脊柱阶段性解剖特点及其损伤的力学机制与诊疗策略
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摘要
脊柱在结构支撑、力学传递及神经保护方面发挥着重要的作用。脊柱损伤及其造成的畸形、残疾在现代社会日益引起临床工作者的重视,但由于其解剖结构和损伤的生物力学机制复杂,损伤后往往难以判断其稳定性,为精准的临床治疗带来困难。此外,临床医生少有机会通过常规渠道系统地学习生物力学知识,导致其对脊柱损伤机制及损伤后结构改变所带来的力学影响,认识不深刻,判断不准确,容易造成治疗效果不佳、愈后差等问题。为了简明地了解相关的生理力学特点及损伤机制,本文综述了脊柱的解剖结构和受力时的生物力学特点,并以常见的脊柱骨折为例阐述了颈椎、胸椎、腰椎损伤的发生机制,着重分析了影响脊柱稳定性的相关因素,为临床决策提供理论参考。
The spine plays an important role in structural support, mechanical transmission and neuroprotection. In modern society,spinal injury and its resulting disability have attracted increasing attention from clinical workers. However,due to the complex of anatomical structures and biomechanical mechanism of trauma,it is often difficult to judge its stability after injury,which brings difficulties for accurate clinical treatment. In addition,clinicians seldom have the opportunity to systematically study biomechanics through conventional channels,which makes them cannot sufficiently understand the mechanism of spinal injury and the following structural changes,for which proper treatment and satisfied recovery are never easy to be achieved.To simply review related anatomic and mechanical characteristics,this paper expounds the injury mechanism of cervical vertebra,thoracic vertebra,lumbar and analyzes the related factors which influence the stability of the spine,providing theoretical reference for clinical decision making.
The spine plays an important role in structural support, mechanical transmission and neuroprotection. In modern society,spinal injury and its resulting disability have attracted increasing attention from clinical workers. However,due to the complex of anatomical structures and biomechanical mechanism of trauma,it is often difficult to judge its stability after injury,which brings difficulties for accurate clinical treatment. In addition,clinicians seldom have the opportunity to systematically study biomechanics through conventional channels,which makes them cannot sufficiently understand the mechanism of spinal injury and the following structural changes,for which proper treatment and satisfied recovery are never easy to be achieved.To simply review related anatomic and mechanical characteristics,this paper expounds the injury mechanism of cervical vertebra,thoracic vertebra,lumbar and analyzes the related factors which influence the stability of the spine,providing theoretical reference for clinical decision making.
引文
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[27] Pneumaticos SG,Karampinas PK,Triantafilopoulos G,et al.Evaluation of TLICS for thoracolumbar fractures[J].European Spine J,2016,25(4):1123-1127.
[28] You L,Daming Z,Rui LI.Study of reliability and reproducibility of AO,Denis and TLICS classification systems for thoracolumbar fracture[J].Chinese J Spine Spinal Cord,2011,21(7):566-568.
[29] Joaquim AF,Daubs MD,Lawrence BD,et al.Retrospective evaluation of the validity of the thoracolumbar injury classification system in 458 consecutively treated patients[J].Spine J,2013,13(12):1760-1765.
[30] Schnake KJ,Schroeder GD,Vaccaro AR,et al.AOSpine Classification Systems (Subaxial,Thoracolumbar)[J].J Orthop Trauma,2017,31(S4):S14.
[31] https://www2.aofoundation.org/wps/portal/surgery showPage=diagnosis&bone=Spine&segment/
[32] Reinhold M,Audigé L,Schnake KJ,et al.AO spine injury classification system:a revision proposal for the thoracic and lumbar spine[J].European Spine J,2013,22(10):2184-2201.
[33] Mobbs RJ,Phan K,Malham G,et al.Lumbar interbody fusion:techniques,indications and comparison of interbody fusion options including PLIF,TLIF,MI-TLIF,OLIF/ATP,LLIF and ALIF[J].J Spine Surg,2015,1(1):2.
[34] Xu DS,Walker CT,Godzik J,et al.Minimally invasive anterior,lateral,and oblique lumbar interbody fusion:a literature review[J].Ann Transl Med,2018,6(6):104.
[2] Hayashi K.Clinical anatomy of the cervical spine[M].Cervical Spondylosis And Similar Disorders,2015:15-32.
[3] Rauschning W.Surgical anatomy of the spine,revisited[J].Spine,2017,42(S7):S1.
[4] Munusamy T,Thien A,Anthony MG,et al.Computed tomographic morphometric analysis of cervical pedicles in a multi-ethnic Asian population and relevance to subaxial cervical pedicle screw fixation[J].Eur Spine J,2015,24(1):120-126.
[5] Jones EL,Heller JG,Silcox DH,et al.Cervical pedicle screws versus lateral mass screws.Anatomic feasibility and biomechanical comparison[J].Spine,1997,22(9):977.
[6] Yu CC,Bajwa NS,Toy JO,et al.Pedicle morphometry of upper thoracic vertebrae:an anatomic study of 503 cadaveric specimens[J].Spine,2014,39(20):1201-1209.
[7] Yu CC.Lower thoracic pedicle morphometry:male,taller,and heavier specimens have bigger pedicles[J].Spine,2015,40(6):323-331.
[8] Knez D,Likar B,Pernu? F,et al.Automated determination of pedicle morphometry in the thoracic spine[C]// IEEE,International Symposium on Biomedical Imaging.IEEE,2016:664-667.
[9] Bogduk N.Functional anatomy of the spine[J].Handb Clin Neurol,2016,136:675-688.
[10] Attar A,Ugur HC,Uz A,et al.Lumbar pedicle:surgical anatomic evaluation and relationships[J].European Spine J,2001,10(1):10-15.
[11] Matsukawa K,Yato Y,Nemoto O,et al.Morphometric measurement of cortical bone trajectory for lumbar pedicle screw insertion using computed tomography[J].J Spinal Disord Tech,2013,26(6):E248-253.
[12] Jutte P,Castelein R.Complications of pedicle screws in lumbar and lumbosacral fusions in 105 consecutive primary operations[J].Eur Spine J,2002,11(6):594-598.
[13] Kadow T,Sowa G,Vo N,et al.Molecular basis of intervertebral disc degeneration and herniations:what are the important translational questions[J].Clin Orthop Relat Res,2015,473(6):1-10.
[14] Butt AM,Gill C,Demerdash A,et al.A comprehensive review of the sub-axial ligaments of the vertebral column:part I anatomy and function [J].Childs Nerv Syst,2015,31(7):1037-1059.
[15] Li Y,Shen Z,Huang M,et al.Stepwise resection of the posterior ligamentous complex for stability of a thoracolumbar compression fracture:an in vitro biomechanical investigation[J].Medicine,2017,96(35):e7873.
[16] Vaccaro AR,Jr LR,Hurlbert RJ,et al.A new classification of thoracolumbar injuries:the importance of injury morphology,the integrity of the posterior ligamentous complex,and neurologic status[J].Spine,2005,30(20):2325.
[17] Rupp TK,Ehlers W,Karajan N,et al.A forward dynamics simulation of human lumbar spine flexion predicting the load sharing of intervertebral discs,ligaments,and muscles[J].Biomech Model Mechanobiol,2015,14(5):1-25.
[18] Skotte JH,Essendrop M,Hansen AF,et al.A dynamic 3D biomechanical evaluation of the load on the low back during different patient-handling tasks[J].J Biomech,2002,35(10):1357-1366.
[19] Nabil A.Ebraheim,Ali Hassan,Ming Lee,et al.Functional anatomy of the lumbar spine[J].Seminars Pain Med,2004,2(3):131-137.
[20] Chen H,Shoumura S,Emura S,et al.Regional variations of vertebral trabecular bone microstructure with age and gender[J].Osteoporos Int,2008,19(10):1473-1483.
[21] Thomsen JS,Jensen MV,Niklassen AS,et al.Age-related changes in vertebral and iliac crest 3D bone microstructure-differences and similarities[J].Osteoporos Int,2015,26(1):219-228.
[22] Ciszkiewicz A,Milewski G.A novel kinematic model for a functional spinal unit and a lumbar spine[J].Acta Bioeng Biomech,2016,18(1):87-95.
[23] Wong C,Gehrchen PM,Darvann T,et al.Nonlinear finite-element analysis and biomechanical evaluation of the lumbar spine[J].IEEE Tras Med Imaging,2003,22(6):742-746.
[24] Ohmori K.Clinical application of a novel assessment for lumbosacral stability[J].J Neurosurg Spine,2010,13(2):276.
[25] Denis F.Spinal instability as defined by the three-column spine concept in acute spinal trauma[J].Clini Orthop Relat Res,1984,189(189):65.
[26] Vaccaro AR,Zeiller SC,Hulbert RJ,et al.The thoracolumbar injury severity score:a proposed treatment algorithm[J].J Spinal Disord Tech,2005,18:209-215.
[27] Pneumaticos SG,Karampinas PK,Triantafilopoulos G,et al.Evaluation of TLICS for thoracolumbar fractures[J].European Spine J,2016,25(4):1123-1127.
[28] You L,Daming Z,Rui LI.Study of reliability and reproducibility of AO,Denis and TLICS classification systems for thoracolumbar fracture[J].Chinese J Spine Spinal Cord,2011,21(7):566-568.
[29] Joaquim AF,Daubs MD,Lawrence BD,et al.Retrospective evaluation of the validity of the thoracolumbar injury classification system in 458 consecutively treated patients[J].Spine J,2013,13(12):1760-1765.
[30] Schnake KJ,Schroeder GD,Vaccaro AR,et al.AOSpine Classification Systems (Subaxial,Thoracolumbar)[J].J Orthop Trauma,2017,31(S4):S14.
[31] https://www2.aofoundation.org/wps/portal/surgery showPage=diagnosis&bone=Spine&segment/
[32] Reinhold M,Audigé L,Schnake KJ,et al.AO spine injury classification system:a revision proposal for the thoracic and lumbar spine[J].European Spine J,2013,22(10):2184-2201.
[33] Mobbs RJ,Phan K,Malham G,et al.Lumbar interbody fusion:techniques,indications and comparison of interbody fusion options including PLIF,TLIF,MI-TLIF,OLIF/ATP,LLIF and ALIF[J].J Spine Surg,2015,1(1):2.
[34] Xu DS,Walker CT,Godzik J,et al.Minimally invasive anterior,lateral,and oblique lumbar interbody fusion:a literature review[J].Ann Transl Med,2018,6(6):104.