下颈椎及胸椎椎弓根置钉的解剖形态学CT重建研究
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摘要
背景
随着社会的进步,交通意外、工业和建筑事故、运动伤等外伤的高发以及人口老龄化,创伤性颈椎损伤和颈椎病的发生率不断上升。对颈椎伤病的外科治疗,内固定方法有前路AO带锁钢板螺钉和后路棘突钢丝、侧块螺钉、椎弓根钉固定两大类。颈椎椎弓根钉内固定能为颈椎提供较以往固定方法更可靠的生物力学稳定性,已有实验研究表明,在颈椎的单种内固定方法中,经椎弓根内固定生物力学稳定性最强,植骨融合率高,且在下颈椎后路内固定中,只有椎弓根螺钉固定能保留邻近节段正常的运动功能,其固定效果优于传统钢丝固定和侧块螺钉钢板系统。因而,椎弓根钉固定被越来越多的运用于临床。
由于颈椎椎弓根特殊的解剖和毗邻:内邻脊髓,外邻椎动脉,上下有神经根跨越,本身复杂的三维解剖结构,因此术者行颈椎椎弓根钉固定前需对其解剖熟悉掌握,术前对患者颈椎椎弓根行影像学测量必不可少,以增加手术的安全性。
虽然已有文章对颈椎椎弓根的解剖学特点进行研究,但大部分仍停留在尸体标本的直接测量,少数研究是针对尸体或病人应用普通CT平扫进行,由于颈椎椎弓根的特殊三维解剖结构,尸体标本直接测量和普通CT平扫很难准确了解其形态结构。考虑CT重影、普通CT扫描测量结果准确性与体位关系大、骨标本因干燥及测量误差等原因,上述研究方法均未能准确反映椎弓根的解剖形态,临床参考意义较小。
目前,国内尚没有文献提出术前利用CT重建对颈椎椎弓根解剖进行全面详细的测量评估。CT多平面重建(Multiplanar Reconstruction,MPR)后进行测量可为手术置钉提供可靠的参考数据。颈椎图像进行多平面重建后,能获得平行椎弓根轴线的横断面和垂直椎弓根轴线的冠状面,这种方法可以精确测量到椎弓根的皮质骨和松质骨的高、宽以及椎弓根四个壁的厚度,椎弓根轴线上的各个长度,以及横断面角和矢状面角,这正是其他测量方法无法达到的。CT后台操作系统软件测量能精确到0.01mm和0.01°,测量结果准确,能提供国人下颈椎椎弓根的相关解剖学资料,并为临床椎弓根置钉的螺钉进针方向、螺钉直径及长度等的选择提供应用解剖学基础及形态学依据。
目的
对成人下颈椎椎弓根进行CT多平面重建研究,测量各种相关解剖学参数,寻求较好反映椎弓根解剖形态的测量方法,以提供国人下颈椎椎弓根的相关解剖学资料,并为临床椎弓根置钉时的螺钉进针方向、螺钉直径及长度等的选择提供应用解剖学基础及形态学依据。
材料方法
在门诊和住院颈椎CT检查病人中,排除颈椎病变者(先天畸形,创伤、感染、原发性和转移性脊柱肿瘤)后,随机选40个病人(20男,20女,年龄18～83岁,平均46岁)。男女平均年龄没有统计学差异。本研究应用Lightspeed VCT扫描仪,病人从C3-C7以0.625 mm层厚连续扫描。运用Advantage Workstation AW 4.3_05 and Reformat Software操作系统将所得横断面图像进行容积再现(Volume Rendering VR)。进行MPR重建,得到颈椎椎弓根的矢状面图像,在椎弓根矢状面上,平行椎弓根长轴做横切,获得层厚0.4 mm的平行椎弓根轴线的横断面。在所获得的横断面上垂直其长轴横切获得层厚0.4 mm的椎弓根横断面,也就是椎弓根的冠状面。挑选椎弓根最狭窄的切面,测量颈椎椎弓根的各项指标。运用SPSS 11.0软件进行数据统计分析。数据分为男女两组,结果用均数±标准差( x±s)表示。椎弓根左右侧和男女的数据运用T-test进行统计学差异比较。
结果
1.椎弓根皮质高度、宽度和松质骨高度、宽度:椎弓根皮质高度大于皮质宽度,椎弓根冠状面从C3至C7由椭圆形逐渐变成近似圆形;椎弓根的皮质骨、松质骨宽度,男性C4最小,女性则是C3最小,椎弓根宽度决定椎弓根钉的直径。2.椎弓根上下左右壁皮质厚度:上壁、下壁从C3-C7呈逐渐变小趋势,各椎体呈现上壁比下壁厚的趋势。内侧壁比外侧壁相对较厚,外侧壁最容易受损伤。3.椎弓根轴线长度、椎弓根长度、椎弓根轴线最狭窄处长度:各椎体间变化差别不大,椎弓根轴线长度决定椎弓根钉的长度。4.椎弓根的横断面角和矢状角::从C3、C4开始到C7逐渐减小,男女间差别不大。
结论
1.运用64排CT容积再现和多平面重建,可以较好地呈现下颈椎椎弓根详细解剖结构,精确测量各项相关参数,为椎弓根置钉提供准确的术前评估数据。2.大部分成人颈椎椎弓根的宽度足以接受直径3.0 mm的螺钉固定,只要对进钉点做精确定位,严格掌握进钉方向,挑选合适直径螺钉,椎弓根置钉是相对安全的。3.女性病人椎弓根较男性小,少数女性病人行椎弓根钉固定术需慎重,特别在C3节段。4.颈椎椎弓根解剖形态个体变异程度较大,术前必须对置钉椎体进行CT、X线检查,确定适合个体的进钉点、进钉方向、螺钉直径及长度等,强调个体化进钉。
背景
自1959年椎弓根钉被用于固定腰骶椎成功以来,经椎弓根脊柱内固定技术已在临床上广泛应用。椎弓根螺钉可固定到脊柱的前中后柱,具有固定强度大、矫形效果好的优点,已广泛应用于下胸椎和腰椎的固定。胸椎椎弓根结构解剖上有其特殊性,除了本身的复杂三维解剖结构外,内侧为椎管,容纳硬膜囊和脊髓,外侧为胸膜和肺,椎体前方有大血管、食管,错误进针可导致椎弓根皮质破裂或穿透,脊髓及神经损伤、大血管损伤、硬脊膜撕裂及脑脊液漏等严重并发症。同时,研究表明胸椎椎弓根比颈椎、腰椎椎弓根小,特别在中胸椎,研究及临床上均发现部分病人不适合应用椎弓根钉固定。因此,中胸椎应用椎弓根螺钉固定目前仍有争议。
基于中胸椎椎弓根固定风险大的特点,学者提出了一种新的胸椎固定方法:椎弓根外固定法。该方法将螺钉从胸椎横突尖部置入,途经肋横突和肋椎关节,在胸椎椎弓根外侧进入胸椎椎体,具有远离胸椎椎管、钉道长等优点。其后学者又对该胸椎椎弓根外螺钉固定技术作了进一步的研究,初步证明其是一种安全有效的胸椎固定技术。然而,该技术在国内应用于临床极少,对其临床应用的解剖基础只有少数研究是在尸体标本上进行,运用CT扫描也只是在平扫横断面上进行,这些均未能准确了解其解剖结构。本研究利用CT平扫后进行三维重建,测量,旨在通过胸椎椎弓根与椎弓根肋骨单元的解剖测量、比较,探索椎弓根外螺钉应用于临床的安全性,为临床应用提供解剖学依据。
目的
通过对胸椎椎弓根和对应的椎弓根肋骨单元(PRU)进行多平面重建后测量并作比较,明确PRU置钉与传统的椎弓根置钉的解剖学基础的差异,为PRU螺钉临床应用提供解剖学依据,以增加手术安全性。
材料与方法
在门诊和住院胸椎CT检查病人中,排除胸椎病变者(先天畸形,创伤、感染、原发性和转移性脊柱肿瘤)后,随机选40个病人(20男,20女,年龄18～73岁,平均45岁)。男女平均年龄没有统计学差异。本研究应用Lightspeed Vct CT扫描仪,病人从T1-T12以0.625 mm层厚连续扫描后进行VR重建,并运用Advantage Workstation AW 4.3_05 and Reformat Software操作系统将所得横断面图像进行多平面重建,得到胸椎椎弓根的矢状面图像。在椎弓根矢状面上,平行椎弓根长轴做横切,获得层厚0.7 mm的椎弓根最大宽度上的横断面并进行测量;在横断面上垂直椎弓根轴线做切面,获得椎弓根的冠状面,并进行测量。选择显示完整的肋骨头、横突及椎弓根等结构的CT横断面图像,对下列结构进行测量:(1)椎弓根宽度(PW),椎弓根肋骨单元宽度(PRUW);(2)椎弓根钉道长度(PL),椎弓根肋骨单元钉道长度(PRUL);(3)椎弓根横断面角(PA),椎弓根肋骨单元横断面角(PRUA )。统计学处理:采用SPSS 11.0统计软件进行统计分析,数据均以均数±标准差( x±s)表示,所测数据进行男女之间、椎弓根和椎弓根肋骨单元进行比较,行T检验,α值取0.05, P<0.05为差异有统计学意义。
结果
1. PW和PRUW测量结果:在T1-12节段,PW男女均在T4最小,分别为4.44 mm和3.91 mm;男女PW均以T1为最大,分别为8.43 mm和7.91 mm;男女PRUW均在T1最大,分别为17.89 mm和16.59 mm,PRUW男性以T5最小,为13.73 mm,女性则在T5最小,为12.00 mm。PW、PRUW均从T1至T4、T5逐渐减小,至T12逐渐增大。
2. PL和PRUL测量结果:男女PL均以T1为最小,分别为35.54 mm和32.85 mm,均以T11最大,分别为45.19 mm和42.39 mm;男女PL均从T1至T11逐渐增大,T12变小。男性PRUL在T1最小,为43.00 mm,T11最大,为59.90 mm;由T1至T11逐渐增大,T12变小。女性T1最小,为39.42 mm,在T12最大,为55.92 mm,在T1至12逐渐增大。
3. PA和PRUA测量结果:男女PA均在T1最大,分别为29.92°和30.46°,由T1至T12逐渐减小,到T12分别为-1.39°和-1.40°。男女PRUA均在T1最大,分别为40.10°和40.47°,到T12逐渐减小,到T12分别为9.68°和9.55°。
4.男性PW、PURW、PL和PRUL大于女性,差别有统计学意义;而PA、PRUA男女间比较差异无统计学意义。
5.所有参数,椎弓根肋骨单元均较椎弓根大,差别有显著统计学意义。
结论
1.运用64排CT容积再现和多平面重建,可以较好的呈现胸椎椎弓根、椎弓根肋骨单元的详细解剖结构,能够精确测量各项相关参数,为椎弓根置钉、椎弓根肋骨单元置钉提供精确的术前评估数据。
2.女性病人椎弓根宽度较男性小。中胸段椎弓根横径最小,大部分病人行椎弓根螺钉内固定需慎重。
3.胸椎椎弓根肋骨单元的横径、钉道长度均较同节段的椎弓根大,因此,PRU置钉技术可置入更粗更长的螺钉,同时也使置钉更加安全。
4.胸椎椎弓根和椎弓根肋骨单元的各项参数在男女间、在不同节段以及在同一节段不同个体间均有较大差异,其解剖形态个体变异程度较大,术前必须对置钉椎体进行CT、X线检查,确定适合个体的进钉点、进钉方向、螺钉直径及长度等,强调个体化进钉。
Background
With the development of the society, there are more traffic accidents, industrial and architectural accidents, sports trauma, there are more traumatic cervical injury. And with the coming aged society, there are more cervical spondylosis patients. Dealing with cervical diseases with surgery, there are several ways, anterior approach AO plate fixation and spinous process wire fixation, lateral mass screw fixation and pedicle screw fixation. Pedicle screw fixation was generally accepted because of its three collumn fixation.
Cervical pedicle fixation has better biomechanics stability than the other internal fixations. It has the advantage of best biomechanics stability, high rate of bone graft fuse and need not outer fixation after operation. In all the cervical internal fixations, only pedicle fixation can keep the movement of near segments. It is better than wire fixation and lateral mass fixation.
Cervical pedicle has special anatomy and adjacent structure: spinal cord medially, vertebral artery latterly, nerve roots superiorly and inferiorly, variation of pedicle anatomy. Surgeons must know the anatomy of pedicle well before surgery, and it necessary to evaluate the morphology of cervical pedicle. There are reports about the anatomy of cervical pedicle of cadaver and patients by using caliper and general CT scan. Both of them could not evaluate pedicle accurately. Three-dimensional CT evaluation can provide accurate parameters of pedicle. By using reformatted CT, we can get the transverse view paralleling pedicle axis and coral view vertical to pedicle axis. We can get accurate parameter of pedicle from these views which are very useful information for surgeon to decide the direction, diameter and length of screw.
Objects
Evaluate the adult lower cervical pedicles by using reformatted CT,pursuit a better way to evaluate the morphology of cervical pedicle and measure the relative parameters. Provide the parameters of cervical pedicle for surgeons to decide the direction, diameter and length of screw.
Materials and Methods
The study consisted of 40 patients of Chinese origin, who were chosen randomly from the patients’registry. The patients were aged from 18-83 years (mean age was 46 years), including 20 males and 20 females. There was no statistical difference in the mean ages of male and female patients. Those who had thoracic spinal abnormalities (congenital deformity, trauma, infection, primary or secondary tumor) were excluded.
A Lightspeed Vct CT scanner system was used. C3-C7 vertebrae were scanned continuously with a thickness of 0.625 mm. Advantage Workstation AW 4.3_05 and Reformat Software were applied to reformat the transverse view of the image by MPR to get the sagittal section of the pedicles. From these sagittal images, the authors’cut paralleled the pedicle axis with a thickness of 0.4 mm to obtain the transverse view which paralleled the pedicle axis. Thus in the transverse view, the reformatted CT cuts were made vertical to the pedicle axis and get the coronal section. We choose the smallest side pedicle section to measure all the parameters. The authors performed the statistical analysis using SPSS for windows 11.0. Means and standard deviations of every parameter were calculated for the groups of male and female individuals. Statistical differences of the parameters were compared between right and left pedicles and between male and female patients at every level using the independent T test.
Results
1. PH, PSH, PW and PSW: PH is larger than PW, coronal plane are oval-shape like and become near round from C3 to C7. PW and PSW in male are smallest at C4 and in female at C3. PW decide the diameter of pedicle screw. 2. PCS, PCI, PCM, PCL: PCS and PCI become smaller from C3 to C7. PCS are larger than PCI. PCM are larger than PCL. PCM are easer to be injuried during pedicle screw fixation. 3. La, Lb and PD: All the length very near in different vertebral. They decide the length of pedicle. 4. TA and SA: Both become smaller form C3 to C7 and have no statistics difference between male and female.
Conclusions
1. Evaluate the cervical pedicle by Reformatted CT can provide accurate parameters for surgeon to perform pedicle screw fixation before surgery. 2. Most of the cervical pedicles can accept 3.0 mm crews. It is safe to perform pedicle screw fixation with precise entrance point, exact direction and proper length. 3. Pedicle side in female in smaller than male, some female patients are not suitable to be performed pedicle screw fixation, especially in C3. 4. Variation is common in pedicle morphology. It is necessary to evaluate the pedicle morphology before surgery by CT and X-ray.
Background
Pedicle screw has become popular since it was used to fix lumbosacral vertebrae in 1959. Pedicle fixation was used extensively in lower thoracic and lumbar pedicle because of its strong intensity and good reshaping ability. Three are special anatomic structure around thoracic pedicle including spinal cord medially, lung and thoracic membrane lately, artery and esophagus anterior. There will be serious results if the adjacent structure were injuried, including violating pedicle cortical, injury of spinal cord and nerve, breaking artery, rupture of spinal dura, leakage of cerebrospinal fluid. At the same time, it is reported that thoracic pedicles are smaller than cervical and lumbar pedicles and are not suitable for pedicle screw fixation. Therefore, it is controversial to use pedicle screw in thoracic pedicles
Because of high risk of middle thoracic pedicle fixation, researcher found a new way to take the place of pedicle screw fixation, that is extrapedicular screw fixation. Extrapedicular screw enter the vertebral beginning at the point of tip of transverse process, through costovertebral joint, laterally to the pedicle. It is far away from spinal column and has enough length. Later, research found that it is a safe and effective thoracic spinal fixation. Therefore, it is at the beginning to this technique in our country and we have no much relative parameters for clinic application. Our study is to evaluate the morphology of pedicle and pedicle rib units in the thoracic spine in normal thoracic human spines, and provide some anatomic information for extrapedicular screw fixation applied clinically.
Objects
Evaluate the morphology of pedicle and pedicle rib unit by reformatted CT. Make clear the difference of anatomic information of extrapedicular screw fixation and pedicle screw fixation. Provide anatomic parameters for extrapedicular screw fixation.
Materials and Methods
The study consisted of 40 patients of Chinese origin, who were chosen randomly from the patients’registry. The patients were aged from 18-73 years (mean age was 45 years), including 20 males and 20 females. There was no significant difference in the mean ages of male and female patients. Those who had thoracic spinal abnormalities (congenital deformity, trauma, infection, primary or secondary tumor) were excluded.
A Lightspeed Vct CT scanner system was used. C3-C7 vertebrae were scanned continuously with a thickness of 0.625 mm. Advantage Workstation AW 4.3_05 and Reformat Software were applied to reformat the transverse view of the image to get the sagittal section of the pedicles . From these sagittal images, the authors’cut paralleled the pedicle axis with a thickness of 0.7 mm to obtain the transverse view which paralleled to the pedicle axis. Thus in the transverse view, we choose the smallest pedicle section to measure. And then we cut the tranverse view vertically to the peidcle axis and get the coral view of the pedelce and measure. The authors performed the statistical analysis using SPSS for windows 11.0. Means and standard deviations of every parameter were calculated for the groups of male and female individuals. Statistical differences of the parameters were compared between male and female patients, between pedicle and pedicle rib unit at every level using the independent T test.
Results
1. PW and PRUW: Both in male and female, PW is smallest at T4( 4.44 mm and 3.91 mm respectively) and biggest at T1 (8.43 mm and 7.91 mm respectively). PRUW is biggest at T1 both in male and female (17.89 mm and 16.59 mm respectively), and is smallest at T5 in male(13.73 mm) and at T4 in female(12.00 mm). PW and PRUW are both become smaller from T1 to T4, T5 and become larger from T4, T5 to T12.
2. PL and PRUL: Both in male and female, PL is smallest at T1(35.54 mm and 32.85 respectively), largest at T11(45.19 mm and 42.39 mm respectively). PL becomes larger from T1 to T11, and then becomes smaller at T12. PRUL is smallest at T1 both in male and female(43.00 mm and 39.42 mm), but largest at T11 in male(59.90 mm) and at T12 in female(55.92 mm). Both of them become larger from T1 to T12.
3. PA and PRUA: Both in male and female, PA is largest at T1(29.92°and 30.46°respectively), and becomes smaller at T12(-1.39°and -1.40°). Both in male and female, PRUA is biggest at T1(40.10°and 40.47°respectively), and becomes smaller at T12(9.68°and 9.55°).
4. Of all the parameters except PA and PUR-A, are larger in male than in female.
5. All the parameters of the pedicle rib unit were significantly larger than corresponding pedicle measurements at all levels.
Conclusions
1. Evaluate the morphology of pedicle and pedicle rib unit by Reformatted CT can provide accurate parameters for surgeon to perform pedicle screw and extrapedicular screw fixation before surgery.
2. PW in female is smaller than that in male. PW is smallest in middle thoracic pedicle, most of the patients are not suitable to perform pedicle screw fixation.
3. PRUW and PRUL are larger than PW and PL respectively. PRU can accept more longer and bigger screw, so PRU screw is safer than pedicle screw.
4. Variation is common in pedicle and PRU morphology. It is necessary to evaluate the they morphology before surgery by CT and X-ray to clear the entrance point, direction, diameter and length of screw and to place screw individually.
随着社会的进步,交通意外、工业和建筑事故、运动伤等外伤的高发以及人口老龄化,创伤性颈椎损伤和颈椎病的发生率不断上升。对颈椎伤病的外科治疗,内固定方法有前路AO带锁钢板螺钉和后路棘突钢丝、侧块螺钉、椎弓根钉固定两大类。颈椎椎弓根钉内固定能为颈椎提供较以往固定方法更可靠的生物力学稳定性,已有实验研究表明,在颈椎的单种内固定方法中,经椎弓根内固定生物力学稳定性最强,植骨融合率高,且在下颈椎后路内固定中,只有椎弓根螺钉固定能保留邻近节段正常的运动功能,其固定效果优于传统钢丝固定和侧块螺钉钢板系统。因而,椎弓根钉固定被越来越多的运用于临床。
由于颈椎椎弓根特殊的解剖和毗邻:内邻脊髓,外邻椎动脉,上下有神经根跨越,本身复杂的三维解剖结构,因此术者行颈椎椎弓根钉固定前需对其解剖熟悉掌握,术前对患者颈椎椎弓根行影像学测量必不可少,以增加手术的安全性。
虽然已有文章对颈椎椎弓根的解剖学特点进行研究,但大部分仍停留在尸体标本的直接测量,少数研究是针对尸体或病人应用普通CT平扫进行,由于颈椎椎弓根的特殊三维解剖结构,尸体标本直接测量和普通CT平扫很难准确了解其形态结构。考虑CT重影、普通CT扫描测量结果准确性与体位关系大、骨标本因干燥及测量误差等原因,上述研究方法均未能准确反映椎弓根的解剖形态,临床参考意义较小。
目前,国内尚没有文献提出术前利用CT重建对颈椎椎弓根解剖进行全面详细的测量评估。CT多平面重建(Multiplanar Reconstruction,MPR)后进行测量可为手术置钉提供可靠的参考数据。颈椎图像进行多平面重建后,能获得平行椎弓根轴线的横断面和垂直椎弓根轴线的冠状面,这种方法可以精确测量到椎弓根的皮质骨和松质骨的高、宽以及椎弓根四个壁的厚度,椎弓根轴线上的各个长度,以及横断面角和矢状面角,这正是其他测量方法无法达到的。CT后台操作系统软件测量能精确到0.01mm和0.01°,测量结果准确,能提供国人下颈椎椎弓根的相关解剖学资料,并为临床椎弓根置钉的螺钉进针方向、螺钉直径及长度等的选择提供应用解剖学基础及形态学依据。
目的
对成人下颈椎椎弓根进行CT多平面重建研究,测量各种相关解剖学参数,寻求较好反映椎弓根解剖形态的测量方法,以提供国人下颈椎椎弓根的相关解剖学资料,并为临床椎弓根置钉时的螺钉进针方向、螺钉直径及长度等的选择提供应用解剖学基础及形态学依据。
材料方法
在门诊和住院颈椎CT检查病人中,排除颈椎病变者(先天畸形,创伤、感染、原发性和转移性脊柱肿瘤)后,随机选40个病人(20男,20女,年龄18～83岁,平均46岁)。男女平均年龄没有统计学差异。本研究应用Lightspeed VCT扫描仪,病人从C3-C7以0.625 mm层厚连续扫描。运用Advantage Workstation AW 4.3_05 and Reformat Software操作系统将所得横断面图像进行容积再现(Volume Rendering VR)。进行MPR重建,得到颈椎椎弓根的矢状面图像,在椎弓根矢状面上,平行椎弓根长轴做横切,获得层厚0.4 mm的平行椎弓根轴线的横断面。在所获得的横断面上垂直其长轴横切获得层厚0.4 mm的椎弓根横断面,也就是椎弓根的冠状面。挑选椎弓根最狭窄的切面,测量颈椎椎弓根的各项指标。运用SPSS 11.0软件进行数据统计分析。数据分为男女两组,结果用均数±标准差( x±s)表示。椎弓根左右侧和男女的数据运用T-test进行统计学差异比较。
结果
1.椎弓根皮质高度、宽度和松质骨高度、宽度:椎弓根皮质高度大于皮质宽度,椎弓根冠状面从C3至C7由椭圆形逐渐变成近似圆形;椎弓根的皮质骨、松质骨宽度,男性C4最小,女性则是C3最小,椎弓根宽度决定椎弓根钉的直径。2.椎弓根上下左右壁皮质厚度:上壁、下壁从C3-C7呈逐渐变小趋势,各椎体呈现上壁比下壁厚的趋势。内侧壁比外侧壁相对较厚,外侧壁最容易受损伤。3.椎弓根轴线长度、椎弓根长度、椎弓根轴线最狭窄处长度:各椎体间变化差别不大,椎弓根轴线长度决定椎弓根钉的长度。4.椎弓根的横断面角和矢状角::从C3、C4开始到C7逐渐减小,男女间差别不大。
结论
1.运用64排CT容积再现和多平面重建,可以较好地呈现下颈椎椎弓根详细解剖结构,精确测量各项相关参数,为椎弓根置钉提供准确的术前评估数据。2.大部分成人颈椎椎弓根的宽度足以接受直径3.0 mm的螺钉固定,只要对进钉点做精确定位,严格掌握进钉方向,挑选合适直径螺钉,椎弓根置钉是相对安全的。3.女性病人椎弓根较男性小,少数女性病人行椎弓根钉固定术需慎重,特别在C3节段。4.颈椎椎弓根解剖形态个体变异程度较大,术前必须对置钉椎体进行CT、X线检查,确定适合个体的进钉点、进钉方向、螺钉直径及长度等,强调个体化进钉。
背景
自1959年椎弓根钉被用于固定腰骶椎成功以来,经椎弓根脊柱内固定技术已在临床上广泛应用。椎弓根螺钉可固定到脊柱的前中后柱,具有固定强度大、矫形效果好的优点,已广泛应用于下胸椎和腰椎的固定。胸椎椎弓根结构解剖上有其特殊性,除了本身的复杂三维解剖结构外,内侧为椎管,容纳硬膜囊和脊髓,外侧为胸膜和肺,椎体前方有大血管、食管,错误进针可导致椎弓根皮质破裂或穿透,脊髓及神经损伤、大血管损伤、硬脊膜撕裂及脑脊液漏等严重并发症。同时,研究表明胸椎椎弓根比颈椎、腰椎椎弓根小,特别在中胸椎,研究及临床上均发现部分病人不适合应用椎弓根钉固定。因此,中胸椎应用椎弓根螺钉固定目前仍有争议。
基于中胸椎椎弓根固定风险大的特点,学者提出了一种新的胸椎固定方法:椎弓根外固定法。该方法将螺钉从胸椎横突尖部置入,途经肋横突和肋椎关节,在胸椎椎弓根外侧进入胸椎椎体,具有远离胸椎椎管、钉道长等优点。其后学者又对该胸椎椎弓根外螺钉固定技术作了进一步的研究,初步证明其是一种安全有效的胸椎固定技术。然而,该技术在国内应用于临床极少,对其临床应用的解剖基础只有少数研究是在尸体标本上进行,运用CT扫描也只是在平扫横断面上进行,这些均未能准确了解其解剖结构。本研究利用CT平扫后进行三维重建,测量,旨在通过胸椎椎弓根与椎弓根肋骨单元的解剖测量、比较,探索椎弓根外螺钉应用于临床的安全性,为临床应用提供解剖学依据。
目的
通过对胸椎椎弓根和对应的椎弓根肋骨单元(PRU)进行多平面重建后测量并作比较,明确PRU置钉与传统的椎弓根置钉的解剖学基础的差异,为PRU螺钉临床应用提供解剖学依据,以增加手术安全性。
材料与方法
在门诊和住院胸椎CT检查病人中,排除胸椎病变者(先天畸形,创伤、感染、原发性和转移性脊柱肿瘤)后,随机选40个病人(20男,20女,年龄18～73岁,平均45岁)。男女平均年龄没有统计学差异。本研究应用Lightspeed Vct CT扫描仪,病人从T1-T12以0.625 mm层厚连续扫描后进行VR重建,并运用Advantage Workstation AW 4.3_05 and Reformat Software操作系统将所得横断面图像进行多平面重建,得到胸椎椎弓根的矢状面图像。在椎弓根矢状面上,平行椎弓根长轴做横切,获得层厚0.7 mm的椎弓根最大宽度上的横断面并进行测量;在横断面上垂直椎弓根轴线做切面,获得椎弓根的冠状面,并进行测量。选择显示完整的肋骨头、横突及椎弓根等结构的CT横断面图像,对下列结构进行测量:(1)椎弓根宽度(PW),椎弓根肋骨单元宽度(PRUW);(2)椎弓根钉道长度(PL),椎弓根肋骨单元钉道长度(PRUL);(3)椎弓根横断面角(PA),椎弓根肋骨单元横断面角(PRUA )。统计学处理:采用SPSS 11.0统计软件进行统计分析,数据均以均数±标准差( x±s)表示,所测数据进行男女之间、椎弓根和椎弓根肋骨单元进行比较,行T检验,α值取0.05, P<0.05为差异有统计学意义。
结果
1. PW和PRUW测量结果:在T1-12节段,PW男女均在T4最小,分别为4.44 mm和3.91 mm;男女PW均以T1为最大,分别为8.43 mm和7.91 mm;男女PRUW均在T1最大,分别为17.89 mm和16.59 mm,PRUW男性以T5最小,为13.73 mm,女性则在T5最小,为12.00 mm。PW、PRUW均从T1至T4、T5逐渐减小,至T12逐渐增大。
2. PL和PRUL测量结果:男女PL均以T1为最小,分别为35.54 mm和32.85 mm,均以T11最大,分别为45.19 mm和42.39 mm;男女PL均从T1至T11逐渐增大,T12变小。男性PRUL在T1最小,为43.00 mm,T11最大,为59.90 mm;由T1至T11逐渐增大,T12变小。女性T1最小,为39.42 mm,在T12最大,为55.92 mm,在T1至12逐渐增大。
3. PA和PRUA测量结果:男女PA均在T1最大,分别为29.92°和30.46°,由T1至T12逐渐减小,到T12分别为-1.39°和-1.40°。男女PRUA均在T1最大,分别为40.10°和40.47°,到T12逐渐减小,到T12分别为9.68°和9.55°。
4.男性PW、PURW、PL和PRUL大于女性,差别有统计学意义;而PA、PRUA男女间比较差异无统计学意义。
5.所有参数,椎弓根肋骨单元均较椎弓根大,差别有显著统计学意义。
结论
1.运用64排CT容积再现和多平面重建,可以较好的呈现胸椎椎弓根、椎弓根肋骨单元的详细解剖结构,能够精确测量各项相关参数,为椎弓根置钉、椎弓根肋骨单元置钉提供精确的术前评估数据。
2.女性病人椎弓根宽度较男性小。中胸段椎弓根横径最小,大部分病人行椎弓根螺钉内固定需慎重。
3.胸椎椎弓根肋骨单元的横径、钉道长度均较同节段的椎弓根大,因此,PRU置钉技术可置入更粗更长的螺钉,同时也使置钉更加安全。
4.胸椎椎弓根和椎弓根肋骨单元的各项参数在男女间、在不同节段以及在同一节段不同个体间均有较大差异,其解剖形态个体变异程度较大,术前必须对置钉椎体进行CT、X线检查,确定适合个体的进钉点、进钉方向、螺钉直径及长度等,强调个体化进钉。
Background
With the development of the society, there are more traffic accidents, industrial and architectural accidents, sports trauma, there are more traumatic cervical injury. And with the coming aged society, there are more cervical spondylosis patients. Dealing with cervical diseases with surgery, there are several ways, anterior approach AO plate fixation and spinous process wire fixation, lateral mass screw fixation and pedicle screw fixation. Pedicle screw fixation was generally accepted because of its three collumn fixation.
Cervical pedicle fixation has better biomechanics stability than the other internal fixations. It has the advantage of best biomechanics stability, high rate of bone graft fuse and need not outer fixation after operation. In all the cervical internal fixations, only pedicle fixation can keep the movement of near segments. It is better than wire fixation and lateral mass fixation.
Cervical pedicle has special anatomy and adjacent structure: spinal cord medially, vertebral artery latterly, nerve roots superiorly and inferiorly, variation of pedicle anatomy. Surgeons must know the anatomy of pedicle well before surgery, and it necessary to evaluate the morphology of cervical pedicle. There are reports about the anatomy of cervical pedicle of cadaver and patients by using caliper and general CT scan. Both of them could not evaluate pedicle accurately. Three-dimensional CT evaluation can provide accurate parameters of pedicle. By using reformatted CT, we can get the transverse view paralleling pedicle axis and coral view vertical to pedicle axis. We can get accurate parameter of pedicle from these views which are very useful information for surgeon to decide the direction, diameter and length of screw.
Objects
Evaluate the adult lower cervical pedicles by using reformatted CT,pursuit a better way to evaluate the morphology of cervical pedicle and measure the relative parameters. Provide the parameters of cervical pedicle for surgeons to decide the direction, diameter and length of screw.
Materials and Methods
The study consisted of 40 patients of Chinese origin, who were chosen randomly from the patients’registry. The patients were aged from 18-83 years (mean age was 46 years), including 20 males and 20 females. There was no statistical difference in the mean ages of male and female patients. Those who had thoracic spinal abnormalities (congenital deformity, trauma, infection, primary or secondary tumor) were excluded.
A Lightspeed Vct CT scanner system was used. C3-C7 vertebrae were scanned continuously with a thickness of 0.625 mm. Advantage Workstation AW 4.3_05 and Reformat Software were applied to reformat the transverse view of the image by MPR to get the sagittal section of the pedicles. From these sagittal images, the authors’cut paralleled the pedicle axis with a thickness of 0.4 mm to obtain the transverse view which paralleled the pedicle axis. Thus in the transverse view, the reformatted CT cuts were made vertical to the pedicle axis and get the coronal section. We choose the smallest side pedicle section to measure all the parameters. The authors performed the statistical analysis using SPSS for windows 11.0. Means and standard deviations of every parameter were calculated for the groups of male and female individuals. Statistical differences of the parameters were compared between right and left pedicles and between male and female patients at every level using the independent T test.
Results
1. PH, PSH, PW and PSW: PH is larger than PW, coronal plane are oval-shape like and become near round from C3 to C7. PW and PSW in male are smallest at C4 and in female at C3. PW decide the diameter of pedicle screw. 2. PCS, PCI, PCM, PCL: PCS and PCI become smaller from C3 to C7. PCS are larger than PCI. PCM are larger than PCL. PCM are easer to be injuried during pedicle screw fixation. 3. La, Lb and PD: All the length very near in different vertebral. They decide the length of pedicle. 4. TA and SA: Both become smaller form C3 to C7 and have no statistics difference between male and female.
Conclusions
1. Evaluate the cervical pedicle by Reformatted CT can provide accurate parameters for surgeon to perform pedicle screw fixation before surgery. 2. Most of the cervical pedicles can accept 3.0 mm crews. It is safe to perform pedicle screw fixation with precise entrance point, exact direction and proper length. 3. Pedicle side in female in smaller than male, some female patients are not suitable to be performed pedicle screw fixation, especially in C3. 4. Variation is common in pedicle morphology. It is necessary to evaluate the pedicle morphology before surgery by CT and X-ray.
Background
Pedicle screw has become popular since it was used to fix lumbosacral vertebrae in 1959. Pedicle fixation was used extensively in lower thoracic and lumbar pedicle because of its strong intensity and good reshaping ability. Three are special anatomic structure around thoracic pedicle including spinal cord medially, lung and thoracic membrane lately, artery and esophagus anterior. There will be serious results if the adjacent structure were injuried, including violating pedicle cortical, injury of spinal cord and nerve, breaking artery, rupture of spinal dura, leakage of cerebrospinal fluid. At the same time, it is reported that thoracic pedicles are smaller than cervical and lumbar pedicles and are not suitable for pedicle screw fixation. Therefore, it is controversial to use pedicle screw in thoracic pedicles
Because of high risk of middle thoracic pedicle fixation, researcher found a new way to take the place of pedicle screw fixation, that is extrapedicular screw fixation. Extrapedicular screw enter the vertebral beginning at the point of tip of transverse process, through costovertebral joint, laterally to the pedicle. It is far away from spinal column and has enough length. Later, research found that it is a safe and effective thoracic spinal fixation. Therefore, it is at the beginning to this technique in our country and we have no much relative parameters for clinic application. Our study is to evaluate the morphology of pedicle and pedicle rib units in the thoracic spine in normal thoracic human spines, and provide some anatomic information for extrapedicular screw fixation applied clinically.
Objects
Evaluate the morphology of pedicle and pedicle rib unit by reformatted CT. Make clear the difference of anatomic information of extrapedicular screw fixation and pedicle screw fixation. Provide anatomic parameters for extrapedicular screw fixation.
Materials and Methods
The study consisted of 40 patients of Chinese origin, who were chosen randomly from the patients’registry. The patients were aged from 18-73 years (mean age was 45 years), including 20 males and 20 females. There was no significant difference in the mean ages of male and female patients. Those who had thoracic spinal abnormalities (congenital deformity, trauma, infection, primary or secondary tumor) were excluded.
A Lightspeed Vct CT scanner system was used. C3-C7 vertebrae were scanned continuously with a thickness of 0.625 mm. Advantage Workstation AW 4.3_05 and Reformat Software were applied to reformat the transverse view of the image to get the sagittal section of the pedicles . From these sagittal images, the authors’cut paralleled the pedicle axis with a thickness of 0.7 mm to obtain the transverse view which paralleled to the pedicle axis. Thus in the transverse view, we choose the smallest pedicle section to measure. And then we cut the tranverse view vertically to the peidcle axis and get the coral view of the pedelce and measure. The authors performed the statistical analysis using SPSS for windows 11.0. Means and standard deviations of every parameter were calculated for the groups of male and female individuals. Statistical differences of the parameters were compared between male and female patients, between pedicle and pedicle rib unit at every level using the independent T test.
Results
1. PW and PRUW: Both in male and female, PW is smallest at T4( 4.44 mm and 3.91 mm respectively) and biggest at T1 (8.43 mm and 7.91 mm respectively). PRUW is biggest at T1 both in male and female (17.89 mm and 16.59 mm respectively), and is smallest at T5 in male(13.73 mm) and at T4 in female(12.00 mm). PW and PRUW are both become smaller from T1 to T4, T5 and become larger from T4, T5 to T12.
2. PL and PRUL: Both in male and female, PL is smallest at T1(35.54 mm and 32.85 respectively), largest at T11(45.19 mm and 42.39 mm respectively). PL becomes larger from T1 to T11, and then becomes smaller at T12. PRUL is smallest at T1 both in male and female(43.00 mm and 39.42 mm), but largest at T11 in male(59.90 mm) and at T12 in female(55.92 mm). Both of them become larger from T1 to T12.
3. PA and PRUA: Both in male and female, PA is largest at T1(29.92°and 30.46°respectively), and becomes smaller at T12(-1.39°and -1.40°). Both in male and female, PRUA is biggest at T1(40.10°and 40.47°respectively), and becomes smaller at T12(9.68°and 9.55°).
4. Of all the parameters except PA and PUR-A, are larger in male than in female.
5. All the parameters of the pedicle rib unit were significantly larger than corresponding pedicle measurements at all levels.
Conclusions
1. Evaluate the morphology of pedicle and pedicle rib unit by Reformatted CT can provide accurate parameters for surgeon to perform pedicle screw and extrapedicular screw fixation before surgery.
2. PW in female is smaller than that in male. PW is smallest in middle thoracic pedicle, most of the patients are not suitable to perform pedicle screw fixation.
3. PRUW and PRUL are larger than PW and PL respectively. PRU can accept more longer and bigger screw, so PRU screw is safer than pedicle screw.
4. Variation is common in pedicle and PRU morphology. It is necessary to evaluate the they morphology before surgery by CT and X-ray to clear the entrance point, direction, diameter and length of screw and to place screw individually.
引文
1. Abumi, K., H. Itoh, H. Taneichi, et al. Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report. J Spinal Disord, 1994. 7(1):19-28.
2. Jeanneret, B., J.S. Gebhard, F. Magerl, Transpedicular screw fixation of articular mass fracture-separation: results of an anatomical study and operative technique. J Spinal Disord, 1994. 7(3):222-9.
3.校佰平,徐荣明,马维虎等.颈椎椎弓根螺钉内固定术中并发症及其对策.中国骨伤, 2005(9):530-532.
4. Kotani, Y., B.W. Cunningham, K. Abumi, et al. Biomechanical analysis of cervical stabilization systems. An assessment of transpedicular screw fixation in the cervical spine. Spine, 1994. 19(22):2529-39.
5.刘景堂,唐天驷,王东来等.颈椎椎弓根螺钉内固定系统的临床应用.中华骨科杂志, 2003(10):590-594.
6.王春,郑立槟,刘成招,颈椎椎弓根钉固定的临床应用.脊柱外科杂志, 2004(1):20-21,29.
7. Kim, H.S., J.G. Heller, P.A. Hudgins, et al. The accuracy of computed tomography in assessing cervical pedicle screw placement. Spine, 2003. 28(21):2441-6.
8. Reinhold, M., F. Magerl, M. Rieger, et al. Cervical pedicle screw placement: feasibility and accuracy of two new insertion techniques based on morphometric data. Eur Spine J, 2007. 16(1):47-56.
9.解京明,张漾杰,王迎松等.颈椎弓根螺钉内固定在下颈椎骨折中的应用.中华创伤骨科杂志, 2007(5):497-498.
10.朱若夫,杨惠林,王根林等.颈椎椎弓根内固定术的临床应用.苏州大学学报:医学版, 2008(2):310-311.
11.朱若夫,杨惠林,贺喜顺等.颈椎椎弓根钉内固定术治疗下颈椎骨折脱位.中华创伤骨科杂志, 2008(3):249-252.
12.孙韶华,马维虎,黄雷等.颈椎椎弓根螺钉个体化置钉技术的研究.中国骨与关节损伤杂志, 2009(01).
13.王东来,唐天驷.五种颈椎内固定方法的稳定性生物力学评价.中华外科杂志, 1999(5):301-303.
14.曹珺,代耀军,何飞.下颈椎经椎弓根内固定的生物力学稳定性分析.中国组织工程研究与临床康复, 2008(44).
15.朱若夫,杨惠林,张志明等.颈椎椎弓根内固定系统在枕颈融合术中的应用.中国矫形外科杂志, 2008(16):1201-1203.
16.吴成胜,谭远超,张恩忠等.颈后路椎弓根固定治疗不稳定性颈椎骨折脱位.中医正骨, 2008(6):28-30.
17. Ugur, H.C., A. Attar, A. Uz, et al. Thoracic pedicle: surgical anatomic evaluation and relations. J Spinal Disord, 2001. 14(1):39-45.
18.赖志军,骆立荣,郭汉明等.螺旋Ct扫描下测量颈椎椎弓根尺寸及螺钉置入角度.中国组织工程研究与临床康复, 2008(48).
19. Ebraheim, N.A., R. Xu, T. Knight, et al. Morphometric evaluation of lower cervical pedicle and its projection. Spine, 1997. 22(1):1-6.
20. Panjabi, M.M., K. Takata, V. Goel, et al. Thoracic human vertebrae. Quantitative three-dimensional anatomy. Spine, 1991. 16(8):888-901.
21. Li, B., B. Jiang, Z. Fu, et al. Accurate determination of isthmus of lumbar pedicle: a morphometric study using reformatted computed tomographic images. Spine, 2004. 29(21):2438-44.
22. Jones, E.L., J.G. Heller, D.H. Silcox, et al. Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine, 1997. 22(9):977-82.
23.谢宁,朱青安.下颈椎后路螺钉技术的拔出强度研究.中国矫形外科杂志, 2001(8):797-798.
24.孙宇,李志平.颈椎椎弓根的观测及其临床意义.北京医科大学学报, 1993(4):279-280.
25. Ruofu, Z., Y. Huilin, H. Xiaoyun, et al. CT evaluation of cervical pedicle in a Chinese population for surgical application of transpedicular screw placement. Surg Radiol Anat, 2008.
26. Liau, K.M., M.I. Yusof, M.S. Abdullah, et al. Computed tomographic morphometry of thoracic pedicles: safety margin of transpedicular screw fixation in malaysian malaypopulation. Spine, 2006. 31(16):E545-50.
27. Shin, E.K., M.M. Panjabi, N.C. Chen, et al. The anatomic variability of human cervical pedicles: considerations for transpedicular screw fixation in the middle and lower cervical spine. Eur Spine J, 2000. 9(1):61-6.
28. Karaikovic, E.E., S. Kunakornsawat, M.D. Daubs, et al. Surgical anatomy of the cervical pedicles: landmarks for posterior cervical pedicle entrance localization. J Spinal Disord, 2000. 13(1):63-72.
29. Karaikovic, E.E., M.D. Daubs, R.W. Madsen, et al. Morphologic characteristics of human cervical pedicles. Spine, 1997. 22(5):493-500.
30. Hirano, T., K. Hasegawa, H.E. Takahashi, et al. Structural characteristics of the pedicle and its role in screw stability. Spine, 1997. 22(21):2504-9; discussion 2510.
31. Kayalioglu, G., M. Erturk, T. Varol, et al. Morphometry of the cervical vertebral pedicles as a guide for transpedicular screw fixation. Neurol Med Chir (Tokyo), 2007. 47(3):102-7; discussion 107-8.
32. Neo, M., T. Sakamoto, S. Fujibayashi, et al. The clinical risk of vertebral artery injury from cervical pedicle screws inserted in degenerative vertebrae. Spine, 2005. 30(24):2800-5.
33. Abumi, K., Y. Shono, M. Ito, et al. Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine, 2000. 25(8):962-9.
34.解京明,张漾杰,鲁宁等.下颈椎经椎弓根螺钉内固定相关解剖学观察.脊柱外科杂志, 2006(6):354-358.
35. Abumi, K., K. Kaneda, Pedicle screw fixation for nontraumatic lesions of the cervical spine. Spine, 1997. 22(16):1853-63.
36. Bozbuga, M., A. Ozturk, Z. Ari, et al. Morphometric evaluation of subaxial cervical vertebrae for surgical application of transpedicular screw fixation. Spine, 2004. 29(17):1876-80.
37.王东来,唐天驷.下颈椎椎弓根内固定的解剖学研究与临床应用.中华骨科杂志, 1998(11):659-662.
38. Maat, G.J., B. Matricali, E.L. van Persijn van Meerten, Postnatal development and structure of the neurocentral junction. Its relevance for spinal surgery. Spine, 1996.21(6):661-6.
39. Heller, J.G., M.D. Alson, M.B. Schaffler, et al. Quantitative internal dens morphology. Spine, 1992. 17(8):861-6.
40. Ludwig, S.C., J.M. Kowalski, C.C. Edwards, 2nd, et al. Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine, 2000. 25(20):2675-81.
41. Richter, M., B. Cakir, R. Schmidt, Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws. Spine, 2005. 30(20):2280-7.
42. Mao, G.P., J.N. Zhao, Y.R. Wang, et al. Design of cervical pedicle locator and three-dimensional location of cervical pedicle. Spine, 2005. 30(9):1045-50.
1. Dvorak, M., S. MacDonald, K.R. Gurr, et al. An anatomic, radiographic, and biomechanical assessment of extrapedicular screw fixation in the thoracic spine. Spine, 1993. 18(12):1689-94.
2. Gaines, R.W., Jr., The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Joint Surg Am, 2000. 82-A(10):1458-76.
3. Guven, O., T. Esemenli, S. Yalcin, et al. Transpedicular fixation in the treatment of various spinal disorders. Acta Chir Belg, 1993. 93(4):188-92.
4. Boos, N.J.K. Webb, Pedicle screw fixation in spinal disorders: a European view. Eur Spine J, 1997. 6(1):2-18.
5.赵建华,刘鹏.胸椎椎弓根解剖与临床.局解手术学杂志, 2008(5):297-299.
6. Liljenqvist, U., L. Hackenberg, T. Link, et al. Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Acta Orthop Belg, 2001. 67(2):157-63.
7. Kim, K.D., J.P. Johnson, J.D. Babbitz, Image-guided thoracic pedicle screw placement: a technical study in cadavers and preliminary clinical experience. Neurosurg Focus, 2001. 10(2):E2.
8. Belmont, P.J., Jr., W.R. Klemme, A. Dhawan, et al. In vivo accuracy of thoracic pedicle screws. Spine, 2001. 26(21):2340-6.
9. Lien, S.B., N.H. Liou, S.S. Wu, Analysis of anatomic morphometry of the pedicles and the safe zone for through-pedicle procedures in the thoracic and lumbar spine. Eur Spine J, 2007. 16(8):1215-22.
10. Fisher, C.G., V. Sahajpal, O. Keynan, et al. Accuracy and safety of pedicle screw fixation in thoracic spine trauma. J Neurosurg Spine, 2006. 5(6):520-6.
11. Ebraheim, N.A., G. Jabaly, R. Xu, et al. Anatomic relations of the thoracic pedicle to the adjacent neural structures. Spine, 1997. 22(14):1553-6; discussion 1557.
12. Youkilis, A.S., D.J. Quint, J.E. McGillicuddy, et al. Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery, 2001. 48(4):771-8; discussion 778-9.
13. Liljenqvist, U.R., H.F. Halm, T.M. Link, Pedicle screw instrumentation of the thoracicspine in idiopathic scoliosis. Spine, 1997. 22(19):2239-45.
14. West, J.L., 3rd, J.W. Ogilvie, D.S. Bradford, Complications of the variable screw plate pedicle screw fixation. Spine, 1991. 16(5):576-9.
15. Kim, Y.J., L.G. Lenke, K.H. Bridwell, et al. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine, 2004. 29(3):333-42; discussion 342.
16. Suk, S.I., W.J. Kim, S.M. Lee, et al. Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine, 2001. 26(18):2049-57.
17. Husted, D.S., J.J. Yue, T.A. Fairchild, et al. An extrapedicular approach to the placement of screws in the thoracic spine: an anatomic and radiographic assessment. Spine, 2003. 28(20):2324-30.
18. Husted, D.S., A.H. Haims, T.A. Fairchild, et al. Morphometric comparison of the pedicle rib unit to pedicles in the thoracic spine. Spine, 2004. 29(2):139-46.
19. Morgenstern, W., S.J. Ferguson, S. Berey, et al. Posterior thoracic extrapedicular fixation: a biomechanical study. Spine, 2003. 28(16):1829-35.
20. Ugur, H.C., A. Attar, A. Uz, et al. Thoracic pedicle: surgical anatomic evaluation and relations. J Spinal Disord, 2001. 14(1):39-45.
21.林炎生,吕发金等.下位腰椎椎弓根内固定术的断层解剖与CT.中国临床解剖学杂志, 2002(3):194-197.
22. Tan, S.H., E.C. Teo, H.C. Chua, Quantitative three-dimensional anatomy of cervical, thoracic and lumbar vertebrae of Chinese Singaporeans. Eur Spine J, 2004. 13(2):137-46.
23. Liau, K.M., M.I. Yusof, M.S. Abdullah, et al. Computed tomographic morphometry of thoracic pedicles: safety margin of transpedicular screw fixation in malaysian malay population. Spine, 2006. 31(16):E545-50.
24. Kim, N.H., H.M. Lee, I.H. Chung, et al. Morphometric study of the pedicles of thoracic and lumbar vertebrae in Koreans. Spine, 1994. 19(12):1390-4.
25. Datir, S.P., S.R. Mitra, Morphometric study of the thoracic vertebral pedicle in an Indian population. Spine, 2004. 29(11):1174-81.
26. Zindrick, M.R., L.L. Wiltse, A. Doornik, et al. Analysis of the morphometric characteristics of the thoracic and lumbar pedicles. Spine, 1987. 12(2):160-6.
27. Panjabi, M.M., K. Takata, V. Goel, et al. Thoracic human vertebrae. Quantitativethree-dimensional anatomy. Spine, 1991. 16(8):888-901.
28. Ebraheim, N.A., R. Xu, M. Ahmad, et al. Projection of the thoracic pedicle and its morphometric analysis. Spine, 1997. 22(3):233-8.
29. Vaccaro, A.R., S.J. Rizzolo, T.J. Allardyce, et al. Placement of pedicle screws in the thoracic spine. Part I: Morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am, 1995. 77(8):1193-9.
30. Cinotti, G., S. Gumina, M. Ripani, et al. Pedicle instrumentation in the thoracic spine. A morphometric and cadaveric study for placement of screws. Spine, 1999. 24(2):114-9.
31.史亚民,柴伟等.胸椎椎弓根形态测量研究.中国脊柱脊髓杂志, 2002(3):191-193.
32.严军,宦坚,郑祖根等.上中胸椎椎弓根-肋单位的CT测量及临床意义.中国临床解剖学杂志, 2007(6):636-639.
33.王欢喜,邓展生,向铁城等.胸椎弓根与其周围神经解剖关系的研究.湘南学院学报:自然科学版, 2005(4):8-9,12.
34. Liljenqvist, U.R., T. Allkemper, L. Hackenberg, et al. Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction. J Bone Joint Surg Am, 2002. 84-A(3):359-68.
35. Liljenqvist, U.R., T.M. Link, H.F. Halm, Morphometric analysis of thoracic and lumbar vertebrae in idiopathic scoliosis. Spine, 2000. 25(10):1247-53.
36. Vaccaro, A.R., S.J. Rizzolo, R.A. Balderston, et al. Placement of pedicle screws in the thoracic spine. Part II: An anatomical and radiographic assessment. J Bone Joint Surg Am, 1995. 77(8):1200-6.
37. Xu, R., N.A. Ebraheim, Y. Ou, et al. Anatomic considerations of pedicle screw placement in the thoracic spine. Roy-Camille technique versus open-lamina technique. Spine, 1998. 23(9):1065-8.
38. Gertzbein, S.D., S.E. Robbins, Accuracy of pedicular screw placement in vivo. Spine, 1990. 15(1):11-4.
39.谢陶敢,陈其昕,李方才等.胸椎椎弓根-肋骨单元与椎弓根的Ct测量.中国脊柱脊髓杂志, 2008(9):665-668.
40.崔新刚,张佐伦,陈海松等.胸椎椎弓根根外内固定的应用解剖学研究及其意义.中华创伤杂志, 2005(10):768-772.
41.殷渠东,郑祖根,蔡建平.置入胸椎“椎弓根-肋骨”单元螺钉的应用解剖和力学测试.中国临床解剖学杂志, 2005(5):538-539.
42. O'Brien, M.F., L.G. Lenke, S. Mardjetko, et al. Pedicle morphology in thoracic adolescent idiopathic scoliosis: is pedicle fixation an anatomically viable technique? Spine, 2000. 25(18):2285-93.
43. White, K.K., R. Oka, A.T. Mahar, et al. Pullout strength of thoracic pedicle screw instrumentation: comparison of the transpedicular and extrapedicular techniques. Spine, 2006. 31(12):E355-8.
1. Abumi, K., H. Itoh, H. Taneichi, et al. Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report. J Spinal Disord, 1994. 7(1):19-28.
2. Jeanneret, B., J.S. Gebhard, F. Magerl, Transpedicular screw fixation of articular mass fracture-separation: results of an anatomical study and operative technique. J Spinal Disord, 1994. 7(3):222-9.
3.校佰平,徐荣明,马维虎等.颈椎椎弓根螺钉内固定术中并发症及其对策.中国骨伤, 2005(9):530-532.
4. Kotani, Y., B.W. Cunningham, K. Abumi, et al. Biomechanical analysis of cervical stabilization systems. An assessment of transpedicular screw fixation in the cervical spine. Spine, 1994. 19(22):2529-39.
5.刘景堂,唐天驷,王东来等.颈椎椎弓根螺钉内固定系统的临床应用.中华骨科杂志, 2003(10):590-594.
6.王春,郑立槟刘成招.颈椎椎弓根钉固定的临床应用.脊柱外科杂志, 2004(1):20-21,29.
7. Kim, H.S., J.G. Heller, P.A. Hudgins, et al. The accuracy of computed tomography in assessing cervical pedicle screw placement. Spine, 2003. 28(21):2441-6.
8. Reinhold, M., F. Magerl, M. Rieger, et al. Cervical pedicle screw placement: feasibility and accuracy of two new insertion techniques based on morphometric data. Eur Spine J, 2007. 16(1):47-56.
9.解京明,张漾杰,王迎松等.颈椎弓根螺钉内固定在下颈椎骨折中的应用.中华创伤骨科杂志, 2007(5):497-498.
10.朱若夫,杨惠林,王根林等.颈椎椎弓根内固定术的临床应用.苏州大学学报:医学版, 2008(2):310-311.
11.朱若夫,杨惠林,贺喜顺等.颈椎椎弓根钉内固定术治疗下颈椎骨折脱位.中华创伤骨科杂志, 2008(3):249-252.
12.孙韶华,马维虎,黄雷等.颈椎椎弓根螺钉个体化置钉技术的研究.中国骨与关节损伤杂志, 2009(01).
13. Michele, A.A., T.C. Harper, A method of spinal fusion by arthrodesis and iliac bone grafts. Mil Surg, 1949. 104(2):90-4.
14. Panjabi, M.M., J. Duranceau, V. Goel, et al. Cervical human vertebrae. Quantitative three-dimensional anatomy of the middle and lower regions. Spine, 1991. 16(8):861-9.
15. Panjabi, M.M., E.K. Shin, N.C. Chen, et al. Internal morphology of human cervical pedicles. Spine, 2000. 25(10):1197-205.
16. Karaikovic, E.E., M.D. Daubs, R.W. Madsen, et al. Morphologic characteristics of human cervical pedicles. Spine, 1997. 22(5):493-500.
17. Maat, G.J., B. Matricali, E.L. van Persijn van Meerten, Postnatal development and structure of the neurocentral junction. Its relevance for spinal surgery. Spine, 1996. 21(6):661-6.
18. Rezcallah, A.T., R. Xu, N.A. Ebraheim, et al. Axial computed tomography of the pedicle in the lower cervical spine. Am J Orthop, 2001. 30(1):59-61.
19. Ruofu, Z., Y. Huilin, H. Xiaoyun, et al. CT evaluation of cervical pedicle in a Chinese population for surgical application of transpedicular screw placement. Surg Radiol Anat, 2008.
20. Liau, K.M., M.I. Yusof, M.S. Abdullah, et al. Computed tomographic morphometry of thoracic pedicles: safety margin of transpedicular screw fixation in malaysian malay population. Spine, 2006. 31(16):E545-50.
21. Ebraheim, N.A., R. Xu, T. Knight, et al. Morphometric evaluation of lower cervical pedicle and its projection. Spine, 1997. 22(1):1-6.
22. Ugur, H.C., A. Attar, A. Uz, et al. Surgical anatomic evaluation of the cervical pedicle and adjacent neural structures. Neurosurgery, 2000. 47(5):1162-8; discussion 1168-9.
23. Hirano, T., K. Hasegawa, H.E. Takahashi, et al. Structural characteristics of the pedicle and its role in screw stability. Spine, 1997. 22(21):2504-9; discussion 2510.
24.闫德强,谢志军等.颈椎弓根螺钉内固定的解剖学研究.中华骨科杂志, 2002(11):657-661.
25.王东来,唐天驷.下颈椎椎弓根内固定的解剖学研究与临床应用.中华骨科杂志, 1998(11):659-662.
26.杨代耘,王跃等.颈椎椎弓根的形态观测及临床意义.四川解剖学杂志,1997(4):208-211.
27.王东来,唐天驷.下颈椎经椎弓根内固定应用解剖学研究.中国临床解剖学杂志, 1998(4):289-293.
28.孙宇,李志平.颈椎椎弓根的观测及其临床意义.北京医科大学学报, 1993(4):279-280.
29.黄东生,苏培强,马若凡等.颈椎椎弓根Ct测量在椎弓根螺钉内固定中的作用.中国临床解剖学杂志, 2004(2):186-189.
30. Yusof, M.I., L.K. Ming, M.S. Abdullah, et al. Computerized tomographic measurement of the cervical pedicles diameter in a Malaysian population and the feasibility for transpedicular fixation. Spine, 2006. 31(8):E221-4.
31. Abumi, K., M.M. Panjabi, J. Duranceau, Biomechanical evaluation of spinal fixation devices. Part III. Stability provided by six spinal fixation devices and interbody bone graft. Spine, 1989. 14(11):1249-55.
32. Coe, J.D., K.E. Warden, C.E. Sutterlin, 3rd, et al. Biomechanical evaluation of cervical spinal stabilization methods in a human cadaveric model. Spine, 1989. 14(10):1122-31.
33. Jones, E.L., J.G. Heller, D.H. Silcox, et al. Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine, 1997. 22(9):977-82.
34.王东来,唐天驷.五种颈椎内固定方法的稳定性生物力学评价.中华外科杂志, 1999(5):301-303.
35.谢宁,朱青安等,下颈椎后路螺钉技术的拔出强度研究.中国矫形外科杂志, 2001(8):797-798.
36. Ludwig, S.C., J.M. Kowalski, C.C. Edwards, 2nd, et al. Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine, 2000. 25(20):2675-81.
37. Richter, M., B. Cakir, R. Schmidt, Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws. Spine, 2005. 30(20):2280-7.
38.张峰,王春.下颈椎椎弓根螺钉固定的研究进展.临床和实验医学杂志, 2006(9):1435-1437.
39. Miller, R.M., N.A. Ebraheim, R. Xu, et al. Anatomic consideration of transpedicular screw placement in the cervical spine. An analysis of two approaches. Spine, 1996. 21(20):2317-22.
40. Abumi, K., Y. Shono, M. Ito, et al. Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine, 2000. 25(8):962-9.
41.毛广平,赵建宁,陈跃先等.颈椎椎弓根三种置钉法的实验研究.中国矫形外科杂志, 2005(1):47-50.
42. Liljenqvist, U., L. Hackenberg, T. Link, et al, Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Acta Orthop Belg, 2001. 67(2):157-63.
43. Kim, K.D., J.P. Johnson, J.D. Babbitz, Image-guided thoracic pedicle screw placement: a technical study in cadavers and preliminary clinical experience. Neurosurg Focus, 2001. 10(2):E2.
44. Belmont, P.J., Jr., W.R. Klemme, A. Dhawan, et al. In vivo accuracy of thoracic pedicle screws. Spine, 2001. 26(21):2340-6.
45. Lien, S.B., N.H. Liou, S.S. Wu, Analysis of anatomic morphometry of the pedicles and the safe zone for through-pedicle procedures in the thoracic and lumbar spine. Eur Spine J, 2007. 16(8):1215-22.
46. Fisher, C.G., V. Sahajpal, O. Keynan, et al. Accuracy and safety of pedicle screw fixation in thoracic spine trauma. J Neurosurg Spine, 2006. 5(6):520-6.
47. Ebraheim, N.A., G. Jabaly, R. Xu, et al. Anatomic relations of the thoracic pedicle to the adjacent neural structures. Spine, 1997. 22(14):1553-6; discussion 1557.
48. Youkilis, A.S., D.J. Quint, J.E. McGillicuddy, et al. Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery, 2001. 48(4):771-8; discussion 778-9.
49. Liljenqvist, U.R., H.F. Halm, T.M. Link, Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine, 1997. 22(19):2239-45.
50. West, J.L., 3rd, J.W. Ogilvie, D.S. Bradford, Complications of the variable screw plate pedicle screw fixation. Spine, 1991. 16(5):576-9.
51. Kim, Y.J., L.G. Lenke, K.H. Bridwell, et al. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine, 2004. 29(3):333-42; discussion 342.
52. Suk, S.I., W.J. Kim, S.M. Lee, et al. Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine, 2001. 26(18):2049-57.
53. Dvorak, M., S. MacDonald, K.R. Gurr, et al. An anatomic, radiographic, andbiomechanical assessment of extrapedicular screw fixation in the thoracic spine. Spine, 1993. 18(12):1689-94.
54.史亚民,柴伟等.胸椎椎弓根形态测量研究.中国脊柱脊髓杂志, 2002(3):191-193.
55.林炎生,吕发金等.下位腰椎椎弓根内固定术的断层解剖与Ct.中国临床解剖学杂志, 2002(3):194-197.
56. DeCoster, T.A., D.B. Heetderks, D.J. Downey, et al. Optimizing bone screw pullout force. J Orthop Trauma, 1990. 4(2):169-74.
57. Vaccaro, A.R., S.J. Rizzolo, T.J. Allardyce, et al. Placement of pedicle screws in the thoracic spine. Part I: Morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am, 1995. 77(8):1193-9.
58. Cinotti, G., S. Gumina, M. Ripani, et al. Pedicle instrumentation in the thoracic spine. A morphometric and cadaveric study for placement of screws. Spine, 1999. 24(2):114-9.
59. Tan, S.H., E.C. Teo, H.C. Chua, Quantitative three-dimensional anatomy of cervical, thoracic and lumbar vertebrae of Chinese Singaporeans. Eur Spine J, 2004. 13(2):137-46.
60. Kim, N.H., H.M. Lee, I.H. Chung, et al. Morphometric study of the pedicles of thoracic and lumbar vertebrae in Koreans. Spine, 1994. 19(12):1390-4.
61. Datir, S.P., S.R. Mitra, Morphometric study of the thoracic vertebral pedicle in an Indian population. Spine, 2004. 29(11):1174-81.
62. Zindrick, M.R., L.L. Wiltse, A. Doornik, et al. Analysis of the morphometric characteristics of the thoracic and lumbar pedicles. Spine, 1987. 12(2):160-6.
63. Panjabi, M.M., K. Takata, V. Goel, et al. Thoracic human vertebrae. Quantitative three-dimensional anatomy. Spine, 1991. 16(8):888-901.
64. Ebraheim, N.A., R. Xu, M. Ahmad, et al. Projection of the thoracic pedicle and its morphometric analysis. Spine, 1997. 22(3):233-8.
65.王欢喜,邓展生,向铁城等.胸椎弓根与其周围神经解剖关系的研究.湘南学院学报:自然科学版, 2005(4):8-9,12.
66. Husted, D.S., J.J. Yue, T.A. Fairchild, et al. An extrapedicular approach to the placement of screws in the thoracic spine: an anatomic and radiographic assessment. Spine, 2003. 28(20):2324-30.
67. Husted, D.S., A.H. Haims, T.A. Fairchild, et al. Morphometric comparison of the pediclerib unit to pedicles in the thoracic spine. Spine, 2004. 29(2):139-46.
68. Morgenstern, W., S.J. Ferguson, S. Berey, et al. Posterior thoracic extrapedicular fixation: a biomechanical study. Spine, 2003. 28(16):1829-35.
69.严军,宦坚,郑祖根等.上中胸椎椎弓根-肋单位的Ct测量及临床意义.中国临床解剖学杂志, 2007(6):636-639.
70.谢陶敢,陈其昕,李方才等.胸椎椎弓根-肋骨单元与椎弓根的Ct测量.中国脊柱脊髓杂志, 2008(9):665-668.
71.崔新刚,张佐伦,陈海松等.胸椎椎弓根根外内固定的应用解剖学研究及其意义.中华创伤杂志, 2005(10):768-772.
72.殷渠东,郑祖根,蔡建平.置入胸椎“椎弓根-肋骨”单元螺钉的应用解剖和力学测试.中国临床解剖学杂志, 2005(5):538-539.
73. O'Brien, M.F., L.G. Lenke, S. Mardjetko, et al. Pedicle morphology in thoracic adolescent idiopathic scoliosis: is pedicle fixation an anatomically viable technique? Spine, 2000. 25(18):2285-93.
74. White, K.K., R. Oka, A.T. Mahar, et al. Pullout strength of thoracic pedicle screw instrumentation: comparison of the transpedicular and extrapedicular techniques. Spine, 2006. 31(12):E355-8.
2. Jeanneret, B., J.S. Gebhard, F. Magerl, Transpedicular screw fixation of articular mass fracture-separation: results of an anatomical study and operative technique. J Spinal Disord, 1994. 7(3):222-9.
3.校佰平,徐荣明,马维虎等.颈椎椎弓根螺钉内固定术中并发症及其对策.中国骨伤, 2005(9):530-532.
4. Kotani, Y., B.W. Cunningham, K. Abumi, et al. Biomechanical analysis of cervical stabilization systems. An assessment of transpedicular screw fixation in the cervical spine. Spine, 1994. 19(22):2529-39.
5.刘景堂,唐天驷,王东来等.颈椎椎弓根螺钉内固定系统的临床应用.中华骨科杂志, 2003(10):590-594.
6.王春,郑立槟,刘成招,颈椎椎弓根钉固定的临床应用.脊柱外科杂志, 2004(1):20-21,29.
7. Kim, H.S., J.G. Heller, P.A. Hudgins, et al. The accuracy of computed tomography in assessing cervical pedicle screw placement. Spine, 2003. 28(21):2441-6.
8. Reinhold, M., F. Magerl, M. Rieger, et al. Cervical pedicle screw placement: feasibility and accuracy of two new insertion techniques based on morphometric data. Eur Spine J, 2007. 16(1):47-56.
9.解京明,张漾杰,王迎松等.颈椎弓根螺钉内固定在下颈椎骨折中的应用.中华创伤骨科杂志, 2007(5):497-498.
10.朱若夫,杨惠林,王根林等.颈椎椎弓根内固定术的临床应用.苏州大学学报:医学版, 2008(2):310-311.
11.朱若夫,杨惠林,贺喜顺等.颈椎椎弓根钉内固定术治疗下颈椎骨折脱位.中华创伤骨科杂志, 2008(3):249-252.
12.孙韶华,马维虎,黄雷等.颈椎椎弓根螺钉个体化置钉技术的研究.中国骨与关节损伤杂志, 2009(01).
13.王东来,唐天驷.五种颈椎内固定方法的稳定性生物力学评价.中华外科杂志, 1999(5):301-303.
14.曹珺,代耀军,何飞.下颈椎经椎弓根内固定的生物力学稳定性分析.中国组织工程研究与临床康复, 2008(44).
15.朱若夫,杨惠林,张志明等.颈椎椎弓根内固定系统在枕颈融合术中的应用.中国矫形外科杂志, 2008(16):1201-1203.
16.吴成胜,谭远超,张恩忠等.颈后路椎弓根固定治疗不稳定性颈椎骨折脱位.中医正骨, 2008(6):28-30.
17. Ugur, H.C., A. Attar, A. Uz, et al. Thoracic pedicle: surgical anatomic evaluation and relations. J Spinal Disord, 2001. 14(1):39-45.
18.赖志军,骆立荣,郭汉明等.螺旋Ct扫描下测量颈椎椎弓根尺寸及螺钉置入角度.中国组织工程研究与临床康复, 2008(48).
19. Ebraheim, N.A., R. Xu, T. Knight, et al. Morphometric evaluation of lower cervical pedicle and its projection. Spine, 1997. 22(1):1-6.
20. Panjabi, M.M., K. Takata, V. Goel, et al. Thoracic human vertebrae. Quantitative three-dimensional anatomy. Spine, 1991. 16(8):888-901.
21. Li, B., B. Jiang, Z. Fu, et al. Accurate determination of isthmus of lumbar pedicle: a morphometric study using reformatted computed tomographic images. Spine, 2004. 29(21):2438-44.
22. Jones, E.L., J.G. Heller, D.H. Silcox, et al. Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine, 1997. 22(9):977-82.
23.谢宁,朱青安.下颈椎后路螺钉技术的拔出强度研究.中国矫形外科杂志, 2001(8):797-798.
24.孙宇,李志平.颈椎椎弓根的观测及其临床意义.北京医科大学学报, 1993(4):279-280.
25. Ruofu, Z., Y. Huilin, H. Xiaoyun, et al. CT evaluation of cervical pedicle in a Chinese population for surgical application of transpedicular screw placement. Surg Radiol Anat, 2008.
26. Liau, K.M., M.I. Yusof, M.S. Abdullah, et al. Computed tomographic morphometry of thoracic pedicles: safety margin of transpedicular screw fixation in malaysian malaypopulation. Spine, 2006. 31(16):E545-50.
27. Shin, E.K., M.M. Panjabi, N.C. Chen, et al. The anatomic variability of human cervical pedicles: considerations for transpedicular screw fixation in the middle and lower cervical spine. Eur Spine J, 2000. 9(1):61-6.
28. Karaikovic, E.E., S. Kunakornsawat, M.D. Daubs, et al. Surgical anatomy of the cervical pedicles: landmarks for posterior cervical pedicle entrance localization. J Spinal Disord, 2000. 13(1):63-72.
29. Karaikovic, E.E., M.D. Daubs, R.W. Madsen, et al. Morphologic characteristics of human cervical pedicles. Spine, 1997. 22(5):493-500.
30. Hirano, T., K. Hasegawa, H.E. Takahashi, et al. Structural characteristics of the pedicle and its role in screw stability. Spine, 1997. 22(21):2504-9; discussion 2510.
31. Kayalioglu, G., M. Erturk, T. Varol, et al. Morphometry of the cervical vertebral pedicles as a guide for transpedicular screw fixation. Neurol Med Chir (Tokyo), 2007. 47(3):102-7; discussion 107-8.
32. Neo, M., T. Sakamoto, S. Fujibayashi, et al. The clinical risk of vertebral artery injury from cervical pedicle screws inserted in degenerative vertebrae. Spine, 2005. 30(24):2800-5.
33. Abumi, K., Y. Shono, M. Ito, et al. Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine, 2000. 25(8):962-9.
34.解京明,张漾杰,鲁宁等.下颈椎经椎弓根螺钉内固定相关解剖学观察.脊柱外科杂志, 2006(6):354-358.
35. Abumi, K., K. Kaneda, Pedicle screw fixation for nontraumatic lesions of the cervical spine. Spine, 1997. 22(16):1853-63.
36. Bozbuga, M., A. Ozturk, Z. Ari, et al. Morphometric evaluation of subaxial cervical vertebrae for surgical application of transpedicular screw fixation. Spine, 2004. 29(17):1876-80.
37.王东来,唐天驷.下颈椎椎弓根内固定的解剖学研究与临床应用.中华骨科杂志, 1998(11):659-662.
38. Maat, G.J., B. Matricali, E.L. van Persijn van Meerten, Postnatal development and structure of the neurocentral junction. Its relevance for spinal surgery. Spine, 1996.21(6):661-6.
39. Heller, J.G., M.D. Alson, M.B. Schaffler, et al. Quantitative internal dens morphology. Spine, 1992. 17(8):861-6.
40. Ludwig, S.C., J.M. Kowalski, C.C. Edwards, 2nd, et al. Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine, 2000. 25(20):2675-81.
41. Richter, M., B. Cakir, R. Schmidt, Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws. Spine, 2005. 30(20):2280-7.
42. Mao, G.P., J.N. Zhao, Y.R. Wang, et al. Design of cervical pedicle locator and three-dimensional location of cervical pedicle. Spine, 2005. 30(9):1045-50.
1. Dvorak, M., S. MacDonald, K.R. Gurr, et al. An anatomic, radiographic, and biomechanical assessment of extrapedicular screw fixation in the thoracic spine. Spine, 1993. 18(12):1689-94.
2. Gaines, R.W., Jr., The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Joint Surg Am, 2000. 82-A(10):1458-76.
3. Guven, O., T. Esemenli, S. Yalcin, et al. Transpedicular fixation in the treatment of various spinal disorders. Acta Chir Belg, 1993. 93(4):188-92.
4. Boos, N.J.K. Webb, Pedicle screw fixation in spinal disorders: a European view. Eur Spine J, 1997. 6(1):2-18.
5.赵建华,刘鹏.胸椎椎弓根解剖与临床.局解手术学杂志, 2008(5):297-299.
6. Liljenqvist, U., L. Hackenberg, T. Link, et al. Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Acta Orthop Belg, 2001. 67(2):157-63.
7. Kim, K.D., J.P. Johnson, J.D. Babbitz, Image-guided thoracic pedicle screw placement: a technical study in cadavers and preliminary clinical experience. Neurosurg Focus, 2001. 10(2):E2.
8. Belmont, P.J., Jr., W.R. Klemme, A. Dhawan, et al. In vivo accuracy of thoracic pedicle screws. Spine, 2001. 26(21):2340-6.
9. Lien, S.B., N.H. Liou, S.S. Wu, Analysis of anatomic morphometry of the pedicles and the safe zone for through-pedicle procedures in the thoracic and lumbar spine. Eur Spine J, 2007. 16(8):1215-22.
10. Fisher, C.G., V. Sahajpal, O. Keynan, et al. Accuracy and safety of pedicle screw fixation in thoracic spine trauma. J Neurosurg Spine, 2006. 5(6):520-6.
11. Ebraheim, N.A., G. Jabaly, R. Xu, et al. Anatomic relations of the thoracic pedicle to the adjacent neural structures. Spine, 1997. 22(14):1553-6; discussion 1557.
12. Youkilis, A.S., D.J. Quint, J.E. McGillicuddy, et al. Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery, 2001. 48(4):771-8; discussion 778-9.
13. Liljenqvist, U.R., H.F. Halm, T.M. Link, Pedicle screw instrumentation of the thoracicspine in idiopathic scoliosis. Spine, 1997. 22(19):2239-45.
14. West, J.L., 3rd, J.W. Ogilvie, D.S. Bradford, Complications of the variable screw plate pedicle screw fixation. Spine, 1991. 16(5):576-9.
15. Kim, Y.J., L.G. Lenke, K.H. Bridwell, et al. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine, 2004. 29(3):333-42; discussion 342.
16. Suk, S.I., W.J. Kim, S.M. Lee, et al. Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine, 2001. 26(18):2049-57.
17. Husted, D.S., J.J. Yue, T.A. Fairchild, et al. An extrapedicular approach to the placement of screws in the thoracic spine: an anatomic and radiographic assessment. Spine, 2003. 28(20):2324-30.
18. Husted, D.S., A.H. Haims, T.A. Fairchild, et al. Morphometric comparison of the pedicle rib unit to pedicles in the thoracic spine. Spine, 2004. 29(2):139-46.
19. Morgenstern, W., S.J. Ferguson, S. Berey, et al. Posterior thoracic extrapedicular fixation: a biomechanical study. Spine, 2003. 28(16):1829-35.
20. Ugur, H.C., A. Attar, A. Uz, et al. Thoracic pedicle: surgical anatomic evaluation and relations. J Spinal Disord, 2001. 14(1):39-45.
21.林炎生,吕发金等.下位腰椎椎弓根内固定术的断层解剖与CT.中国临床解剖学杂志, 2002(3):194-197.
22. Tan, S.H., E.C. Teo, H.C. Chua, Quantitative three-dimensional anatomy of cervical, thoracic and lumbar vertebrae of Chinese Singaporeans. Eur Spine J, 2004. 13(2):137-46.
23. Liau, K.M., M.I. Yusof, M.S. Abdullah, et al. Computed tomographic morphometry of thoracic pedicles: safety margin of transpedicular screw fixation in malaysian malay population. Spine, 2006. 31(16):E545-50.
24. Kim, N.H., H.M. Lee, I.H. Chung, et al. Morphometric study of the pedicles of thoracic and lumbar vertebrae in Koreans. Spine, 1994. 19(12):1390-4.
25. Datir, S.P., S.R. Mitra, Morphometric study of the thoracic vertebral pedicle in an Indian population. Spine, 2004. 29(11):1174-81.
26. Zindrick, M.R., L.L. Wiltse, A. Doornik, et al. Analysis of the morphometric characteristics of the thoracic and lumbar pedicles. Spine, 1987. 12(2):160-6.
27. Panjabi, M.M., K. Takata, V. Goel, et al. Thoracic human vertebrae. Quantitativethree-dimensional anatomy. Spine, 1991. 16(8):888-901.
28. Ebraheim, N.A., R. Xu, M. Ahmad, et al. Projection of the thoracic pedicle and its morphometric analysis. Spine, 1997. 22(3):233-8.
29. Vaccaro, A.R., S.J. Rizzolo, T.J. Allardyce, et al. Placement of pedicle screws in the thoracic spine. Part I: Morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am, 1995. 77(8):1193-9.
30. Cinotti, G., S. Gumina, M. Ripani, et al. Pedicle instrumentation in the thoracic spine. A morphometric and cadaveric study for placement of screws. Spine, 1999. 24(2):114-9.
31.史亚民,柴伟等.胸椎椎弓根形态测量研究.中国脊柱脊髓杂志, 2002(3):191-193.
32.严军,宦坚,郑祖根等.上中胸椎椎弓根-肋单位的CT测量及临床意义.中国临床解剖学杂志, 2007(6):636-639.
33.王欢喜,邓展生,向铁城等.胸椎弓根与其周围神经解剖关系的研究.湘南学院学报:自然科学版, 2005(4):8-9,12.
34. Liljenqvist, U.R., T. Allkemper, L. Hackenberg, et al. Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction. J Bone Joint Surg Am, 2002. 84-A(3):359-68.
35. Liljenqvist, U.R., T.M. Link, H.F. Halm, Morphometric analysis of thoracic and lumbar vertebrae in idiopathic scoliosis. Spine, 2000. 25(10):1247-53.
36. Vaccaro, A.R., S.J. Rizzolo, R.A. Balderston, et al. Placement of pedicle screws in the thoracic spine. Part II: An anatomical and radiographic assessment. J Bone Joint Surg Am, 1995. 77(8):1200-6.
37. Xu, R., N.A. Ebraheim, Y. Ou, et al. Anatomic considerations of pedicle screw placement in the thoracic spine. Roy-Camille technique versus open-lamina technique. Spine, 1998. 23(9):1065-8.
38. Gertzbein, S.D., S.E. Robbins, Accuracy of pedicular screw placement in vivo. Spine, 1990. 15(1):11-4.
39.谢陶敢,陈其昕,李方才等.胸椎椎弓根-肋骨单元与椎弓根的Ct测量.中国脊柱脊髓杂志, 2008(9):665-668.
40.崔新刚,张佐伦,陈海松等.胸椎椎弓根根外内固定的应用解剖学研究及其意义.中华创伤杂志, 2005(10):768-772.
41.殷渠东,郑祖根,蔡建平.置入胸椎“椎弓根-肋骨”单元螺钉的应用解剖和力学测试.中国临床解剖学杂志, 2005(5):538-539.
42. O'Brien, M.F., L.G. Lenke, S. Mardjetko, et al. Pedicle morphology in thoracic adolescent idiopathic scoliosis: is pedicle fixation an anatomically viable technique? Spine, 2000. 25(18):2285-93.
43. White, K.K., R. Oka, A.T. Mahar, et al. Pullout strength of thoracic pedicle screw instrumentation: comparison of the transpedicular and extrapedicular techniques. Spine, 2006. 31(12):E355-8.
1. Abumi, K., H. Itoh, H. Taneichi, et al. Transpedicular screw fixation for traumatic lesions of the middle and lower cervical spine: description of the techniques and preliminary report. J Spinal Disord, 1994. 7(1):19-28.
2. Jeanneret, B., J.S. Gebhard, F. Magerl, Transpedicular screw fixation of articular mass fracture-separation: results of an anatomical study and operative technique. J Spinal Disord, 1994. 7(3):222-9.
3.校佰平,徐荣明,马维虎等.颈椎椎弓根螺钉内固定术中并发症及其对策.中国骨伤, 2005(9):530-532.
4. Kotani, Y., B.W. Cunningham, K. Abumi, et al. Biomechanical analysis of cervical stabilization systems. An assessment of transpedicular screw fixation in the cervical spine. Spine, 1994. 19(22):2529-39.
5.刘景堂,唐天驷,王东来等.颈椎椎弓根螺钉内固定系统的临床应用.中华骨科杂志, 2003(10):590-594.
6.王春,郑立槟刘成招.颈椎椎弓根钉固定的临床应用.脊柱外科杂志, 2004(1):20-21,29.
7. Kim, H.S., J.G. Heller, P.A. Hudgins, et al. The accuracy of computed tomography in assessing cervical pedicle screw placement. Spine, 2003. 28(21):2441-6.
8. Reinhold, M., F. Magerl, M. Rieger, et al. Cervical pedicle screw placement: feasibility and accuracy of two new insertion techniques based on morphometric data. Eur Spine J, 2007. 16(1):47-56.
9.解京明,张漾杰,王迎松等.颈椎弓根螺钉内固定在下颈椎骨折中的应用.中华创伤骨科杂志, 2007(5):497-498.
10.朱若夫,杨惠林,王根林等.颈椎椎弓根内固定术的临床应用.苏州大学学报:医学版, 2008(2):310-311.
11.朱若夫,杨惠林,贺喜顺等.颈椎椎弓根钉内固定术治疗下颈椎骨折脱位.中华创伤骨科杂志, 2008(3):249-252.
12.孙韶华,马维虎,黄雷等.颈椎椎弓根螺钉个体化置钉技术的研究.中国骨与关节损伤杂志, 2009(01).
13. Michele, A.A., T.C. Harper, A method of spinal fusion by arthrodesis and iliac bone grafts. Mil Surg, 1949. 104(2):90-4.
14. Panjabi, M.M., J. Duranceau, V. Goel, et al. Cervical human vertebrae. Quantitative three-dimensional anatomy of the middle and lower regions. Spine, 1991. 16(8):861-9.
15. Panjabi, M.M., E.K. Shin, N.C. Chen, et al. Internal morphology of human cervical pedicles. Spine, 2000. 25(10):1197-205.
16. Karaikovic, E.E., M.D. Daubs, R.W. Madsen, et al. Morphologic characteristics of human cervical pedicles. Spine, 1997. 22(5):493-500.
17. Maat, G.J., B. Matricali, E.L. van Persijn van Meerten, Postnatal development and structure of the neurocentral junction. Its relevance for spinal surgery. Spine, 1996. 21(6):661-6.
18. Rezcallah, A.T., R. Xu, N.A. Ebraheim, et al. Axial computed tomography of the pedicle in the lower cervical spine. Am J Orthop, 2001. 30(1):59-61.
19. Ruofu, Z., Y. Huilin, H. Xiaoyun, et al. CT evaluation of cervical pedicle in a Chinese population for surgical application of transpedicular screw placement. Surg Radiol Anat, 2008.
20. Liau, K.M., M.I. Yusof, M.S. Abdullah, et al. Computed tomographic morphometry of thoracic pedicles: safety margin of transpedicular screw fixation in malaysian malay population. Spine, 2006. 31(16):E545-50.
21. Ebraheim, N.A., R. Xu, T. Knight, et al. Morphometric evaluation of lower cervical pedicle and its projection. Spine, 1997. 22(1):1-6.
22. Ugur, H.C., A. Attar, A. Uz, et al. Surgical anatomic evaluation of the cervical pedicle and adjacent neural structures. Neurosurgery, 2000. 47(5):1162-8; discussion 1168-9.
23. Hirano, T., K. Hasegawa, H.E. Takahashi, et al. Structural characteristics of the pedicle and its role in screw stability. Spine, 1997. 22(21):2504-9; discussion 2510.
24.闫德强,谢志军等.颈椎弓根螺钉内固定的解剖学研究.中华骨科杂志, 2002(11):657-661.
25.王东来,唐天驷.下颈椎椎弓根内固定的解剖学研究与临床应用.中华骨科杂志, 1998(11):659-662.
26.杨代耘,王跃等.颈椎椎弓根的形态观测及临床意义.四川解剖学杂志,1997(4):208-211.
27.王东来,唐天驷.下颈椎经椎弓根内固定应用解剖学研究.中国临床解剖学杂志, 1998(4):289-293.
28.孙宇,李志平.颈椎椎弓根的观测及其临床意义.北京医科大学学报, 1993(4):279-280.
29.黄东生,苏培强,马若凡等.颈椎椎弓根Ct测量在椎弓根螺钉内固定中的作用.中国临床解剖学杂志, 2004(2):186-189.
30. Yusof, M.I., L.K. Ming, M.S. Abdullah, et al. Computerized tomographic measurement of the cervical pedicles diameter in a Malaysian population and the feasibility for transpedicular fixation. Spine, 2006. 31(8):E221-4.
31. Abumi, K., M.M. Panjabi, J. Duranceau, Biomechanical evaluation of spinal fixation devices. Part III. Stability provided by six spinal fixation devices and interbody bone graft. Spine, 1989. 14(11):1249-55.
32. Coe, J.D., K.E. Warden, C.E. Sutterlin, 3rd, et al. Biomechanical evaluation of cervical spinal stabilization methods in a human cadaveric model. Spine, 1989. 14(10):1122-31.
33. Jones, E.L., J.G. Heller, D.H. Silcox, et al. Cervical pedicle screws versus lateral mass screws. Anatomic feasibility and biomechanical comparison. Spine, 1997. 22(9):977-82.
34.王东来,唐天驷.五种颈椎内固定方法的稳定性生物力学评价.中华外科杂志, 1999(5):301-303.
35.谢宁,朱青安等,下颈椎后路螺钉技术的拔出强度研究.中国矫形外科杂志, 2001(8):797-798.
36. Ludwig, S.C., J.M. Kowalski, C.C. Edwards, 2nd, et al. Cervical pedicle screws: comparative accuracy of two insertion techniques. Spine, 2000. 25(20):2675-81.
37. Richter, M., B. Cakir, R. Schmidt, Cervical pedicle screws: conventional versus computer-assisted placement of cannulated screws. Spine, 2005. 30(20):2280-7.
38.张峰,王春.下颈椎椎弓根螺钉固定的研究进展.临床和实验医学杂志, 2006(9):1435-1437.
39. Miller, R.M., N.A. Ebraheim, R. Xu, et al. Anatomic consideration of transpedicular screw placement in the cervical spine. An analysis of two approaches. Spine, 1996. 21(20):2317-22.
40. Abumi, K., Y. Shono, M. Ito, et al. Complications of pedicle screw fixation in reconstructive surgery of the cervical spine. Spine, 2000. 25(8):962-9.
41.毛广平,赵建宁,陈跃先等.颈椎椎弓根三种置钉法的实验研究.中国矫形外科杂志, 2005(1):47-50.
42. Liljenqvist, U., L. Hackenberg, T. Link, et al, Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine. Acta Orthop Belg, 2001. 67(2):157-63.
43. Kim, K.D., J.P. Johnson, J.D. Babbitz, Image-guided thoracic pedicle screw placement: a technical study in cadavers and preliminary clinical experience. Neurosurg Focus, 2001. 10(2):E2.
44. Belmont, P.J., Jr., W.R. Klemme, A. Dhawan, et al. In vivo accuracy of thoracic pedicle screws. Spine, 2001. 26(21):2340-6.
45. Lien, S.B., N.H. Liou, S.S. Wu, Analysis of anatomic morphometry of the pedicles and the safe zone for through-pedicle procedures in the thoracic and lumbar spine. Eur Spine J, 2007. 16(8):1215-22.
46. Fisher, C.G., V. Sahajpal, O. Keynan, et al. Accuracy and safety of pedicle screw fixation in thoracic spine trauma. J Neurosurg Spine, 2006. 5(6):520-6.
47. Ebraheim, N.A., G. Jabaly, R. Xu, et al. Anatomic relations of the thoracic pedicle to the adjacent neural structures. Spine, 1997. 22(14):1553-6; discussion 1557.
48. Youkilis, A.S., D.J. Quint, J.E. McGillicuddy, et al. Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery, 2001. 48(4):771-8; discussion 778-9.
49. Liljenqvist, U.R., H.F. Halm, T.M. Link, Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine, 1997. 22(19):2239-45.
50. West, J.L., 3rd, J.W. Ogilvie, D.S. Bradford, Complications of the variable screw plate pedicle screw fixation. Spine, 1991. 16(5):576-9.
51. Kim, Y.J., L.G. Lenke, K.H. Bridwell, et al. Free hand pedicle screw placement in the thoracic spine: is it safe? Spine, 2004. 29(3):333-42; discussion 342.
52. Suk, S.I., W.J. Kim, S.M. Lee, et al. Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine, 2001. 26(18):2049-57.
53. Dvorak, M., S. MacDonald, K.R. Gurr, et al. An anatomic, radiographic, andbiomechanical assessment of extrapedicular screw fixation in the thoracic spine. Spine, 1993. 18(12):1689-94.
54.史亚民,柴伟等.胸椎椎弓根形态测量研究.中国脊柱脊髓杂志, 2002(3):191-193.
55.林炎生,吕发金等.下位腰椎椎弓根内固定术的断层解剖与Ct.中国临床解剖学杂志, 2002(3):194-197.
56. DeCoster, T.A., D.B. Heetderks, D.J. Downey, et al. Optimizing bone screw pullout force. J Orthop Trauma, 1990. 4(2):169-74.
57. Vaccaro, A.R., S.J. Rizzolo, T.J. Allardyce, et al. Placement of pedicle screws in the thoracic spine. Part I: Morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am, 1995. 77(8):1193-9.
58. Cinotti, G., S. Gumina, M. Ripani, et al. Pedicle instrumentation in the thoracic spine. A morphometric and cadaveric study for placement of screws. Spine, 1999. 24(2):114-9.
59. Tan, S.H., E.C. Teo, H.C. Chua, Quantitative three-dimensional anatomy of cervical, thoracic and lumbar vertebrae of Chinese Singaporeans. Eur Spine J, 2004. 13(2):137-46.
60. Kim, N.H., H.M. Lee, I.H. Chung, et al. Morphometric study of the pedicles of thoracic and lumbar vertebrae in Koreans. Spine, 1994. 19(12):1390-4.
61. Datir, S.P., S.R. Mitra, Morphometric study of the thoracic vertebral pedicle in an Indian population. Spine, 2004. 29(11):1174-81.
62. Zindrick, M.R., L.L. Wiltse, A. Doornik, et al. Analysis of the morphometric characteristics of the thoracic and lumbar pedicles. Spine, 1987. 12(2):160-6.
63. Panjabi, M.M., K. Takata, V. Goel, et al. Thoracic human vertebrae. Quantitative three-dimensional anatomy. Spine, 1991. 16(8):888-901.
64. Ebraheim, N.A., R. Xu, M. Ahmad, et al. Projection of the thoracic pedicle and its morphometric analysis. Spine, 1997. 22(3):233-8.
65.王欢喜,邓展生,向铁城等.胸椎弓根与其周围神经解剖关系的研究.湘南学院学报:自然科学版, 2005(4):8-9,12.
66. Husted, D.S., J.J. Yue, T.A. Fairchild, et al. An extrapedicular approach to the placement of screws in the thoracic spine: an anatomic and radiographic assessment. Spine, 2003. 28(20):2324-30.
67. Husted, D.S., A.H. Haims, T.A. Fairchild, et al. Morphometric comparison of the pediclerib unit to pedicles in the thoracic spine. Spine, 2004. 29(2):139-46.
68. Morgenstern, W., S.J. Ferguson, S. Berey, et al. Posterior thoracic extrapedicular fixation: a biomechanical study. Spine, 2003. 28(16):1829-35.
69.严军,宦坚,郑祖根等.上中胸椎椎弓根-肋单位的Ct测量及临床意义.中国临床解剖学杂志, 2007(6):636-639.
70.谢陶敢,陈其昕,李方才等.胸椎椎弓根-肋骨单元与椎弓根的Ct测量.中国脊柱脊髓杂志, 2008(9):665-668.
71.崔新刚,张佐伦,陈海松等.胸椎椎弓根根外内固定的应用解剖学研究及其意义.中华创伤杂志, 2005(10):768-772.
72.殷渠东,郑祖根,蔡建平.置入胸椎“椎弓根-肋骨”单元螺钉的应用解剖和力学测试.中国临床解剖学杂志, 2005(5):538-539.
73. O'Brien, M.F., L.G. Lenke, S. Mardjetko, et al. Pedicle morphology in thoracic adolescent idiopathic scoliosis: is pedicle fixation an anatomically viable technique? Spine, 2000. 25(18):2285-93.
74. White, K.K., R. Oka, A.T. Mahar, et al. Pullout strength of thoracic pedicle screw instrumentation: comparison of the transpedicular and extrapedicular techniques. Spine, 2006. 31(12):E355-8.