经寰椎椎弓根螺钉固定新置钉方法的探索
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摘要
目的本实验研究通过改变寰椎椎弓根螺钉进钉点和进钉角度来获得较好的钉道,以降低临床实践中寰椎椎弓根螺钉置钉的风险。
方法选择福建医科大学和闽东卫校解剖教研室提供的30具成人上颈椎尸体标本,按标本提供的顺序随机分成两组A、B组,每组15个标本。A组按马向阳等介绍的方法(经枢椎侧块内、外缘的中点作纵垂线,与寰椎后弓上缘交点的正下方3.0 mm处即螺钉的进钉点,向内倾斜约10°、上仰约5°置钉。B组依据我们自己提出的方法置钉(较马向阳等提出近钉点偏外2mm,内倾角为20°,上仰5°,同时把寰椎上关节凹后突作为参考标志)。按上述两种方法行寰椎椎弓根钉固定术,手术操作均由同一人完成。术后CT像上分别测量A组和B组可利用间隙宽(The space available for the transpedicular screw,SAS),即钉道宽度；钉道长度(the length of transpedicular screw trajectory, LST);外侧安全间隙的距离(outside safe clearance OSC),即横突孔内侧缘到螺钉外缘的最短距离；内侧安全间隙的距离(inside safe clearance ISC),即椎管外侧缘到螺钉内缘的最短距离;选出内外安全间隙距离中较小者(smaller safe clearance,SSC),计算出内外安全间隙距离差的绝对值(|LSC-MSC|)及各组椎弓根钉穿破骨质的数量。最后用SPSS13.0统计软件对数据进行处理,得出结论。
结果A组的SAS的值为6.8到11.7mm,B组的SAS的值为7.8到13.0mm,两组间有显著性差异(P<0.01,独立样本t检验)。A组的钉道长度比B组的钉道长度短(P<0.01,独立样本t检验)；A组的SSC平均值为2.1±0.1mm,B组的SSC平均值为3.0±0.1mm,有显著性差异(P<0.01,独立样本t检验)；A组的|LSC-MSC|平均值为1.5±0.1mm,B组的|LSC-MSC|平均值为0.6±0.1mm。A组和B组椎弓根钉穿破椎弓根的数量均为0。
结论1、我们认为寰椎椎弓根螺钉进钉点应为：经枢椎侧块内外缘中点外侧2mm作纵垂线,与寰椎后弓上缘交点的正下方3.0 mm处,置钉方向为：内侧倾20°,头向倾斜5°。2、新的置钉方法钉道宽,钉道长,识别标志与椎弓根的位置关系恒定且置钉点的识别标志明确,可以作为临床有意义的借鉴。3、新置钉方法充分利用了可利用间隙。
Objective This experimental study was designed to provide a safe transpedicular screw trajectory and reduce the risk of pedicle screw placement by changing the entrance points and the insertion angles of transpedicular screws.
Methods 30 adult human upper cervical specimens, provided by the department of anatomy from medical colleges, were randomly divided into two groups,group A and group B.The placement of pedicle screw in group A were according to method provided by Ma Xiangyang. (The entry point of C1 pedicle screw was defined as the method of making a vertical line through the midpoint of C2 lateral mass, and the entry point was 3 mm under the cross point of the superior rim of C1 posterior arch with the vertical line. The direction of the screw is approximately 10°in a convergent and about 5°cephalad to the transverse plane). Pedicle screw insertions in group B were in accordance with the new way. (The entry point of C1 pedicle screw was 2mm lateraler than group A. The direction of the screw is approximately 20°in a convergent and 5°in caudal-to-cephalad inclination). C1 pedicle screw insertions according to the above-mentioned methods were finshed by the same person. Thin cut 0.5 mm computed tomography axial cuts were made through the pedicles after pedicle screw insertion.. Measurements of the space available for the transpedicular screw(SAS), the length of transpedicular screw trajectory(LST), outside safe clearance(OSC), inside safe clearance(ISC).|LSC-MSC| and the number of screws which perforated the atlas pedicle in each group were accounted. The datas were statistical analysised by SPSS 13.0.
Results SAS in group A ranged from 6.8 to 11.7 mm. SAS in group B ranged from 7.8 to 13.0 mm.SAS-group A and SAS-group B were significantly different(P<0.01;independent samples t test). The mean length of transpedicular screw trajectory(LST) in group A is shorter compared with group B (P<0.01;independent samples t test).The mean smaller safe clearance(SSC) in group A is 2.1±0.1mm,and is 3.0±0.1 mm in group B.The mean |LSC-MSC| in group A is 1.5±0.1mm, and is 0.6±0.1mm in group B,.The number of screws,which perforated the atlas pedicle in both group, are zero.
Conclusions 1、We believe that the entry point of the pedicle screw should be located 2mm lateraler from the vertical line through the central point of C2 lateral mass,and about 3mm under the superior rim of C1 posterior arch,the screw insertion angle of C1 transpedicle screw should be close to 20°in a medial inclination and 5°in a cephalad direction.2、SAS according to new method is wider,LST according to new method is longer. The relationship between anatomical landmark and atlas pedicle is constant and anatomical landmark is clear. New method can be used for reference in clinic application.3、New method can take full advantage of the space available for the transpedicular screw(SAS).
方法选择福建医科大学和闽东卫校解剖教研室提供的30具成人上颈椎尸体标本,按标本提供的顺序随机分成两组A、B组,每组15个标本。A组按马向阳等介绍的方法(经枢椎侧块内、外缘的中点作纵垂线,与寰椎后弓上缘交点的正下方3.0 mm处即螺钉的进钉点,向内倾斜约10°、上仰约5°置钉。B组依据我们自己提出的方法置钉(较马向阳等提出近钉点偏外2mm,内倾角为20°,上仰5°,同时把寰椎上关节凹后突作为参考标志)。按上述两种方法行寰椎椎弓根钉固定术,手术操作均由同一人完成。术后CT像上分别测量A组和B组可利用间隙宽(The space available for the transpedicular screw,SAS),即钉道宽度；钉道长度(the length of transpedicular screw trajectory, LST);外侧安全间隙的距离(outside safe clearance OSC),即横突孔内侧缘到螺钉外缘的最短距离；内侧安全间隙的距离(inside safe clearance ISC),即椎管外侧缘到螺钉内缘的最短距离;选出内外安全间隙距离中较小者(smaller safe clearance,SSC),计算出内外安全间隙距离差的绝对值(|LSC-MSC|)及各组椎弓根钉穿破骨质的数量。最后用SPSS13.0统计软件对数据进行处理,得出结论。
结果A组的SAS的值为6.8到11.7mm,B组的SAS的值为7.8到13.0mm,两组间有显著性差异(P<0.01,独立样本t检验)。A组的钉道长度比B组的钉道长度短(P<0.01,独立样本t检验)；A组的SSC平均值为2.1±0.1mm,B组的SSC平均值为3.0±0.1mm,有显著性差异(P<0.01,独立样本t检验)；A组的|LSC-MSC|平均值为1.5±0.1mm,B组的|LSC-MSC|平均值为0.6±0.1mm。A组和B组椎弓根钉穿破椎弓根的数量均为0。
结论1、我们认为寰椎椎弓根螺钉进钉点应为：经枢椎侧块内外缘中点外侧2mm作纵垂线,与寰椎后弓上缘交点的正下方3.0 mm处,置钉方向为：内侧倾20°,头向倾斜5°。2、新的置钉方法钉道宽,钉道长,识别标志与椎弓根的位置关系恒定且置钉点的识别标志明确,可以作为临床有意义的借鉴。3、新置钉方法充分利用了可利用间隙。
Objective This experimental study was designed to provide a safe transpedicular screw trajectory and reduce the risk of pedicle screw placement by changing the entrance points and the insertion angles of transpedicular screws.
Methods 30 adult human upper cervical specimens, provided by the department of anatomy from medical colleges, were randomly divided into two groups,group A and group B.The placement of pedicle screw in group A were according to method provided by Ma Xiangyang. (The entry point of C1 pedicle screw was defined as the method of making a vertical line through the midpoint of C2 lateral mass, and the entry point was 3 mm under the cross point of the superior rim of C1 posterior arch with the vertical line. The direction of the screw is approximately 10°in a convergent and about 5°cephalad to the transverse plane). Pedicle screw insertions in group B were in accordance with the new way. (The entry point of C1 pedicle screw was 2mm lateraler than group A. The direction of the screw is approximately 20°in a convergent and 5°in caudal-to-cephalad inclination). C1 pedicle screw insertions according to the above-mentioned methods were finshed by the same person. Thin cut 0.5 mm computed tomography axial cuts were made through the pedicles after pedicle screw insertion.. Measurements of the space available for the transpedicular screw(SAS), the length of transpedicular screw trajectory(LST), outside safe clearance(OSC), inside safe clearance(ISC).|LSC-MSC| and the number of screws which perforated the atlas pedicle in each group were accounted. The datas were statistical analysised by SPSS 13.0.
Results SAS in group A ranged from 6.8 to 11.7 mm. SAS in group B ranged from 7.8 to 13.0 mm.SAS-group A and SAS-group B were significantly different(P<0.01;independent samples t test). The mean length of transpedicular screw trajectory(LST) in group A is shorter compared with group B (P<0.01;independent samples t test).The mean smaller safe clearance(SSC) in group A is 2.1±0.1mm,and is 3.0±0.1 mm in group B.The mean |LSC-MSC| in group A is 1.5±0.1mm, and is 0.6±0.1mm in group B,.The number of screws,which perforated the atlas pedicle in both group, are zero.
Conclusions 1、We believe that the entry point of the pedicle screw should be located 2mm lateraler from the vertical line through the central point of C2 lateral mass,and about 3mm under the superior rim of C1 posterior arch,the screw insertion angle of C1 transpedicle screw should be close to 20°in a medial inclination and 5°in a cephalad direction.2、SAS according to new method is wider,LST according to new method is longer. The relationship between anatomical landmark and atlas pedicle is constant and anatomical landmark is clear. New method can be used for reference in clinic application.3、New method can take full advantage of the space available for the transpedicular screw(SAS).
引文
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