构建3D椎体模型比较经皮椎体后凸成形与经皮椎体成形治疗胸腰椎压缩性骨折的力学变化
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摘要
背景:老年人胸腰椎骨折与一般骨折相比有不同的病理变化,多伴有其他全身疾患。较常用的手术方法为经皮椎体成形和经皮椎体后凸成形,不同的术式选择与术后再骨折发生率有关,而如何选择有效的内固定系统及治疗方式对减少老年胸腰椎骨折手术固定失败至关重要。目的:在3D椎体模型上构建压缩性骨折胸腰椎模型,分析腰椎压缩性骨折的力学变化特点。方法:选择1例56岁男性腰痛患者(后确诊为腰肌劳损),椎体形态无明显异常;1例54岁男性由于骨质疏松导致的胸腰椎压缩性骨折患者,2例患者对实验方案知情同意,且得到医院伦理委员会批准,均获取T_(12)-L_1节段CT资料。根据腰痛志愿者CT数据,利用Mimics 10.0软件建立椎体3D数字模型,利用三维有限元分析软件Ansys 12.0建立椎体3D实体模型。参照骨折患者资料对正常椎体有限元模型中的L_1模拟椎体压缩性骨折,并在此基础上模拟经皮椎体后凸成形和经皮椎体成形手术过程,记录不同载荷下模型各部分Von Mises应力以及变形。结果与结论:(1)与其他作者体外生物力学测试实验结果比较,此模型的实验结果与其基本一致(P> 0.05);(2)经皮椎体后凸成形模型在直立及前屈、后伸、侧弯及右旋荷载下,T_(12)与L_1节段变形均显著小于术前及经皮椎体成形模型(P <0.05);经皮椎体成形模型的骨折节段T_(12)与L_1在各种荷载下的脊椎变形与术前差异无显著性意义(P> 0.05);(3)经皮椎体后凸成形模型骨折节段T_(12)与L_1在直立及前屈、后伸、侧弯及右旋荷载下的最大应力较术前及经皮椎体成形模型显著减小(P <0.05);经皮椎体成形模型的骨折节段T_(12)与L_1在各种荷载下最大应力与术前差异无显著性意义(P> 0.05);(4)提示经皮椎体后凸成形在直立及前屈、后伸、侧弯及右旋荷载下,T_(12)与L_1节段变形及应力均显著小于术前的压缩性骨折模型及经皮椎体成形治疗模型,表明经皮椎体后凸成形可显著增加脊柱胸腰段刚度,经皮椎体成形对于胸腰段刚度无明显影响。
BACKGROUND: Compared with general fractures, thoracolumbar fractures in the elderly have different pathological changes and are often accompanied by other systemic diseases. Percutaneous vertebroplasty and percutaneous kyphoplasty are the most commonly used surgical methods. The choice of different surgical methods is related to the incidence of re-fracture after operation. How to choose an effective internal fixation system and surgical methods is very important to reduce the failure of surgical treatment of thoracolumbar fractures in the elderly. OBJECTIVE: To study and compare the finite element mechanics of lumbar vertebral compression fracture by establishing 3D vertebral digital model and thoracolumbar compression fracture model. METHODS: A 56-year-old male patient with low back pain(later diagnosed as lumbar muscle strain) had no abnormal vertebral shape and a 54-year-old male patient with thoracolumbar vertebral compression fracture induced by osteoporosis were selected in this study. The two patients signed informed consent. This study was approved by the Hospital Ethics Committee. CT data of T_(12)-L_1 segments were obtained. Based on CT data of volunteers with low back pain, a three-dimensional digital model of vertebral body was established by using Mimics 10.0 software. Three-dimensional finite element analysis software Ansys 12.0 was used to establish the three-dimensional solid model of the vertebral body. L_1 of vertebral compression fracture in finite element model of normal vertebral body was simulated with reference to fracture patient data. On this basis, the procedures of percutaneous vertebroplasty and percutaneous kyphoplasty were simulated to record Von Mises stresses and the deformation of different parts of the model under different loads. RESULTS AND CONCLUSION:(1) Compared with the results of in vitro biomechanical test, the experimental results of this model were basically consistent with those of in vitro(P > 0.05).(2) Under vertical and forward bending, backward extension, lateral bending and right-handed loads, the deformations of T_(12) and L_1 were significantly smaller in percutaneous kyphoplasty models than those of preoperative compressive fracture models and percutaneous vertebroplasty treatment models(P < 0.05). There was no significant difference in the spinal deformations of T_(12)-L_1 under various loads between percutaneous vertebroplasty models and preoperative models(P > 0.05).(3) The maximum stress of T_(12) and L_1 was significantly lower in percutaneous kyphoplasty models than in preoperative models and percutaneous vertebroplasty models under vertical and forward bending, backward extension, lateral bending and right-handed loads(P < 0.05). There was no significant difference in the maximum stress of T_(12) and L_1 between percutaneous vertebroplasty models and preoperative models under various loads(P > 0.05).(4) The deformation and stress of T_(12) and L1 segments of percutaneous kyphoplasty models were significantly less than those of preoperative compressive fracture models and percutaneous vertebroplasty models under vertical and forward bending, backward extension, lateral bending and right-handed loads. These suggest that percutaneous kyphoplasty can significantly increase the thoracolumbar stiffness of the spine, while percutaneous vertebroplasty has no significant effect on the thoracolumbar stiffness.
BACKGROUND: Compared with general fractures, thoracolumbar fractures in the elderly have different pathological changes and are often accompanied by other systemic diseases. Percutaneous vertebroplasty and percutaneous kyphoplasty are the most commonly used surgical methods. The choice of different surgical methods is related to the incidence of re-fracture after operation. How to choose an effective internal fixation system and surgical methods is very important to reduce the failure of surgical treatment of thoracolumbar fractures in the elderly. OBJECTIVE: To study and compare the finite element mechanics of lumbar vertebral compression fracture by establishing 3D vertebral digital model and thoracolumbar compression fracture model. METHODS: A 56-year-old male patient with low back pain(later diagnosed as lumbar muscle strain) had no abnormal vertebral shape and a 54-year-old male patient with thoracolumbar vertebral compression fracture induced by osteoporosis were selected in this study. The two patients signed informed consent. This study was approved by the Hospital Ethics Committee. CT data of T_(12)-L_1 segments were obtained. Based on CT data of volunteers with low back pain, a three-dimensional digital model of vertebral body was established by using Mimics 10.0 software. Three-dimensional finite element analysis software Ansys 12.0 was used to establish the three-dimensional solid model of the vertebral body. L_1 of vertebral compression fracture in finite element model of normal vertebral body was simulated with reference to fracture patient data. On this basis, the procedures of percutaneous vertebroplasty and percutaneous kyphoplasty were simulated to record Von Mises stresses and the deformation of different parts of the model under different loads. RESULTS AND CONCLUSION:(1) Compared with the results of in vitro biomechanical test, the experimental results of this model were basically consistent with those of in vitro(P > 0.05).(2) Under vertical and forward bending, backward extension, lateral bending and right-handed loads, the deformations of T_(12) and L_1 were significantly smaller in percutaneous kyphoplasty models than those of preoperative compressive fracture models and percutaneous vertebroplasty treatment models(P < 0.05). There was no significant difference in the spinal deformations of T_(12)-L_1 under various loads between percutaneous vertebroplasty models and preoperative models(P > 0.05).(3) The maximum stress of T_(12) and L_1 was significantly lower in percutaneous kyphoplasty models than in preoperative models and percutaneous vertebroplasty models under vertical and forward bending, backward extension, lateral bending and right-handed loads(P < 0.05). There was no significant difference in the maximum stress of T_(12) and L_1 between percutaneous vertebroplasty models and preoperative models under various loads(P > 0.05).(4) The deformation and stress of T_(12) and L1 segments of percutaneous kyphoplasty models were significantly less than those of preoperative compressive fracture models and percutaneous vertebroplasty models under vertical and forward bending, backward extension, lateral bending and right-handed loads. These suggest that percutaneous kyphoplasty can significantly increase the thoracolumbar stiffness of the spine, while percutaneous vertebroplasty has no significant effect on the thoracolumbar stiffness.
引文
[1]笪巍伟,唐德志,舒冰,等.原发性骨质疏松症及椎体压缩性骨折的防治进展[J].广东医学,2016,37(11):1714-1717.
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[3]粟迎春.经皮椎体成形术和经皮椎体后凸成形术治疗骨质疏松性椎体压缩骨折的疗效[J].实用医学杂志,2017,40(2):74-75.
[4]宋仁谦,周英杰,赵刚,等.高黏度骨水泥经皮椎体成形术与经皮椎体后凸成形术治疗骨质疏松压缩骨折的临床疗效观察[J].中国矫形外科杂志,2016,24(8):692-696.
[5]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.
[6]Nakashima D,Kanchiku T,Nishida N,et al.Finite element analysis of compression fractures at the thoracolumbar junction using models constructed from medical images.Exp Ther Med.2018;15(4):3225-3230.
[7]Liu Y,Xu J,Sun D,et al.Biomechanical and finite element analyses of bone cement‐Injectable cannulated pedicle screw fixation in osteoporotic bone.J Biomed Mater Res B Appl Biomater.2016104(5):960-967.
[8]崔志刚,张德光,刘福全.PVP与PKP治疗骨质疏松性胸腰椎体骨折的疗效对比[J].重庆医学,2017,46(21):2971-2974.
[9]Hedayati Z,Shomali M.Maxillary anterior en masse retraction using different antero-posterior position of mini screw:a 3D finite element study.Prog Orthod.2016;17(1):31.
[10]El-Anwar M,Ghali R,Aboelnagga M.3D finite element study on:bar splinted implants supporting partial denture in the reconstructed mandible.Open Access Maced J Med Sci.2016;4(1):164-171.
[11]王吉博.有限元法评估经皮椎体成形和后凸成形治疗脊柱三明治骨折的生物力学变化[J].中国组织工程研究,2017,21(35):5703-5708.
[12]Shamami DZ,Karimi A,Beigzadeh B,et al.A 3D finite element study for stress analysis in bone tissue around single implants with different materials and various bone qualities.J Biom Tissue Eng.2014;4(8):632-637.
[13]林娟颖,刘晓颖,邢立杰,等.基于有限元法的跟骨生物力学分析[J].医用生物力学,2018,33(1):37-41.
[14]周伟,刘贵省,周丽萍,等.不同方式灌注骨水泥治疗骨质疏松性椎体压缩骨折的比较[J].中国组织工程研究,2017,21(14):2147-2152.
[15]Cheong VS,Blunn GW,Coathup MJ,et al.A novel adaptive algorithm for 3D finite element analysis to model extracortical bone growth.Comput Methods Biomech Biomed Engin.2018;21(2):129-138.
[16]张立峰,张元智,华子恺,等.髋臼前柱顺行拉力螺钉固定钉道的设计及有限元分析[J].中华骨科杂志,2017,37(5):276-283.
[17]潘元星,米川,施学东,等.经皮椎体成形术治疗多发性骨髓瘤患者椎体多发病理骨折44例临床分析[J].解放军医学杂志,2016,41(11):945-948.
[18]高琨,杨隆秋,胡美琴,等.脊柱微创术治疗症状性椎体血管瘤合并腰椎间盘突出症[J].中国矫形外科杂志,2018,26(21):2003-2006.
[19]李大明,徐丽军.经皮椎体成形术治疗老年骨质疏松性胸腰椎压缩性骨折的疗效[J].重庆医学,2017,2(46):322-324.
[20]李坤,梅继文,胡守力,等.PVP联合RFA对骨质疏松性椎体压缩性骨折患者术后疼痛及生活质量的影响[J].山东医药,2017,57(46):83-85.
[21]马俊.经皮椎体后凸成形术与经皮椎体成形术治疗骨质疏松椎体压缩骨折的疗效比较[J].中国矫形外科杂志,2017,25(6):571-573.
[22]许正伟,贺宝荣,郝定均,等.胸腰椎骨质疏松性骨折经皮椎体成形术后骨水泥渗漏的研究进展[J].中华骨科杂志,2016,36(17):1142-1148.
[23]唐冲,吴四军,刘正,等.高粘度骨水泥经皮椎体成形术治疗骨质疏松性椎体压缩骨折的疗效分析[J].中国脊柱脊髓杂志,2017,27(8):720-726.
[24]Feng L,Feng C,Chen J,et al.The risk factors of vertebral refracture after kyphoplasty in patients with osteoporotic vertebral compression fractures:a study protocol for a prospective cohort study.BMC Musculoskelet Disord.2018;19(1):195-202.
[25]李穗鸥,杨波,尹飚,等.经皮椎体成形术或经皮后凸成形术治疗合并脊柱侧凸的脊柱压缩性骨折[J].中国微创外科杂志,2018,18(3):244-248.
[26]包拥政,祝周兴,冯云升,等.低弹性模量骨水泥对骨质疏松压缩性骨折椎体及邻近椎体应力的影响:三维有限元分析[J].中国组织工程研究,2016,20(16):2285-2293.
[27]唐勇涛,魏思奇,吴长军,等.PKP不同增强方式对相邻椎体结构生物力学影响的有限元分析[J].中国骨科临床与基础研究杂志,2017,9(3):167-174.
[28]王志鹏,张晓刚,赵文韬,等.有限元分析在腰椎手法治疗中的生物力学研究进展[J].医用生物力学,2017,32(3):293-298.
[29]Sharma A,Sargar K,Salter A.Temporal evolution of disc in young patients with low back pain and stress reaction in lumbar vertebrae.Ajnr Am J Neuroradiol.2017;38(8):1647-1652.
[30]郭秀珍,高斌礼,林森,等.基于PVP和PKP的脊柱骨折的有限元生物力学研究[J].基因组学与应用生物学,2018,37(2):497-504.
[2]Wang H,Sribastav SS,Ye F,et al.Comparison of percutaneous vertebroplasty and balloon kyphoplasty for the treatment of single level vertebral compression fractures:a meta-analysis of the literature.Pain Physician.2015;18(3):209.
[3]粟迎春.经皮椎体成形术和经皮椎体后凸成形术治疗骨质疏松性椎体压缩骨折的疗效[J].实用医学杂志,2017,40(2):74-75.
[4]宋仁谦,周英杰,赵刚,等.高黏度骨水泥经皮椎体成形术与经皮椎体后凸成形术治疗骨质疏松压缩骨折的临床疗效观察[J].中国矫形外科杂志,2016,24(8):692-696.
[5]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.
[6]Nakashima D,Kanchiku T,Nishida N,et al.Finite element analysis of compression fractures at the thoracolumbar junction using models constructed from medical images.Exp Ther Med.2018;15(4):3225-3230.
[7]Liu Y,Xu J,Sun D,et al.Biomechanical and finite element analyses of bone cement‐Injectable cannulated pedicle screw fixation in osteoporotic bone.J Biomed Mater Res B Appl Biomater.2016104(5):960-967.
[8]崔志刚,张德光,刘福全.PVP与PKP治疗骨质疏松性胸腰椎体骨折的疗效对比[J].重庆医学,2017,46(21):2971-2974.
[9]Hedayati Z,Shomali M.Maxillary anterior en masse retraction using different antero-posterior position of mini screw:a 3D finite element study.Prog Orthod.2016;17(1):31.
[10]El-Anwar M,Ghali R,Aboelnagga M.3D finite element study on:bar splinted implants supporting partial denture in the reconstructed mandible.Open Access Maced J Med Sci.2016;4(1):164-171.
[11]王吉博.有限元法评估经皮椎体成形和后凸成形治疗脊柱三明治骨折的生物力学变化[J].中国组织工程研究,2017,21(35):5703-5708.
[12]Shamami DZ,Karimi A,Beigzadeh B,et al.A 3D finite element study for stress analysis in bone tissue around single implants with different materials and various bone qualities.J Biom Tissue Eng.2014;4(8):632-637.
[13]林娟颖,刘晓颖,邢立杰,等.基于有限元法的跟骨生物力学分析[J].医用生物力学,2018,33(1):37-41.
[14]周伟,刘贵省,周丽萍,等.不同方式灌注骨水泥治疗骨质疏松性椎体压缩骨折的比较[J].中国组织工程研究,2017,21(14):2147-2152.
[15]Cheong VS,Blunn GW,Coathup MJ,et al.A novel adaptive algorithm for 3D finite element analysis to model extracortical bone growth.Comput Methods Biomech Biomed Engin.2018;21(2):129-138.
[16]张立峰,张元智,华子恺,等.髋臼前柱顺行拉力螺钉固定钉道的设计及有限元分析[J].中华骨科杂志,2017,37(5):276-283.
[17]潘元星,米川,施学东,等.经皮椎体成形术治疗多发性骨髓瘤患者椎体多发病理骨折44例临床分析[J].解放军医学杂志,2016,41(11):945-948.
[18]高琨,杨隆秋,胡美琴,等.脊柱微创术治疗症状性椎体血管瘤合并腰椎间盘突出症[J].中国矫形外科杂志,2018,26(21):2003-2006.
[19]李大明,徐丽军.经皮椎体成形术治疗老年骨质疏松性胸腰椎压缩性骨折的疗效[J].重庆医学,2017,2(46):322-324.
[20]李坤,梅继文,胡守力,等.PVP联合RFA对骨质疏松性椎体压缩性骨折患者术后疼痛及生活质量的影响[J].山东医药,2017,57(46):83-85.
[21]马俊.经皮椎体后凸成形术与经皮椎体成形术治疗骨质疏松椎体压缩骨折的疗效比较[J].中国矫形外科杂志,2017,25(6):571-573.
[22]许正伟,贺宝荣,郝定均,等.胸腰椎骨质疏松性骨折经皮椎体成形术后骨水泥渗漏的研究进展[J].中华骨科杂志,2016,36(17):1142-1148.
[23]唐冲,吴四军,刘正,等.高粘度骨水泥经皮椎体成形术治疗骨质疏松性椎体压缩骨折的疗效分析[J].中国脊柱脊髓杂志,2017,27(8):720-726.
[24]Feng L,Feng C,Chen J,et al.The risk factors of vertebral refracture after kyphoplasty in patients with osteoporotic vertebral compression fractures:a study protocol for a prospective cohort study.BMC Musculoskelet Disord.2018;19(1):195-202.
[25]李穗鸥,杨波,尹飚,等.经皮椎体成形术或经皮后凸成形术治疗合并脊柱侧凸的脊柱压缩性骨折[J].中国微创外科杂志,2018,18(3):244-248.
[26]包拥政,祝周兴,冯云升,等.低弹性模量骨水泥对骨质疏松压缩性骨折椎体及邻近椎体应力的影响:三维有限元分析[J].中国组织工程研究,2016,20(16):2285-2293.
[27]唐勇涛,魏思奇,吴长军,等.PKP不同增强方式对相邻椎体结构生物力学影响的有限元分析[J].中国骨科临床与基础研究杂志,2017,9(3):167-174.
[28]王志鹏,张晓刚,赵文韬,等.有限元分析在腰椎手法治疗中的生物力学研究进展[J].医用生物力学,2017,32(3):293-298.
[29]Sharma A,Sargar K,Salter A.Temporal evolution of disc in young patients with low back pain and stress reaction in lumbar vertebrae.Ajnr Am J Neuroradiol.2017;38(8):1647-1652.
[30]郭秀珍,高斌礼,林森,等.基于PVP和PKP的脊柱骨折的有限元生物力学研究[J].基因组学与应用生物学,2018,37(2):497-504.