3D打印导航模板与计算机导航辅助置入C_2椎弓根和侧块螺钉的对比研究
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摘要
目的比较3D打印导航模板辅助C_2椎弓根和侧块螺钉置钉与计算机导航辅助置钉准确性和安全性的差异,探讨3D打印导板在C_2螺钉置钉中的应用价值。方法纳入我院采用C_2椎弓根螺钉和C_2侧块螺钉后路内固定患者64例,根据辅助螺钉置入方法的不同分为3D打印导航模板置钉组(A组)和计算机导航置钉组(B组),其中A组又分A1(导板置入C_2椎弓根螺钉)、A2(导板置入C_2侧块螺钉)两个亚组;B组又分B1(导航置入C_2椎弓根螺钉)、B2(导航置入C_2侧块螺钉)两个亚组。A组:纳入我院2015年6月至2018年9月采用3D打印导板置钉患者32例,其中男21例,女11例;年龄27～64岁,平均(47.2±11.1)岁。B组:纳入我院2014年1月至2018年9月采用计算机导航置钉患者32例,其中男19例,女13例;年龄25～60岁,平均(45.6±10.4)岁。所有患者术前均行颈椎X线、CT、MRI及CTA。记录并比较两组患者疾病类型、置钉时间、术中出血量、术中透视次数、术前、术后3 d、术后6个月的VAS评分及JOA评分。所有患者术后均行颈椎CT平扫,按照Hlubek等提出的新的C_2螺钉分级标准、根据CT结果分别记录并比较两组的置钉准确率及相关并发症的发生率。结果两组中A组置钉时间、术中透视次数均优于B组,差异有统计学意义(P<0.05),术中出血量比较差异无统计学意义(P>0.05)。两组术前视觉模拟评分(visual analogue scale,VAS)和日本矫形外科协会(Japanese orthopedic association,JOA)评分差异无统计学意义(P>0.05),术后3 d及术后6个月两组的VAS评分和JOA评分较术前均明显改善,差异有统计学意义(P<0.05),组间比较差异无统计学意义(P>0.05)。两组中A组共置入C_2螺钉64枚,A级置钉精确率为95.31%,其中A1组共置入52枚,A级置钉精确率为96.15%;A2组共置入12枚,A级置钉精确率为91.67%。B组共置入C_2螺钉64枚,A级置钉精确率为84.38%,其中B1组共置入50枚,A级置钉精确率为84.00%;B2组共置入14枚,A级置钉精确率为85.71%。A组与B组置钉准确率差异有统计学意义(P=0.041),A1组与B1组置钉精确率差异有统计学意义(P=0.039);A2组与B2组置钉精确率差异无统计学意义(P=0.636)。两组均无置钉相关的血管、神经并发症发生。结论虽然3D打印导航模板与计算机导航辅助置入C_2椎弓根、侧块螺钉均能提供较高的准确性、安全性和临床疗效,但导板技术在C_2椎弓根螺钉置入准确率方面更优于导航技术。
Objective To compare the accuracy and safety of 3 D printing navigation template and computer navigation-assisted C_2 pedicle and pars screws placement and explore the advantages of the 3 D printing template based C_2 screws placement.Methods 64 patients who underwentthe C_2 pedicle screws and C_2 pars screws insertion in our hospital were included.According to the different methods of screw placement,they were divided into the 3 D printing navigation template group(group A) and the computer navigation group(group B).Group A was divided into two subgroups:A1(C_2 pedicle screw) and A2(C_2 parsscrew);Group B was divided into B1(C_2 pedicle screw) and B2(C_2 parsscrew).Group A consisted of 32 patients,including 21 males and 11 females with a mean age of 47.2±11.1 years(27～64 years).All patients were treated with 3 D printing navigation template between June 2015 and September 2018.Group B consisted of 32 patients,including 19 males and 13 females with a mean age of 45.6±10.4 years(25～60 years).All patients were treated with the computer navigation between January 2014 and September 2018.All patients underwent cervical X-ray,CT,MRI and CTA before surgery.The disease types,nail placement time,intraoperative blood loss,intraoperative fluoroscopy frequency were compared between the two groups.Besides,the VAS score and JOA score were compared before operation,3 days after operation,and 6 months after operation.All patients undertook cervical CT scan after surgery,and the accuracy of screw placement and the incidence of related complications in the two groups were compared according to Hlubek's new C2 screw grading standard and CT results.Results In the two groups,the time of screw placement and intraoperative fluoroscopy in group A were better than that in group B,and the difference was statistically significant(P<0.05).The difference of intraoperative blood loss was not statistically significant(P>0.05).There was no significant difference in preoperative VAS score and JOA score between the two groups(P>0.05),and VAS and JOA scores were significantly improved 3 days after surgery and 6 months after surgery,with statistically significant differences(P<0.05).There was no significant difference between the two groups(P>0.05).64 C2 screws were implanted in group A,and the accuracy rate of grade A was 95.31%,among which 52 screws were implanted in group A1,and the accuracy rate of grade A was 96.15%.12 screws were implanted in group A2,and the accuracy rate of grade A was 91.67%.64 C2 screws were implanted in group B,and the accuracy rate of grade A was 84.38%,among which 50 screws were implanted in group B1,and the accuracy rate of grade A was 84.00%.14 screws were implanted in group B2,and the accuracy rate of grade A was 85.71%.The accuracy of screw placement between group A and group B was statistically significant(P=0.041),and the accuracy of screw placement between group A1 and group B1 was statistically significant(P=0.039).There was no significant difference between group A2 and group B2(P=0.636).There were no complications of blood vessel and nerve related to nail placement in both groups.Conclusion Although the placement of C2 pedicle screws and C2 pars screws by 3 Dprinting navigation template and computer navigation implantation can provide higher accuracy,safety and clinical efficacy.The guide template technology is better than the navigation technology in the accuracy of C2 pedicle screw implantation.
Objective To compare the accuracy and safety of 3 D printing navigation template and computer navigation-assisted C_2 pedicle and pars screws placement and explore the advantages of the 3 D printing template based C_2 screws placement.Methods 64 patients who underwentthe C_2 pedicle screws and C_2 pars screws insertion in our hospital were included.According to the different methods of screw placement,they were divided into the 3 D printing navigation template group(group A) and the computer navigation group(group B).Group A was divided into two subgroups:A1(C_2 pedicle screw) and A2(C_2 parsscrew);Group B was divided into B1(C_2 pedicle screw) and B2(C_2 parsscrew).Group A consisted of 32 patients,including 21 males and 11 females with a mean age of 47.2±11.1 years(27～64 years).All patients were treated with 3 D printing navigation template between June 2015 and September 2018.Group B consisted of 32 patients,including 19 males and 13 females with a mean age of 45.6±10.4 years(25～60 years).All patients were treated with the computer navigation between January 2014 and September 2018.All patients underwent cervical X-ray,CT,MRI and CTA before surgery.The disease types,nail placement time,intraoperative blood loss,intraoperative fluoroscopy frequency were compared between the two groups.Besides,the VAS score and JOA score were compared before operation,3 days after operation,and 6 months after operation.All patients undertook cervical CT scan after surgery,and the accuracy of screw placement and the incidence of related complications in the two groups were compared according to Hlubek's new C2 screw grading standard and CT results.Results In the two groups,the time of screw placement and intraoperative fluoroscopy in group A were better than that in group B,and the difference was statistically significant(P<0.05).The difference of intraoperative blood loss was not statistically significant(P>0.05).There was no significant difference in preoperative VAS score and JOA score between the two groups(P>0.05),and VAS and JOA scores were significantly improved 3 days after surgery and 6 months after surgery,with statistically significant differences(P<0.05).There was no significant difference between the two groups(P>0.05).64 C2 screws were implanted in group A,and the accuracy rate of grade A was 95.31%,among which 52 screws were implanted in group A1,and the accuracy rate of grade A was 96.15%.12 screws were implanted in group A2,and the accuracy rate of grade A was 91.67%.64 C2 screws were implanted in group B,and the accuracy rate of grade A was 84.38%,among which 50 screws were implanted in group B1,and the accuracy rate of grade A was 84.00%.14 screws were implanted in group B2,and the accuracy rate of grade A was 85.71%.The accuracy of screw placement between group A and group B was statistically significant(P=0.041),and the accuracy of screw placement between group A1 and group B1 was statistically significant(P=0.039).There was no significant difference between group A2 and group B2(P=0.636).There were no complications of blood vessel and nerve related to nail placement in both groups.Conclusion Although the placement of C2 pedicle screws and C2 pars screws by 3 Dprinting navigation template and computer navigation implantation can provide higher accuracy,safety and clinical efficacy.The guide template technology is better than the navigation technology in the accuracy of C2 pedicle screw implantation.
引文
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[6]Pham MH,Joshua B,Reid PC,et al.Evaluation of C2pedicle screw placement via the freehand technique by neurosurgical trainees[J].J Neurosurg Spine,2018,29(3):235-240.
[7]Yang YL,Zhou DS,He JL.Comparison of isocentric C-arm 3-dimensional navigation and conventional fluoroscopy for C1lateral mass and C2pedicle screw placement for atlantoaxial instability[J].J Spinal Disord Tech,2013,26(3):127-134.
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[10]Goel A,Laheri V.Plate and screw fixation for atlanto-axial subluxation[J].Acta Neurochir,1994,129(1-2):47-53.
[11]Wajanavisit W,Lertudomphonwanit T,Fuangfa P,et al.Prevalence of high-riding vertebral artery and morphometry of C2pedicles using a novel computed tomography reconstruction technique[J].Asian Spine J,2016,10(6):1141-1148.
[12]Elliott RE,Tanweer O,Boah A,et al.Comparison of safety and stability of C2pars and pedicle screws for atlantoaxial fusion:meta-analysis and review of the literature[J].J Neurosurg Spine,2012,17(6):577-593.
[13]王兴文,陈赞,吴浩,等.不适合枢椎椎弓根螺钉植入的颅颈交界区后路螺钉固定方法的选择[J].中华神经外科杂志,2013,29(9):867-870.
[14]Tian W,Liu Y,Zheng S,et al.Accuracy of lower cervical pedicle screw placement with assistance of distinct navigation systems:a human cadaveric study[J].Eur Spine J,2013,22(1):148-155.
[15]Li FN,Huang X,Wang K,et al.Preparation and assessment of an individualized navigation template for lower cervical anterior transpedicular screw insertion using a three-dimensional printing technique[J].Spine,2018,43(6):E348-E356.
[16]蒲兴魏,罗春山,邱冰,等.改良3D打印导航模板辅助寰枢椎椎弓根螺钉置钉的准确性分析[J].中国脊柱脊髓杂志,2017,27(8):686-691.
[17]Sugawara T,Kaneyama S,Higashiyama N,et al.Prospective multicenter study of a multistep screw insertion technique using patient-specific screw guide templates for the cervical and thoracic spine[J].Spine,2018,43(23):1685-1694.
[18]Yu Z,Zhang G,Chen X,et al.Application of a novel3Ddrill template for cervical pedicle screw tunnel design:a cadaveric study[J].Eur Spine J,2017,26(9):2348-2356.
[19]吴超,邓佳燕,谭伦,等.复合型3D打印导航模板辅助枢椎椎弓根或椎板置钉的临床研究[J].中国脊柱脊髓杂志,2018,28(11):982-988.
[20]Singh PK,Garg K,Sawarkar D,et al.Computed tomography-guided C2 pedicle screw placement for treatment of unstable hangman fractures.[J].Spine,2014,39(18):1058-1065.
[21]Lu T,Liu C,Dong J,et al.Cervical screw placement using rapid prototyping drill templates for navigation:a literature review[J].Int J Comput Assist Radiol Surg,2016,11(12):2231-2240.
[22]Patton AG,Morris RP,Kuo YF,et al.Accuracy of fluoroscopy versus computer-assisted navigation for the placement of anterior cervical pedicle screws[J].Spine,2015,40(7):404-410.
[23]Zhang G,Yu Z,Chen X,et al.Accurate placement of cervical pedicle screws using 3D-printed navigational templates:An improved technique with continuous image registration[J].Orthopade,2018,47(5):428-436.
[24]Lu S,Xu YQ,Zhang YZ,et al.A novel computer-assisted drill guide template for placement of C2laminar screws[J].Eur Spine J,2009,18(9):1379-1385.
[25]Deng T,Jiang M,Lei Q,et al.The accuracy and the safety of individualized 3Dprinting screws insertion templates for cervical screw insertion[J].Comput Assist Surg,2016,21(1):143-149.
[26]王飞,刘志斌,张建华,等.3D打印导航模板在辅助寰枢椎椎弓根螺钉置入中的应用价值[J].中国脊柱脊髓杂志,2017,27(1):61-68.
[27]陈德健,罗叙文,姚浩群,等.3D打印导板在寰枢椎椎弓根置钉中的应用价值[J].中国骨与关节损伤杂志,2019,34(3):266-267.
[2]Yeom JS,Buchowski JM,Kim HJ,et al.Risk of vertebral artery injury:comparison between C1~C2transarticular and C2 pedicle screws[J].Spine J,2013,13(7):775-785.
[3]Su BW,Shimer AL,Chinthakunta S,et al.Comparison of fatigue strength of C2pedicle screws,C2pars screws and a hybrid construct in C1~C2fixation[J].Spine,2014,39(1):12-19.
[4]Bydon M,Mathios D,Macki M,et al.Accuracy of C2pedicle screw placement using the anatomic freehand technique[J].Clin Neurol Neurosurg,2014,125(10):24-27.
[5]Punyarat P,Riew KD,Klawson BT,et al.Freehand technique for C2pedicle and pars screw placement:safe or not?[J].Spine J,2018,18(7):1197-1203.
[6]Pham MH,Joshua B,Reid PC,et al.Evaluation of C2pedicle screw placement via the freehand technique by neurosurgical trainees[J].J Neurosurg Spine,2018,29(3):235-240.
[7]Yang YL,Zhou DS,He JL.Comparison of isocentric C-arm 3-dimensional navigation and conventional fluoroscopy for C1lateral mass and C2pedicle screw placement for atlantoaxial instability[J].J Spinal Disord Tech,2013,26(3):127-134.
[8]Kaneyama S,Sugawara T,Sumi M,et al.A novel screw guiding method with a screw guide template system for posterior C-2fixation:clinical article[J].J Neurosurg Spine,2014,21(2):231-238.
[9]Lee SH,Park DH,Kim SD,et al.Analysis of 3-Dimensional course of the intra-axial vertebral artery for C2 pedicle screw trajectory[J].Spine,2014,39(17):1010-1014.
[10]Goel A,Laheri V.Plate and screw fixation for atlanto-axial subluxation[J].Acta Neurochir,1994,129(1-2):47-53.
[11]Wajanavisit W,Lertudomphonwanit T,Fuangfa P,et al.Prevalence of high-riding vertebral artery and morphometry of C2pedicles using a novel computed tomography reconstruction technique[J].Asian Spine J,2016,10(6):1141-1148.
[12]Elliott RE,Tanweer O,Boah A,et al.Comparison of safety and stability of C2pars and pedicle screws for atlantoaxial fusion:meta-analysis and review of the literature[J].J Neurosurg Spine,2012,17(6):577-593.
[13]王兴文,陈赞,吴浩,等.不适合枢椎椎弓根螺钉植入的颅颈交界区后路螺钉固定方法的选择[J].中华神经外科杂志,2013,29(9):867-870.
[14]Tian W,Liu Y,Zheng S,et al.Accuracy of lower cervical pedicle screw placement with assistance of distinct navigation systems:a human cadaveric study[J].Eur Spine J,2013,22(1):148-155.
[15]Li FN,Huang X,Wang K,et al.Preparation and assessment of an individualized navigation template for lower cervical anterior transpedicular screw insertion using a three-dimensional printing technique[J].Spine,2018,43(6):E348-E356.
[16]蒲兴魏,罗春山,邱冰,等.改良3D打印导航模板辅助寰枢椎椎弓根螺钉置钉的准确性分析[J].中国脊柱脊髓杂志,2017,27(8):686-691.
[17]Sugawara T,Kaneyama S,Higashiyama N,et al.Prospective multicenter study of a multistep screw insertion technique using patient-specific screw guide templates for the cervical and thoracic spine[J].Spine,2018,43(23):1685-1694.
[18]Yu Z,Zhang G,Chen X,et al.Application of a novel3Ddrill template for cervical pedicle screw tunnel design:a cadaveric study[J].Eur Spine J,2017,26(9):2348-2356.
[19]吴超,邓佳燕,谭伦,等.复合型3D打印导航模板辅助枢椎椎弓根或椎板置钉的临床研究[J].中国脊柱脊髓杂志,2018,28(11):982-988.
[20]Singh PK,Garg K,Sawarkar D,et al.Computed tomography-guided C2 pedicle screw placement for treatment of unstable hangman fractures.[J].Spine,2014,39(18):1058-1065.
[21]Lu T,Liu C,Dong J,et al.Cervical screw placement using rapid prototyping drill templates for navigation:a literature review[J].Int J Comput Assist Radiol Surg,2016,11(12):2231-2240.
[22]Patton AG,Morris RP,Kuo YF,et al.Accuracy of fluoroscopy versus computer-assisted navigation for the placement of anterior cervical pedicle screws[J].Spine,2015,40(7):404-410.
[23]Zhang G,Yu Z,Chen X,et al.Accurate placement of cervical pedicle screws using 3D-printed navigational templates:An improved technique with continuous image registration[J].Orthopade,2018,47(5):428-436.
[24]Lu S,Xu YQ,Zhang YZ,et al.A novel computer-assisted drill guide template for placement of C2laminar screws[J].Eur Spine J,2009,18(9):1379-1385.
[25]Deng T,Jiang M,Lei Q,et al.The accuracy and the safety of individualized 3Dprinting screws insertion templates for cervical screw insertion[J].Comput Assist Surg,2016,21(1):143-149.
[26]王飞,刘志斌,张建华,等.3D打印导航模板在辅助寰枢椎椎弓根螺钉置入中的应用价值[J].中国脊柱脊髓杂志,2017,27(1):61-68.
[27]陈德健,罗叙文,姚浩群,等.3D打印导板在寰枢椎椎弓根置钉中的应用价值[J].中国骨与关节损伤杂志,2019,34(3):266-267.