第4组L5在横突中水平线与乳突外缘垂线交点处,距关节突外缘垂线(4.8±0.7)mm.②双入点间距L5最大,C5次之而T5～T7最小.结论C3～L3入点多集中在横突中上水平线与关节突中外垂线限定的四边形内,其中C3～C4、C6～L1均在横突中上水平线与关节突中垂线及中外1/4垂线限定的四边形内;双入点间距变化有明显的规律性.     

下颈椎椎弓根置钉偏差的CT多平面及三维重建研究

目的：通过颈椎CT多平面和三维重建资料的观测，了解下颈椎椎弓根螺钉置入的可行性，评价置钉偏差后的风险。方法：对8例非颈椎椎弓根病患者进行颈椎CT多平面和三维重建观察，对C3椎弓根内外径、内倾角及四壁皮质厚度行数据测量。结果：组成横突孔的四界不在同一高度同时出现，形成内界的椎弓根明显高于外界。CT示部分椎弓根外壁及横突孔前壁存在滋养血管孔（10％和8．8％）。C3椎弓根内壁厚（1．8±0．3）mm，，外壁厚（0．9±0．3）mm，上壁厚（1．3±0．4）mm，下壁厚（1．4±0．4）mm，外径（5．3±0．6）mm，内径（2．6±0．7）mm，内倾角（45．9±4．4）°。结论：下颈椎椎弓根内径小，外壁薄，椎弓根螺钉置入时，外壁容易穿破；椎弓根主体高于横突孔外界，椎弓根螺钉穿破外壁时，椎动脉可向外逃逸，减少损伤。     

CT evaluation of cervical pedicle in a Chinese population for surgical application of transpedicular screw placement

The lower cervical pedicle size differs between the Chinese and the non-Chinese population. Knowledge of pedicle dimensions and surface landmarks is crucial for the safe placement of screws, but few quantitative data concerning the lower cervical pedicle using CT scan and multiplanar reformations (MPR) in a Chinese population exist. The aim of this study was to evaluate lower cervical pedicle (C3-C7) dimensions in a Chinese population by computed axial tomography for surgical application. The dimensions of the pedicles (C3-C7) were determined in 60 patients from CT images of cervical spinal lesions. Measurements of pedicle height, width, pedicle axis length, effective length, and two angles of the pedicles, the distances from the projection point of the pedicle axis to the lateral edge of the lateral mass and to the inferior edge of the superior facet were measured. The smallest outer pedicle width was found at C3 among the female and C4 among the male. This measurement was significantly different between male and female patients in the outer pedicle width (P < 0.05; independent samples t test) at C3 and C4. The mean values of the outer pedicle width ranged from 5.4 to 6.7 mm in males, and 4.4 to 6.3 mm in females. The projection point of the pedicle axis in the lateral-superior area of the cervical lateral mass was the most important. There were significant correlations (P < 0.01; Kendall's W test) between the vertebral level and both pedicle angles (PTA and PSA). The smallest pedicle transverse angle was at C7 in males and females. The cervical spinal cord or vertebral artery may be at risk of injury if the angulation of the screw insert is over-medial or over-lateral in the transverse plane. Therefore, preoperative CT evaluation of pedicle transverse angle is very important. Considering the amount of variation among individuals, our data on CT measurements of pedicle in a Chinese population in conjunction with evaluation of the results of preoperative CT may enhance the safety of transpedicular screw fixation in the lower cervical spine.     

Identification of the anterior and posterior portions of the lateral pedicle cortex by roentgenograms in pedicle screw fixation

Forty lumbar pedicles and pedicle screws in four cadavers were used to identify the anterior and posterior portions of the lumbar pedicle cortex by roentgenograms in order to evaluate the penetration of the pedicle cortex by pedicle screws intraoperatively. Firstly, the transverse pedicle angles were measured on roentgenograms. Three roentgenograms were taken on each pedicle in three different directions: (1). medial to the pedicle axis; (2). pedicle axis; (3). lateral to the pedicle axis. They revealed that the anterior portion of the lateral pedicle cortex was demonstrated by the pedicle lateral outline on the roentgenogram medial to the pedicle axis, and the posterior portion by the pedicle lateral outline on the roentgenogram lateral to the pedicle axis. Wire markers were used to confirm these data. Finally, anterior and/or posterior penetrations on the lateral pedicle cortex in pedicle screw fixation were studied by roentgenograms in these cadavers and showed that anterior penetration of lateral cortex was demonstrated by the view medial to the pedicle axis, and posterior penetration by the view lateral to the pedicle axis. It is concluded that projections medical and lateral to the pedicle axis are necessary to identify lateral screw penetration intraoperatively when X-ray checking is used.     

斜方肌各亚部神经分布和神经入肌点定位

目的为斜方肌各亚部的临床应用提供形态学基础。方法①观察30具成尸斜方肌各亚部的神经来源,并定位神经入肌点。②用6具尸体的斜方肌行Sihler’s肌内神经染色,观察肌内神经分布。结果①斜方肌降部入肌点约在斜方肌前缘的上3/4与下1/4交界处,水平部入肌点在锁骨肩峰端外侧缘中点与第7颈椎棘突上缘连线的中点,升部入肌点在肩胛冈内侧端结节与第4胸椎棘突上缘连线的中点。②斜方肌受副神经和颈丛(C2-4)斜方肌支支配,副神经主干在颈后三角和斜方肌降部深面发出1～3支一级分支到斜方肌降部,颈丛斜方肌支加入副神经主干一起在斜方肌水平部深面发出4～6支一级分支到斜方肌水平部,在斜方肌升部深面发出2～5支一级分支到斜方肌升部。斜方肌各亚部的肌腹中部均有一终未神经分支密集区,它们连成一条连续的约呈"S"形的神经分支带。结论斜方肌的降部仅由副神经支配,斜方肌的水平部和升部由副神经与颈神经双重支配。     

Evaluation of thoracic pedicle morphometry in a Chinese population using 3D reformatted CT

The aim of this study was to investigate the detailed three-dimensional morphology of the pedicles from T1 to T12 in 120 Chinese patients using a light-speed Vct CT (General Electric). After reformatting the original images, the following parameters were studied: outer pedicle width (OPW), outer pedicle height (OPH), pedicle chord length (PCL), pedicle cortical thickness (PCT) of the isthmus, and transverse pedicle angle (TPA). The mean outer pedicle width, outer pedicle height, and pedicle chord length were significantly smaller in females than in males at all levels (P < 0.01). The percentage of outer pedicle width ≤ 5.0 mm and ≤ 4.5 mm was high at mid-thoracic pedicles. No significant differences were found in transverse pedicle angle and pedicle cortical thickness in males and females. Pedicle cortical thickness was significantly thinner in patients over 50 years old compared with patients below 50 years old at most levels. The results showed that a screw of larger than 4.5 mm would be too large for mid-thoracic segments in Chinese population, especially for female patients. Considering the amount of variation between individuals and the complicated structure of the thoracic pedicles, the use of the transpedicular screw fixation must be individualized for each patient and based on detailed preoperative assessment. Reformatted CT assessment is essential before this procedure is performed.     

多层螺旋CT三维重建国人下颈椎椎弓根的临床解剖学意义

背景：因颈椎解剖结构复杂以及个体化差异较大,导致颈椎弓根钉置入内固定技术应用受到很大限制。 目的：应用螺旋CT三维重建国人的下颈椎椎弓根,并对重建图像进行测量评估。 方法：对60例需行颈椎CT扫描的患者C₃~C₇进行颈椎CT扫描,使用Syngo应用软件对原始CT图像进行所需面的重建,测量CT重建后的椎弓根各项指标。 结果与结论：颈椎绝大部分椎弓根峡部的宽度小于高度,男性高度和宽度C₄~C₇逐渐增大,女性则从C₃开始逐渐增大。C₃~C₇椎弓根侧块投射点到上关节突下缘的距离并无规律性,而到侧块外缘的距离从头端到尾端是不断增大的。男性与女性的椎弓根水平角在C₇均最小。结果提示,国人女性患者的C₃及C₄椎体行经颈椎椎弓根内固定应谨慎,大部分国人的C₅到C₇椎体是适合行椎弓根内固定的,但考虑到颈椎弓根个体的差异较大,内固定前颈椎弓根的CT扫描及重建后的评估是必要的。     

A novel entry point for pedicle screw placement in the thoracic spine

This study was aimed to introduce a novel entry point for pedicle screw fixation in the thoracic spine and compare it with the traditional entry point. A novel entry point was found with the aim of improving accuracy, safety and stability of pedicle screw technique based on anatomical structures of the spine. A total of 76 pieces of normal thoracic CT images at the transverse plane and the thoracic pedicle anatomy of 6 cadaveric specimens were recruited. Transverse pedicle angle (TPA), screw length, screw placement accuracy rate and axial pullout strength of the two different entry point groups were compared. There were significant differences in the TPA, screw length, and the screw placement accuracy rate between the two groups (P < 0.05). The maximum axial pullout strength of the novel entry point group was slightly larger than that of the traditional group. However, the difference was not significant (P > 0.05). The novel entry point significantly improved the accuracy, stability and safety of pedicle screw placement. With reference to the advantages above, the new entry point can be used for spinal internal fixations in the thoracic spine.     

肩胛背动脉在肩胛骨内侧缘体表投影的解剖学研究

目的　通过对成人肩胛背动脉的解剖学观察及测量,研究从体表标志确定肩胛背动脉走行路线。 方法　解剖尸体26具（共52侧）,显露肩胛背动脉,测量肩胛背动脉直径及其与肩胛骨内侧缘距离,所得数据经SPSS12.0统计软件处理。 结果 肩胛背动脉与肩胛骨上角距离为(0.34±0.25) cm,与肩胛冈内侧端为(1.58±0.41) cm,与肩胛骨下角为(3.45±0.28) cm,得出肩胛背动脉走行于肩胛骨内侧缘内侧,在距离肩胛骨上角0.34 cm、肩胛冈内侧端1.58 cm、肩胛骨下角3.45 cm三点处做一连线,该连线即为肩胛背动脉的体表投影。 结论 肩胛背动脉的体表投影为医务工作者应该掌握的知识要点,可避免操作过程中的动脉损伤,并可为确定肩胛背动脉皮瓣的中轴核心提供解剖学依据。