脊柱结核病灶清除术中单节段短椎弓根钉固定的三维有限元分析
|
摘要
背景:脊柱结核手术治疗中使用单节段短椎弓根钉的方法已经在临床工作中运用,并取得满意的疗效,但这种固定方法的生物力学效能是否可靠,尚未得到理论研究证实。已有的研究虽证实短椎弓根钉能达到可靠的固定效果,但其研究方法局限于动物骨骼体外模拟实验,不能真实反映人体脊柱的生物力学特性。目的:建立T_(12)-L_3脊柱结核病灶彻底清除术后单节段、短椎弓根钉固定的三维有限元模型,对模型进行力学分析,验证此种固定方式维持脊柱的稳定性。方法:选择1例成年健康的男性志愿者,无脊柱疾病史,CT对脊柱行层厚1 mm的连续扫描,导出图像文件数据,以DICOM格式保存。运用Mimics 20.0,Geomagic Studio,Pro/E 5.0软件完成建立3种脊柱椎弓根钉固定模型,运用Abaqus软件进行有限元分析,在模型椎体上端上缘施加500N的轴向垂直压力;在同一受力点上施加10 Nm大小的力矩,使椎体做前屈、后伸、左右侧弯及旋转运动,观察测量轴向位移及最大偏转角度。结果与结论:对3种模型施加同样的荷载及边界条件,结果显示:(1)附加内固定的模型与正常椎体模型之间的结果无显著性差异;(2)在轴向位移方面,单节段短钉与正常椎体模型相差不到10%;(3)在最大偏转角度方面:后伸状态下两模型数据相差最大,单节段模型比正常模型大18%;(4)跨节段长钉固定模型无论在轴向位移还是在最大偏转角度上均低于正常椎体模型;(5)此2种内固定模型之间相比,单节段短钉模型轴向位移比跨节段长钉模型大16%,在最大偏转角度上后伸状态下两种固定模型的相差最大,单节段固定比跨节段多38%,其他状态下数据相差均较小,将2种固定模型行统计学检验,结果比较无显著性差异;(6)结果证实,单节段短椎弓根钉的固定方式能够达到可靠的生物力学效能,能维持脊柱结核病灶彻底清除术后脊柱的即刻稳定性。
BACKGROUND: Single-segment short pedicle screw has been applied in the surgical treatment of spinal tuberculosis in clinical practice and achieves satisfactory efficacy, but whether the biomechanical efficacy of this fixation method is reliable remains unclear. Although existing studies have proven that short pedicle screw can achieve reliable fixation effect, its research method is limited to animal bone in vitro simulation experiment, and cannot truly reflect the biomechanical characteristics of human spine.OBJECTIVE: To establish the three-dimensional finite element model of single-segment short pedicle screw fixation after the complete removal of T_(12)-L_3 spinal tuberculosis foci, and to undergo the mechanical analysis, thereby verifying its spinal stability.METHODS: One healthy adult male volunteer with no history of spinal disease was selected. CT scanning of the 1 mm thick intervertebral layer was performed continuously, and the image data were derived and saved in DICOM format. Mimics 20.0, Geomagic Studio, and Pro/E5.0 software were used to establish three pedicle screw fixation models of the spine. Finite element analysis was performed using Abaqus software. A torque of 10 Nm was applied at the same stress point to make the vertebral body bend forward, extend backward, bend left and right side and rotate, and the axial displacement and the maximum deflection angle were measured.RESULTS AND CONCLUSION: Applying the same load and boundary conditions to the three models, the results showed that:(1) There was no significant difference between the results of the model with additional internal fixation and the normal vertebral body model.(2) In terms of axial displacement, the single-segment short screw was less than 10% different from the normal vertebral body model.(3) In terms of the maximum deflection angle, the data of the two models were the most different in the post-extension state, and the single-segment model was18% larger than the normal model.(4) The cross-segment screw fixation model was lower than the normal vertebral body model in both axial displacement and maximum deflection angle.(5) Compared between two kinds of internal fixation model, single-segment short nail model axial displacement was 16% larger than cross section long nail model. The difference between the two fixed models is the greatest at the maximum deflection angle and the backward extension state. The single-segment fixation was 38% more than cross section, and the difference of data in other states was small. The results of the two fixed line model statistical tests showed no significant difference.(6) These results indicate that the fixation method of single-segment short pedicle screw can achieve reliable biomechanical efficiency and maintain the immediate stability of the spine after the complete removal of the tuberculosis focus in the spine.
BACKGROUND: Single-segment short pedicle screw has been applied in the surgical treatment of spinal tuberculosis in clinical practice and achieves satisfactory efficacy, but whether the biomechanical efficacy of this fixation method is reliable remains unclear. Although existing studies have proven that short pedicle screw can achieve reliable fixation effect, its research method is limited to animal bone in vitro simulation experiment, and cannot truly reflect the biomechanical characteristics of human spine.OBJECTIVE: To establish the three-dimensional finite element model of single-segment short pedicle screw fixation after the complete removal of T_(12)-L_3 spinal tuberculosis foci, and to undergo the mechanical analysis, thereby verifying its spinal stability.METHODS: One healthy adult male volunteer with no history of spinal disease was selected. CT scanning of the 1 mm thick intervertebral layer was performed continuously, and the image data were derived and saved in DICOM format. Mimics 20.0, Geomagic Studio, and Pro/E5.0 software were used to establish three pedicle screw fixation models of the spine. Finite element analysis was performed using Abaqus software. A torque of 10 Nm was applied at the same stress point to make the vertebral body bend forward, extend backward, bend left and right side and rotate, and the axial displacement and the maximum deflection angle were measured.RESULTS AND CONCLUSION: Applying the same load and boundary conditions to the three models, the results showed that:(1) There was no significant difference between the results of the model with additional internal fixation and the normal vertebral body model.(2) In terms of axial displacement, the single-segment short screw was less than 10% different from the normal vertebral body model.(3) In terms of the maximum deflection angle, the data of the two models were the most different in the post-extension state, and the single-segment model was18% larger than the normal model.(4) The cross-segment screw fixation model was lower than the normal vertebral body model in both axial displacement and maximum deflection angle.(5) Compared between two kinds of internal fixation model, single-segment short nail model axial displacement was 16% larger than cross section long nail model. The difference between the two fixed models is the greatest at the maximum deflection angle and the backward extension state. The single-segment fixation was 38% more than cross section, and the difference of data in other states was small. The results of the two fixed line model statistical tests showed no significant difference.(6) These results indicate that the fixation method of single-segment short pedicle screw can achieve reliable biomechanical efficiency and maintain the immediate stability of the spine after the complete removal of the tuberculosis focus in the spine.
引文
[1]Dara M,Dadu A,Kremer K,et al.Epidemiology of tuberculosis in WHO European Region and public health response.Eur Spine J.2013;22 Suppl 4:549-555.
[2]Charosky S,Guigui P,Blamoutier A,et al.Complications and risk factors of primary adult scoliosis surgery:a multicenter study of 306 patients.Spine.2012;37(8):693-700.
[3]O’Shaughnessy BA,Bridwell KH,Lenke LG,et al.Does a long-fusion“T3-sacrum”portend a worse outcome than a shortfusion“T10-sacrum”in primary surgery for adult scoliosis?Spine.2012;37(10):884-890.
[4]Jin WD,Wang Q,Wang ZL.Complete debridement for treatment of thoracolumbar spinal tuberculosis:a clinical curative effect observation.Spine J.2014;14(6):964-970.
[5]武启军,王自立,戈朝晖,等.脊柱单节段前中柱切除后不同节段椎弓根螺钉内固定的稳定性测试[J].中国脊柱脊髓杂志,2010,20(4):267-271.
[6]Dreischarf M,Zander T,Shirazi-Adl A,et al.Comparison of eight published static finite element models of the intact lumbar spine:predictive power of models improves when combined together.J Biomech.2014;47(8):1757-1766.
[7]Salem W,Lenders C,Mathieu J.In vivo three-dimensional kinematics of thecervical spine during maximal axial rotation.Man Ther.2013;18(4):339-344.
[8]John JD,Saravana Kumar G,Yoganandan N.Cervical spine morphology and ligament property variations:a finite element study of their influence on sagittal bending characteristics.JBiomech.2019;85:18-26.
[9]Guan W,Sun Y,Qi X,et al.Spinal biomechanics modeling and finite element analysis of surgical instrument interaction.Comput Assist Surg(Abingdon).2019.doi:10.1080/24699322.2018.1560086.
[10]Kamal Z,Rouhi G,Arjmand N,et al.A stability-based model of a growing spine with adolescent idiopathic scoliosis:a combination of musculoskeletal and finite element approaches.Med Eng Phys.2019;64:46-55.
[11]Xu G,Fu X,Du C.Biomechanical effects of vertebroplasty on thoracolumbar burst fracture with transpedicular fixation:a finite element model analysis.Orthop Traumatol Surg Res.2014;100(4):379-383.
[12]刘强,张军,孙树椿.有限元在脊柱生物力学中的应用[J].中国骨伤,2017,30(2):190-194.
[13]伍骥,郑超,黄蓉蓉.重新认识胸腰段脊柱骨折的诊断和治疗[J].中国骨与关节杂志,2016,5(6):401-404.
[14]王健,李凯,陈博,等.胸腰椎体压缩性骨折三维有限元模型的建立和分析[J].中国矫形外科杂志,2016,24(16):1498-1503。
[15]Kumar MN,Joseph B,Manur R.Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting.Eur Spine J.2013;22(3):624-632.
[16]Sterba M,Aubin Cé,Wagnac E,et al.Effect of impact velocity and ligament mechanical properties on lumbar spine injuries in posterior-anterior impact loading conditions:a finite element study.Med Biol Eng Comput.2019.doi:10.1007/s11517-019-01964-5.
[17]Wu Y,Chen CH,Tsuang FY,et al.The stability oflongsegment and short-segment fixation for treating severe burst fractures at the thoracolumbar junction in osteoporotic bone:a finite element analysis.PLoS One.2019;14(2):e0211676.
[18]Yin H,Wang K,Gao Y,et al.Surgical approach and management outcomes for junction tuberculous spondylitis:aretrospective study of 77 patients.J Orthop Surg Res.2018;13(1):312
[19]Zhou Y,Li W,Liu J,et al.Comparison of single posterior debridement,bone grafting and instrumentation with single-stage anterior debridement,bone grafting and posterior instrumentation in the treatment ofthoracic and thoracolumbar spinal tuberculosis.BMC Surg.2018;18(1):71.
[20]Norton RP,Milne EL,Kaimrajh DN,et al.Biomechanical analysis of four-versus six-screw constructs for short-segment pedicle screw and rod instrumentation of unstable thoracolumbar fractures.2014;14(8):1734-1739.
[21]Wadhwa RK,Thakur JD,Khan IS,et al.Adjustment of suboptimally placed lumbar pedicle screws decreases pullout strength and alters biomechanics of the construct:a pilotcadaveric study.World Neurosurg.2014;2(14):1878-1880.
[22]楚野,梁斌,曾佳兴.腰椎退变性疾病融合术后邻近节段退变的研究进展[J].中国脊柱脊髓杂志,2014,24(2):175-178.
[23]Christiansen PA,La Bagnara M,Sure DR,et al.Complications of surgical intervention in adult lumbar scoliosis.Curr Rev Musculoskelet Med.2016;3(9):281-289.
[24]Smith JS,Klineberg E,Lalage V,et al.Prospective multicenter assessment perioperative and minimum-2-year postoperative complication rates associated with adult spinal deformity surgery.J Neurosurg Spine.2016;25(1):1-14.
[25]张会军,鲁增辉,朱昌生.经病椎短钉内固定术治疗短节段脊柱结核的临床分析[J].中国矫形外科杂志,2018,26(2):178-181.
[26]刘宁,杨波,贺西京.经皮与Wiltse入路短节段椎弓根钉内固定联合伤椎置钉治疗胸腰段脊柱骨折的比较[J].中国骨与关节损伤杂志,2018,33(1):9-12.
[27]Singh S,Kumaraswamy V,Sharma N,et al.Evaluation of role of anterior debridement and decompression of spinal cord and instrumentation in treatment of tubercular spondylitis.Asian Spine J.2012;6(3):183-193.
[28]Liu SH,Deng ZS,Chen J,et al.Surgical treatment for thoracic spinal tuberculosis with intraspinal abscesses by unilateral vertebral lamina limited decompression via posterior-only approach.Zhong Nan Da Xue Xue Bao Yi Xue Ban.2015;40(12):1345-1351.
[29]Kim MW,Lee SB,Park JH.Cervical spondyloptosis successfully treated with only posterior short segment fusion using cervical pedicle screw fixation.Neurol Med Chir(Tokyo).2019;59(1):33-38.
[30]Kim HJ,Kang KT,Chang BS,et al.Biomechanical analysis of fusion segment rigidity upon stress at both the fusion and adjacent segments:a comparison between unilateral and bilateral pedicle screw fixation.Yonsei Med J.2014;55(5):1386-1394.
[2]Charosky S,Guigui P,Blamoutier A,et al.Complications and risk factors of primary adult scoliosis surgery:a multicenter study of 306 patients.Spine.2012;37(8):693-700.
[3]O’Shaughnessy BA,Bridwell KH,Lenke LG,et al.Does a long-fusion“T3-sacrum”portend a worse outcome than a shortfusion“T10-sacrum”in primary surgery for adult scoliosis?Spine.2012;37(10):884-890.
[4]Jin WD,Wang Q,Wang ZL.Complete debridement for treatment of thoracolumbar spinal tuberculosis:a clinical curative effect observation.Spine J.2014;14(6):964-970.
[5]武启军,王自立,戈朝晖,等.脊柱单节段前中柱切除后不同节段椎弓根螺钉内固定的稳定性测试[J].中国脊柱脊髓杂志,2010,20(4):267-271.
[6]Dreischarf M,Zander T,Shirazi-Adl A,et al.Comparison of eight published static finite element models of the intact lumbar spine:predictive power of models improves when combined together.J Biomech.2014;47(8):1757-1766.
[7]Salem W,Lenders C,Mathieu J.In vivo three-dimensional kinematics of thecervical spine during maximal axial rotation.Man Ther.2013;18(4):339-344.
[8]John JD,Saravana Kumar G,Yoganandan N.Cervical spine morphology and ligament property variations:a finite element study of their influence on sagittal bending characteristics.JBiomech.2019;85:18-26.
[9]Guan W,Sun Y,Qi X,et al.Spinal biomechanics modeling and finite element analysis of surgical instrument interaction.Comput Assist Surg(Abingdon).2019.doi:10.1080/24699322.2018.1560086.
[10]Kamal Z,Rouhi G,Arjmand N,et al.A stability-based model of a growing spine with adolescent idiopathic scoliosis:a combination of musculoskeletal and finite element approaches.Med Eng Phys.2019;64:46-55.
[11]Xu G,Fu X,Du C.Biomechanical effects of vertebroplasty on thoracolumbar burst fracture with transpedicular fixation:a finite element model analysis.Orthop Traumatol Surg Res.2014;100(4):379-383.
[12]刘强,张军,孙树椿.有限元在脊柱生物力学中的应用[J].中国骨伤,2017,30(2):190-194.
[13]伍骥,郑超,黄蓉蓉.重新认识胸腰段脊柱骨折的诊断和治疗[J].中国骨与关节杂志,2016,5(6):401-404.
[14]王健,李凯,陈博,等.胸腰椎体压缩性骨折三维有限元模型的建立和分析[J].中国矫形外科杂志,2016,24(16):1498-1503。
[15]Kumar MN,Joseph B,Manur R.Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting.Eur Spine J.2013;22(3):624-632.
[16]Sterba M,Aubin Cé,Wagnac E,et al.Effect of impact velocity and ligament mechanical properties on lumbar spine injuries in posterior-anterior impact loading conditions:a finite element study.Med Biol Eng Comput.2019.doi:10.1007/s11517-019-01964-5.
[17]Wu Y,Chen CH,Tsuang FY,et al.The stability oflongsegment and short-segment fixation for treating severe burst fractures at the thoracolumbar junction in osteoporotic bone:a finite element analysis.PLoS One.2019;14(2):e0211676.
[18]Yin H,Wang K,Gao Y,et al.Surgical approach and management outcomes for junction tuberculous spondylitis:aretrospective study of 77 patients.J Orthop Surg Res.2018;13(1):312
[19]Zhou Y,Li W,Liu J,et al.Comparison of single posterior debridement,bone grafting and instrumentation with single-stage anterior debridement,bone grafting and posterior instrumentation in the treatment ofthoracic and thoracolumbar spinal tuberculosis.BMC Surg.2018;18(1):71.
[20]Norton RP,Milne EL,Kaimrajh DN,et al.Biomechanical analysis of four-versus six-screw constructs for short-segment pedicle screw and rod instrumentation of unstable thoracolumbar fractures.2014;14(8):1734-1739.
[21]Wadhwa RK,Thakur JD,Khan IS,et al.Adjustment of suboptimally placed lumbar pedicle screws decreases pullout strength and alters biomechanics of the construct:a pilotcadaveric study.World Neurosurg.2014;2(14):1878-1880.
[22]楚野,梁斌,曾佳兴.腰椎退变性疾病融合术后邻近节段退变的研究进展[J].中国脊柱脊髓杂志,2014,24(2):175-178.
[23]Christiansen PA,La Bagnara M,Sure DR,et al.Complications of surgical intervention in adult lumbar scoliosis.Curr Rev Musculoskelet Med.2016;3(9):281-289.
[24]Smith JS,Klineberg E,Lalage V,et al.Prospective multicenter assessment perioperative and minimum-2-year postoperative complication rates associated with adult spinal deformity surgery.J Neurosurg Spine.2016;25(1):1-14.
[25]张会军,鲁增辉,朱昌生.经病椎短钉内固定术治疗短节段脊柱结核的临床分析[J].中国矫形外科杂志,2018,26(2):178-181.
[26]刘宁,杨波,贺西京.经皮与Wiltse入路短节段椎弓根钉内固定联合伤椎置钉治疗胸腰段脊柱骨折的比较[J].中国骨与关节损伤杂志,2018,33(1):9-12.
[27]Singh S,Kumaraswamy V,Sharma N,et al.Evaluation of role of anterior debridement and decompression of spinal cord and instrumentation in treatment of tubercular spondylitis.Asian Spine J.2012;6(3):183-193.
[28]Liu SH,Deng ZS,Chen J,et al.Surgical treatment for thoracic spinal tuberculosis with intraspinal abscesses by unilateral vertebral lamina limited decompression via posterior-only approach.Zhong Nan Da Xue Xue Bao Yi Xue Ban.2015;40(12):1345-1351.
[29]Kim MW,Lee SB,Park JH.Cervical spondyloptosis successfully treated with only posterior short segment fusion using cervical pedicle screw fixation.Neurol Med Chir(Tokyo).2019;59(1):33-38.
[30]Kim HJ,Kang KT,Chang BS,et al.Biomechanical analysis of fusion segment rigidity upon stress at both the fusion and adjacent segments:a comparison between unilateral and bilateral pedicle screw fixation.Yonsei Med J.2014;55(5):1386-1394.