椎弓根螺钉系统翻修手术的临床研究及其应力有限元分析
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摘要
外科内固定手术常用于治疗胸腰段及腰椎疾患,如骨折、退行性疾病、肿瘤、滑脱以及严重的椎间盘疾患等。曾有几种内固定系统应用于临床。自60年代经椎弓根植入短节段螺钉这一内固定技术应用于临床以来,以其固定坚强,能同时固定脊柱前、中、后柱,且仅涉及病椎上下椎体,手术创伤小、复位满意、安全简便等的优点,在临床上已获得越来越广泛的应用。目前,椎弓根螺钉内固定技术己成为治疗下胸椎及腰椎疾患的标准手术,但是随着该技术的普及,其术后翻修的病例逐年增多。由于翻修手术较第一次更复杂,风险更大,或更换内植物,给患者带来痛苦、增加患者的经济负担,引起患者的强烈不满,常常导致医疗纠纷的发生。因此,如何减少椎弓根螺钉手术后翻修是我国骨科界面临的一项重要课题。本课题对翻修的原因、翻修的方式、翻修手术的效果及载荷下椎弓根的应力分布进行了研究,以总结经验,改进手术技术器械设计,提高手术成功率。
翻修的主要原因包括:椎弓根螺钉系统的断裂、螺钉松动、神经根刺激及假关节形成等。其中椎弓根螺钉内固定系统的断裂最容易因患者不满而引起医疗纠纷。Yahiro研究显示在所有椎弓根螺钉内固定术的患者中系统断裂占7.1%,而其他并发症为5.6%。Yuan等报告6.7%的骨折患者,2.6%的退行性疾病的患者术后发生椎弓根螺钉内固定系统失效或失败。我院592例椎弓根螺钉内固定术中4.9%因内固定系统失效或失败而进行翻修,在86例翻修手术中AR及RF内固定系统翻修49例,占翻修病例的56.92%。因此,有必要对这二种内固
Surgical fixation is used to treat patients with certain lumbar spinal conditions such as fractures, degenerative spondylolisthesis, tumors, degenerative scoliosis, and sever disc disease. Several devices have been used for this purpose. The pedicle screw fixation device had been applied to clinic in 1960s. Because of its hard fixtation , little operational trauma and easy operational way ,the method has been used widely now; now, the method has be looked as the standard way to treat low back spine disorders; at the same time ,more and more people suffered for some disapprociate operation treatment; some of them have to accept another operation to dissolve the pain; and some medical dispute had resulted from them; and now how and what should we do to solve the question has become an important topic.The most important factors which affect the revision operations are the breakage of the pedicle screw, lossening of pedicle fixation, dislocation of lumbar internal device (7 cases) and lumbar adjacent instability after fixation, and so on. Among them, the breakage of the pedicle screw could often result in medical tackle. It's reported by Yahiro that 7.1% of all patients had broken pedicle screws, and Yuan et al reported that the internal fixation system failure could be seen in 6.7% bone-fracture patients, and such phenomena could also be seen in about 2.6%
retrogression disease patients ; in our 592 patients ,the data is about 4.9%.AF and RF fixation system failure is 49 patients ,which is 56.92% of all revision operations, so it is necessary to know the stress distribute characteristic of the 2 fixation system. The finite element method is an ideal tool to study the stress distribution in all parts of the fixation device and hence design a better fixation device in the study. The models of AF and RF fixation system have been set up.We could check different stress distribute on them under different conditions,which is important for doctors and the apparatus designers.Chapter One Clinical Research of Revision of Pedicle ScrewsObjective1 .In order to increases the success rates of the operation and satisfactory clinical outcomes .factors which result in the breakage of short segment pedicle screw instrumentation after spinal internal fixation were taken into account.2. To discuss such factors's role on the reason of revision operation and their effect on the outcome of follow-up visit after revision operation .for example age,sex,operation way .profession and so on.3. To evaluate the therapeutic effect of revision operation and their follow-up visit outcome.4. To find out the ways to decrease complications of short segment pedicle screw after spinal internal fixation.Methods1. To find the situation of implant fixation fixation, all patients who need accept revision operation should be examined by X-ray examination, some of them should be examined by CT or MRI. go over their firstly operation reason and operation way .treatment post-operation. Analyses the reason of the revision ;decide the revision fashion; evaluate the outcome of revision operation and its follow-up visit
outcome.the outcome data would be evaluated by Prolo function and economical standard.2. Stastical analyses:the qualitation data would be described by percent;and the quantitation data would be described by mean±standard deviation;before been analysised;all should be tested by Kolmogorov-Smimov Z test;between different groups; consistent with mormal distribution datas would be tested by independence sample T test;other datas would be tested by Mann-Whitney test; Logistic regression way would be used to analyse the dangerous factor.all these test would be finished by SPSS 11.0 stastical soft.Rusultsl.the stastical analysis of population:among all revision operation cases;the data were analyzed .significant difference between age (F=6.205> P < 0.001) % occupation (F=14.28> P=0.048) ;but no significant difference between sex.2.Compared the first time operation with the revision operation cases; significant difference could be found between the operational time the flood in the operation;at the same time,the operation way were more difficult.The P value of them were 0.485, 0.42 and < 0.001 by turns.3.The cause to the revision operation cases;the brake of implanted fixation system,the loosen of crews,the stimulation to nerve roots and the formation of false articular joint occupy 93% of all cases.Among them,the technical cause occupy 76%,the other is non- technical causes.3.1 The technical cause to the revision operation: (Dthe uncorrectly indication of operation;especially is too loosen;more care should be payed to the old bone rarefaction and the post-operation of young lumbar disc protrusion(the average age of false articular joint formation and screws loosen were 52.5 years old and 50.91 years old ). ?The unsuitable operation way and implant fixation system. ?The
technical of operation, especially the location of screws; among the group; 22 cases of screws loosen and nerve's stimulation were caused by the unsuitable screws location ;the major cause is unfamiliar with anatomy structure, especially on fracture and Degeneration cases; incorrect use of spinal technique(the wrong angel and depth 10cases);and one revision operation was caused by the laceration of putamen and uncorrectly repaired. (4) Uncompletely depression of canalis spinalis,conclude the uncompletely depression of nerve roots;the uncompletely depression of disci intervertebrales;and unsatisfied replacement of bone fracture and slippage of vertebral body. ?The incorrectness way of bone graft;among the revision operation group,all cases accepted lateral vertebral plate bone graft;and the ratio of this bone graft confluence was very low. ?The incorrectional treatment post-operation loading too early;and the shorter protection of orthosis;and the fatigue failure(the average time is 18.85ms) or loosen (the average time is 19ms) of implant fixation system for later dislodgment.3.2 The untechnical causes of complication: (J)The quality of implanted fixation system,among the revision group;the stainless steel material account for 91.67%.? The insufficient design of implanted fixation system;the uneven stress distribution of implanted systems;the lower screws and the conjunction location between the screws and roles were the main stress centrostigma,and at the same time they were the major location where the breakage often happen(18 cases ,account 75% of all ).(3)The spinal vitodynamics character on the bio-radian location often result in so greater stress distribution on the implanted systems(Tnand Li segment 12 cases accounting for 50%, L5 and Si7 cases accounting for 29.17%). ?.The change of vitodynamics post-implanted fixation often result in the close together segment's retrogression;which would accelerate the formation of false articular joint,among the group ,such cases were 8 cases.
4.The revision ratio of different systems is by turns : Dick 17.78% ,Opusl7.65%,Gssl4.29%,Steffel3.25%,AF9.15%,RF8.14%,Diapason5.56% ,CD4.88%.The cause of major revision systems are as follow:among 25 AF revision cases,the breakage's cases are 11 cases,accounting 44%;and among 24 RF revision cases and 19 steffe revision cases,the nerve roots'stimulation cases are 7 cases and 8 cases;accounting the different style cases 29.2% and 42.1%;but no significant can be found among Dick systems.5. The result of revision operations:the data of the first time operation ,the time before or late of revision operations and 6 months follow-up were analysied by analysis of variance .Significant difference can be found among different time group.Tthe result proves that revision operation has good result,but no significant difference could be found among different diagnosis;such result stands that no technical difference among different doctors.The nerve roots' stimulation among the single segment fixation systems are 14 cases ( 38.9% ) ;and such data of multi-segments fixation systems are 15case (32.0%) significant difference could be found between different segments( F=5. 465, P=0. 001) or different operational times (F=314.23, P<0.001) ,and single segment fixation has better result; the result of nerve roots' stimulation case has worse result than other 4 causes;but no significant difference could be found among other 4 kinds causes.The major way of revision operation in our hospital is the dislodgment of implanted fixation systems,accountiong 62.79% of all cases.The analysis of different revision ways stands depression of vertebral canal,loosen of nerve roots, the repair of hard mask and die shorten of screws' tail have better result, ignificant difference could be found among different revision ways(P<0.001). Conclusion1. The breakage of pedicle screw is an complex problem. Many reasons can
cause this complication,including material ,device ,and type of the instrumentation , surgical operation and postoperative treatment.Proper preoperative planning, careful selection of the pedicle screw instrumentation,surgical procedures and suitable postoperative treatment are imperative to prevent this kind of breakage. X-rays should be carefully examined before operation,the indication of operation should be controlled cruelty, and it is essential for spinal surgeons to choose correct surgical approaches,spinal instrumentation techniques and proper post-op treatment in order to minimize this complication; synthetic way should by done to reduce the ratio of revision operations.2. The result of revision operation were relation with the first time operation's way, the fixation segments and the way of bone graft or the revision ways.Good result could be got through revision ways,in order to raise the life quality of patients,control the patients'stiuation,reduce the genesis of medical dispute; revision operationg should be acted as soon as possible ,when the man did need revision way.Chapter two The Setup Finite Element Model of AF and RF ImplantedFixation System and Biomechanics Analysis Objective1. Set up the AF and RF implanted fixation systems' finite element model to mater the stress distribution under loaded.2. Study the the different stress distribution of AF and RF implanted fixation systems under different angel; to find the best angel to reduce the breakage of AF and RF implanted fixation systems. And raise the ratio of operation success and offer the
biomechanics proof for clinical works.3. Study the feature of AF and RF implanted fixation systems' stress distribution ,to master the difference of single segment or multi-segments implanted fixation systems.Methodsl.In clinical works ,RF systems is one single segment fixation systems;and the AF systems were multi-segments fixation system; all material were made of stainless steel;the elastic modulus of them were 1.13X10uN/ m2and the Poisson's ratio were O.3;the adopted Gaussian points of AF's screw and conjunction role were 4362 and 1075;the calculation unit were 116510 and 3608;and ;the adopted Gaussian points of RF's screw and conjunction role were 3350 and 980;the calculation unit were 95630 and 2536;all the measure data were input into the computer ,with the help of Auto CAD and the support of Super-SAP finite element analysis system;the CAD model were translated into finite element model; the different finite element model under Y axes angel 0°,the X axes 0°,5o,10o,15°;and the X axes 0°,the Y axes angel 0°,7°,15° were setup.The normal body load 500N and the ante-drag load 500N were loaded;the stress distribution and straining were measured; measure the Von Misses stress on different points;all the screws were divided into 20 segments,and the conjunction roles were divided into 12 segments from front to fro.All the implanted systems were provided by chande medical apparatus factory.result:1. AF implanted fixation systems:the greatest stress point were the lower foreside conjunction point of screw and roles ,and its rearward stress was relatively lower. The stress loading on inferiority screw roots were higher than the upper sides; no significant difference could be found between the up or lower roots,or the right
and left sides;but the stress loading on right and left sides were higher than it on up or lower roots. With the increase of X axes angel,the stress on the conjunction point between screw and roles increases; with the increase of Y axes angel;the load on the inferiority screw and roles increases,but the stress on the upper screws decreases.2.The greatest stress point on RF implanted fixation systems were roots of screws;among all sides of screws;the upper side of upper screws and the inferiority side of inferiority screw bore the greatest stress;and the inferiority screw bore higher stress than the upper screws; the stress of the lower foreside conjunction point of screw and roles were higher than others sides; With the increase of X axes angel,the stress on the conjunction point between screw and roles increases; with the increase of Y axes angel;the load on the inferiority screw and roles increases,but the stress on the upper screws decreases.3. Compared with the stress distribution between AF and RF: the stress centered point of screws on RF were higher than them on AF;but the the stress centered point of roles on AF were higher than them on RF. Conclusionl.With analysised by finite element way;the stress on different parts of implanted fixations were different;the inferiority screws and the inferiority side of conjunction role were the main stress centered point; and the stress on implanted fixations changed with the change of Y and X axes angel.In order to decrease the stress on implanted fixations and the breakage ratio of implanted systems,the angel which could result in the lower stress loading should be elected;between the single segment and multi-segments implanted systems;the stress on screws and roles were different.2.The study offer the proof of anti-fatigue intensity on stress center point for the design of medical apparatus; all the stress center point were the most often point
where the breakage happen.and the result of finite element measurement were the same as clinical result;the result test: the result of finite element measurement were reliable.
翻修的主要原因包括:椎弓根螺钉系统的断裂、螺钉松动、神经根刺激及假关节形成等。其中椎弓根螺钉内固定系统的断裂最容易因患者不满而引起医疗纠纷。Yahiro研究显示在所有椎弓根螺钉内固定术的患者中系统断裂占7.1%,而其他并发症为5.6%。Yuan等报告6.7%的骨折患者,2.6%的退行性疾病的患者术后发生椎弓根螺钉内固定系统失效或失败。我院592例椎弓根螺钉内固定术中4.9%因内固定系统失效或失败而进行翻修,在86例翻修手术中AR及RF内固定系统翻修49例,占翻修病例的56.92%。因此,有必要对这二种内固
Surgical fixation is used to treat patients with certain lumbar spinal conditions such as fractures, degenerative spondylolisthesis, tumors, degenerative scoliosis, and sever disc disease. Several devices have been used for this purpose. The pedicle screw fixation device had been applied to clinic in 1960s. Because of its hard fixtation , little operational trauma and easy operational way ,the method has been used widely now; now, the method has be looked as the standard way to treat low back spine disorders; at the same time ,more and more people suffered for some disapprociate operation treatment; some of them have to accept another operation to dissolve the pain; and some medical dispute had resulted from them; and now how and what should we do to solve the question has become an important topic.The most important factors which affect the revision operations are the breakage of the pedicle screw, lossening of pedicle fixation, dislocation of lumbar internal device (7 cases) and lumbar adjacent instability after fixation, and so on. Among them, the breakage of the pedicle screw could often result in medical tackle. It's reported by Yahiro that 7.1% of all patients had broken pedicle screws, and Yuan et al reported that the internal fixation system failure could be seen in 6.7% bone-fracture patients, and such phenomena could also be seen in about 2.6%
retrogression disease patients ; in our 592 patients ,the data is about 4.9%.AF and RF fixation system failure is 49 patients ,which is 56.92% of all revision operations, so it is necessary to know the stress distribute characteristic of the 2 fixation system. The finite element method is an ideal tool to study the stress distribution in all parts of the fixation device and hence design a better fixation device in the study. The models of AF and RF fixation system have been set up.We could check different stress distribute on them under different conditions,which is important for doctors and the apparatus designers.Chapter One Clinical Research of Revision of Pedicle ScrewsObjective1 .In order to increases the success rates of the operation and satisfactory clinical outcomes .factors which result in the breakage of short segment pedicle screw instrumentation after spinal internal fixation were taken into account.2. To discuss such factors's role on the reason of revision operation and their effect on the outcome of follow-up visit after revision operation .for example age,sex,operation way .profession and so on.3. To evaluate the therapeutic effect of revision operation and their follow-up visit outcome.4. To find out the ways to decrease complications of short segment pedicle screw after spinal internal fixation.Methods1. To find the situation of implant fixation fixation, all patients who need accept revision operation should be examined by X-ray examination, some of them should be examined by CT or MRI. go over their firstly operation reason and operation way .treatment post-operation. Analyses the reason of the revision ;decide the revision fashion; evaluate the outcome of revision operation and its follow-up visit
outcome.the outcome data would be evaluated by Prolo function and economical standard.2. Stastical analyses:the qualitation data would be described by percent;and the quantitation data would be described by mean±standard deviation;before been analysised;all should be tested by Kolmogorov-Smimov Z test;between different groups; consistent with mormal distribution datas would be tested by independence sample T test;other datas would be tested by Mann-Whitney test; Logistic regression way would be used to analyse the dangerous factor.all these test would be finished by SPSS 11.0 stastical soft.Rusultsl.the stastical analysis of population:among all revision operation cases;the data were analyzed .significant difference between age (F=6.205> P < 0.001) % occupation (F=14.28> P=0.048) ;but no significant difference between sex.2.Compared the first time operation with the revision operation cases; significant difference could be found between the operational time the flood in the operation;at the same time,the operation way were more difficult.The P value of them were 0.485, 0.42 and < 0.001 by turns.3.The cause to the revision operation cases;the brake of implanted fixation system,the loosen of crews,the stimulation to nerve roots and the formation of false articular joint occupy 93% of all cases.Among them,the technical cause occupy 76%,the other is non- technical causes.3.1 The technical cause to the revision operation: (Dthe uncorrectly indication of operation;especially is too loosen;more care should be payed to the old bone rarefaction and the post-operation of young lumbar disc protrusion(the average age of false articular joint formation and screws loosen were 52.5 years old and 50.91 years old ). ?The unsuitable operation way and implant fixation system. ?The
technical of operation, especially the location of screws; among the group; 22 cases of screws loosen and nerve's stimulation were caused by the unsuitable screws location ;the major cause is unfamiliar with anatomy structure, especially on fracture and Degeneration cases; incorrect use of spinal technique(the wrong angel and depth 10cases);and one revision operation was caused by the laceration of putamen and uncorrectly repaired. (4) Uncompletely depression of canalis spinalis,conclude the uncompletely depression of nerve roots;the uncompletely depression of disci intervertebrales;and unsatisfied replacement of bone fracture and slippage of vertebral body. ?The incorrectness way of bone graft;among the revision operation group,all cases accepted lateral vertebral plate bone graft;and the ratio of this bone graft confluence was very low. ?The incorrectional treatment post-operation loading too early;and the shorter protection of orthosis;and the fatigue failure(the average time is 18.85ms) or loosen (the average time is 19ms) of implant fixation system for later dislodgment.3.2 The untechnical causes of complication: (J)The quality of implanted fixation system,among the revision group;the stainless steel material account for 91.67%.? The insufficient design of implanted fixation system;the uneven stress distribution of implanted systems;the lower screws and the conjunction location between the screws and roles were the main stress centrostigma,and at the same time they were the major location where the breakage often happen(18 cases ,account 75% of all ).(3)The spinal vitodynamics character on the bio-radian location often result in so greater stress distribution on the implanted systems(Tnand Li segment 12 cases accounting for 50%, L5 and Si7 cases accounting for 29.17%). ?.The change of vitodynamics post-implanted fixation often result in the close together segment's retrogression;which would accelerate the formation of false articular joint,among the group ,such cases were 8 cases.
4.The revision ratio of different systems is by turns : Dick 17.78% ,Opusl7.65%,Gssl4.29%,Steffel3.25%,AF9.15%,RF8.14%,Diapason5.56% ,CD4.88%.The cause of major revision systems are as follow:among 25 AF revision cases,the breakage's cases are 11 cases,accounting 44%;and among 24 RF revision cases and 19 steffe revision cases,the nerve roots'stimulation cases are 7 cases and 8 cases;accounting the different style cases 29.2% and 42.1%;but no significant can be found among Dick systems.5. The result of revision operations:the data of the first time operation ,the time before or late of revision operations and 6 months follow-up were analysied by analysis of variance .Significant difference can be found among different time group.Tthe result proves that revision operation has good result,but no significant difference could be found among different diagnosis;such result stands that no technical difference among different doctors.The nerve roots' stimulation among the single segment fixation systems are 14 cases ( 38.9% ) ;and such data of multi-segments fixation systems are 15case (32.0%) significant difference could be found between different segments( F=5. 465, P=0. 001) or different operational times (F=314.23, P<0.001) ,and single segment fixation has better result; the result of nerve roots' stimulation case has worse result than other 4 causes;but no significant difference could be found among other 4 kinds causes.The major way of revision operation in our hospital is the dislodgment of implanted fixation systems,accountiong 62.79% of all cases.The analysis of different revision ways stands depression of vertebral canal,loosen of nerve roots, the repair of hard mask and die shorten of screws' tail have better result, ignificant difference could be found among different revision ways(P<0.001). Conclusion1. The breakage of pedicle screw is an complex problem. Many reasons can
cause this complication,including material ,device ,and type of the instrumentation , surgical operation and postoperative treatment.Proper preoperative planning, careful selection of the pedicle screw instrumentation,surgical procedures and suitable postoperative treatment are imperative to prevent this kind of breakage. X-rays should be carefully examined before operation,the indication of operation should be controlled cruelty, and it is essential for spinal surgeons to choose correct surgical approaches,spinal instrumentation techniques and proper post-op treatment in order to minimize this complication; synthetic way should by done to reduce the ratio of revision operations.2. The result of revision operation were relation with the first time operation's way, the fixation segments and the way of bone graft or the revision ways.Good result could be got through revision ways,in order to raise the life quality of patients,control the patients'stiuation,reduce the genesis of medical dispute; revision operationg should be acted as soon as possible ,when the man did need revision way.Chapter two The Setup Finite Element Model of AF and RF ImplantedFixation System and Biomechanics Analysis Objective1. Set up the AF and RF implanted fixation systems' finite element model to mater the stress distribution under loaded.2. Study the the different stress distribution of AF and RF implanted fixation systems under different angel; to find the best angel to reduce the breakage of AF and RF implanted fixation systems. And raise the ratio of operation success and offer the
biomechanics proof for clinical works.3. Study the feature of AF and RF implanted fixation systems' stress distribution ,to master the difference of single segment or multi-segments implanted fixation systems.Methodsl.In clinical works ,RF systems is one single segment fixation systems;and the AF systems were multi-segments fixation system; all material were made of stainless steel;the elastic modulus of them were 1.13X10uN/ m2and the Poisson's ratio were O.3;the adopted Gaussian points of AF's screw and conjunction role were 4362 and 1075;the calculation unit were 116510 and 3608;and ;the adopted Gaussian points of RF's screw and conjunction role were 3350 and 980;the calculation unit were 95630 and 2536;all the measure data were input into the computer ,with the help of Auto CAD and the support of Super-SAP finite element analysis system;the CAD model were translated into finite element model; the different finite element model under Y axes angel 0°,the X axes 0°,5o,10o,15°;and the X axes 0°,the Y axes angel 0°,7°,15° were setup.The normal body load 500N and the ante-drag load 500N were loaded;the stress distribution and straining were measured; measure the Von Misses stress on different points;all the screws were divided into 20 segments,and the conjunction roles were divided into 12 segments from front to fro.All the implanted systems were provided by chande medical apparatus factory.result:1. AF implanted fixation systems:the greatest stress point were the lower foreside conjunction point of screw and roles ,and its rearward stress was relatively lower. The stress loading on inferiority screw roots were higher than the upper sides; no significant difference could be found between the up or lower roots,or the right
and left sides;but the stress loading on right and left sides were higher than it on up or lower roots. With the increase of X axes angel,the stress on the conjunction point between screw and roles increases; with the increase of Y axes angel;the load on the inferiority screw and roles increases,but the stress on the upper screws decreases.2.The greatest stress point on RF implanted fixation systems were roots of screws;among all sides of screws;the upper side of upper screws and the inferiority side of inferiority screw bore the greatest stress;and the inferiority screw bore higher stress than the upper screws; the stress of the lower foreside conjunction point of screw and roles were higher than others sides; With the increase of X axes angel,the stress on the conjunction point between screw and roles increases; with the increase of Y axes angel;the load on the inferiority screw and roles increases,but the stress on the upper screws decreases.3. Compared with the stress distribution between AF and RF: the stress centered point of screws on RF were higher than them on AF;but the the stress centered point of roles on AF were higher than them on RF. Conclusionl.With analysised by finite element way;the stress on different parts of implanted fixations were different;the inferiority screws and the inferiority side of conjunction role were the main stress centered point; and the stress on implanted fixations changed with the change of Y and X axes angel.In order to decrease the stress on implanted fixations and the breakage ratio of implanted systems,the angel which could result in the lower stress loading should be elected;between the single segment and multi-segments implanted systems;the stress on screws and roles were different.2.The study offer the proof of anti-fatigue intensity on stress center point for the design of medical apparatus; all the stress center point were the most often point
where the breakage happen.and the result of finite element measurement were the same as clinical result;the result test: the result of finite element measurement were reliable.
引文
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[15]. Colak A, Kulay M, Demirean N, et al. MR imaging for early complication of transpedicular screw fixation[J]. Eur Spine J, 1999, 8(2): 151-155
[16].陈德玉,贾连顺,袁文等.颈椎前路带锁钢板临床应用的并发症及预防[J].中华骨科杂志,2001,21(5):287～289.
[17]. Suk SI, Kim WJ, Lee SM, et al. Thoracic pedicle screw fixation spinal deformities: a rethey really safe[J]? Spine. 2001, 26(18): 2049～2057.
[18].李增春,张志玉,王以进.骨密度对椎弓根螺钉系统固定的影响之生物力学研究[J].中华骨科杂志,1998,18(5):293-297.
[19].朱青安,李鉴轶,赵卫东等.PMMA强化和修复椎弓根螺钉的生物力学研究[J].中华骨科杂志,2000,20:283-286.
[20]. Blumenthal S, Cillk. Complications of the wiltse pedicle screw fixation system[J]. Spine, 1993, 18: 1867-1871
[21].杨惠林,唐天驷,朱国良,等.胸腰椎骨折患者的椎弓根短节段脊柱内固定器治疗[J].中华外科杂志,1989,27:272-275
[22]. Stephen I, Esses MD, Barton Sachs, et al. Complications associated with the technique of pedicle screw fixation[J]. Spine, 1993, 18(15): 2231-2239
[23].杜心如,叶启彬,赵铃秀等.腰椎人字嵴顶点椎弓根螺钉进钉方法的解剖学研究[J].中国临床解剖学杂志,2002,20(2):86-88.
[24]. Arand M, Hartwig E, Hebola D, et al. Precisionanaly sisofnavigation assisted implanted thoracic and lumbar pedicle screws[J]. Unfall chir urg, 2001, 104(11): 1076～1081.
[25]. Choi WW, Green BA, Levi AD, et al. Computer assisted fluoroscopic targeting system for pedicle screw insertion[J]. Neurosurgery, 2000, 47: 872～880.
[26]. Assaker R, Reyns N, Vinchon M, et al. Transpedicular screw placement: image guided versus lateral view fluoroscopy: in vitro simulation [J]. Spine, 2001, 26: 2160～2164.
[27]. Myles RT, Fong B, Esses SI, et al. Radiographic verification of pedicle screw pilot hole placement using Kirshner wires versus beaded wires[J]. Spine, 1999, 24: 476～80.
[28].杨惠林,唐天驷,朱国良,等.钉杆角椎弓根内固定系统治疗胸腰椎骨折的研究[J].中华骨科杂志,1995,15:570-572
[29]. Mckinley TO, Mclain RF, Yerby SA, et al. Characteristics of pedicle screw loading. Effect of surgical technique on intravertebral and intrapedicular bending moments [J]. Spine, 1999, 24: 18-24.
[30].李增春,王以进.椎弓根螺钉应用于骨质疏松椎体的生物力学研究[J].医用生物力学,1997,227-230
[31]. Hirano T, Hasegawa K, Takahashi HE, et al. Structural characteristics of the pedicle and its role in screw stability [J]. Spine, 1997, 22: 2504-2510.
[32].王向阳.加强和维持椎弓根螺钉系统稳定性的研究进展[J].中国矫形外科杂志,2002,9(1):57-60.
[33]. Polly DW Jr, Orehowski JR, Ellengogen RG. Revision pedicle screws, bigger, longer shims-what is best [J]? Spine 1998, 23: 1374-1379
[34]. Hirano T, Hasegawa K, Washio T, et al. Fracture risk during pedicle screw insertion in osteoporotic Spine [J]. J Spinal Disord, 1998, 11: 493-497.
[35].王正,等.椎弓根螺钉内固定稳定性的生物力学测试[J].医用生物力学, 2002,17:80-84.
[36].王向阳.加强和维持椎弓根螺钉系统稳定性的研究进展[J].中国矫形外科杂志,2002,9(1):57-60.
[37]. Christensen FB, Dalstra M, Sejling F, et al. Titanium-alloy enhances bone-pedicle screw fixation: mechanical and histomorphometrical results of titanium-alloy versus stainless steel[J]. Eur Spine J, 2000, 9: 97-103.
[38]. Deligianni D, Korovessis P, Baikousis A, et al. Factor analysis of the effectiveness of transfixation and rod characteristics on the TSRH screw-rod instrumentation[J]. Spinal Disord, 2000, 13: 50-57
[39]. Lim TH. Eck JC, An HS, et al. Biomechanics of transfixation in pedicle screw instrumentation [J]. Spine, 1996, 21: 2224-2229
[40]. West JT, Ogilive JW, Bradford DS. Complication of the variable screw plate fixation[J]. Spine, 1991, 16: 576-579
[41]. Steffe AD, Biscup RS, Sitkowski. Segmental spine plates with pediacle screw fixation[J]. Clin Orthop, 1986, 203: 45-53
[42]. McKinley TO, McLain RF, Yerby SA, et al.Characteristics of pedicle screw loading. Effect of surgical technique on intravertebral and intrapedicular bending moments [J]. Spine, 1999; 24(1): 18-24.
[43]. Biedermann L. Biomechanics of pedicle fixation as related to imp; and design. Presented at the American-European Meeting on Pedicle fixation of the Spine and Other Advanced Techniques. Munich, Germany, 1994
[44].张光泊.浅谈脊柱内固定的应用与植骨融合[J].中国脊柱脊髓损伤杂志,2002,5:325
[45].史亚民,侯树勋,姚长海等.椎管环形减压治疗胸腰椎骨折[J].中国脊柱脊髓杂志,1999,9:89～90.
[46]. Cripton PA, Jain GM, Wittenberg RH, et al. Load-sharing characteristics of stabilized lumdar spine segments [J]. Spine, 2000, 25: 170-179.
[47].张贵林,荣国威,丁占云,等.脊柱胸腰段骨折术后椎弓根螺丝钉断裂及弯曲松动的原因分析[J].中华骨科杂志,2000,2:470-472.
[48]. Christensen FB, Dalstra M, Sejling F, et al. Titanium-alloy enhances bone-pedicle screw fixation:mechanical and histomorphometfical results of titanium-alloy versus stainless steel[J]. Eur Spine J, 2000, 9: 97-103.
[49]. Dekutoski MB, Schendel MJ, Ogilvie JW, et al. Comparison of invivo and invitro adjacent segment motion after lumbar fusion[J]. Spine, 1994, 19: 1745 1751.
[50]. Mcafee PC, Farey ID, Sutterlin TC. The effects of spinal implant rigidity on vertebral bone density: Acanine model[J]. Spine, 1991,16(suppl): 190 197.
[51]. Kotani YC, Cunningham BW, Cappuccion A, et ai. The effects of spinal fixation and destabilization on the biomechanical and histologic proper ties of spinal ligaments: A invivos study[J]. Spine, 1998, 23: 677 682.
[52]. Shono Y, Kaneda K, Abumi K, et al. Stability of posterior spinal instrumentation and its effects on adjacent motion segments in the lumbaosacral spine[J]. Spine, 1998, 23: 1550 1558.
[53]. Lim TH, Pathwardham AG, Hong JH, et al. Effect of instrumented fusion on the biomechanics of adjacent segmented at the 42nd Annual Meeting, Orthopaedic Research Society, Atlanta, GA, 1996, 19-22.
[54].黄继锋,朱青安,钟世镇.5种后路脊柱内固定器械的生物力学评价[J].中华骨科杂志,1997,17(9):539 543.
[55]. Lim TH, Eck JC, An HS, et al. Biomechanics of transfixation in pedicle screw instrumentation[J]. Spine, 1996, 21: 2224-2229.
[56]. Rahm MD, Hall BB. Adjacent-segment degeneration after lumbar fusion with instrumentation: A retrospective study[J]. J Spinal Disord, 1996, 9: 392-400.
[57]. Niu CC, Chen WJ, Chen LH, et al. Reduction-fixation spinal system in spondylolisthesis[J]. Am J Orthop, 1996, 25: 418-24.
[58]. Chow DHK, Luk KDK, Evans JJ, et al. Effects of short anterior lumbar interbody fusion on biomechanics of neighboring unfused segments[J]. Spine 1996, 21: 549-55.
[59]. Fritsch EW, Heisel J, Rupp S. The failed back surgery syndrome[J]. Spine, 1996, 21: 626-33.
[60].叶晓健,沈康平,贾连顺等.脊柱内固定返修的原因和对策[J].中国矫形外科杂志,2002,10(13):1277—1279.
[61]. David W, Joseph R, Richard G. Revision pedicle screw. Big, longer, shimswhat is best? [J]. Spine, 1998, 23 (12): 1374-1379.
[62]. Arand M, Hartwig E, Hebola D, et al. Precisionanaly sisofnavigation assisted implanted thoracic and lumbar pedicle screws[J].Unfall chir urg, 2001, 104 (11): 1076～1081.
[63]. AccaroAR, BallST. Indications for instrumentation in degenerative lumbar spinal disorders. Orthopedics, 2000; 23(3): 260
[64]. Herkowitz HN. Spine update. Degenerative lumbar spondylolis-thesis[J]. Spine, 1995, 20(9): 1084
[65]. Sjostrom L, Karlstrom G, Pech P, et al. Indirect spinal canal decompression in burst fractures treated with pedicle screw instrumentation[J].Spine, 1996, 21: 113-123.
[66]. Cripton PA, Jain GM, Wittenberg RH, et al. Load-sharing characteristics of stabilized lumdar spine segments [J]. Spine, 2000, 25: 170-179.
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[12]. Boos N, Webb JK. Pedicle screw fixation in spinal disorder, a European view[J]. Eur Spine, 1997, 6: 2-18
[13]. Myles RT, Fong B, Esses SI, et al. Radiographic verification of pedicle screw pilot hole placement using kirshner wires versus beased wires[J]. Spine, 1999, 24: 476-480
[14]. Farbar CL, Place HM, Mazur RA, et al. Accuracy of pedicle screw placement in lumbar fusion by plain radiograph and computed tomography[J]. Spine, 1995, 20(13): 1494-1499
[15]. Colak A, Kulay M, Demirean N, et al. MR imaging for early complication of transpedicular screw fixation[J]. Eur Spine J, 1999, 8(2): 151-155
[16].陈德玉,贾连顺,袁文等.颈椎前路带锁钢板临床应用的并发症及预防[J].中华骨科杂志,2001,21(5):287～289.
[17]. Suk SI, Kim WJ, Lee SM, et al. Thoracic pedicle screw fixation spinal deformities: a rethey really safe[J]? Spine. 2001, 26(18): 2049～2057.
[18].李增春,张志玉,王以进.骨密度对椎弓根螺钉系统固定的影响之生物力学研究[J].中华骨科杂志,1998,18(5):293-297.
[19].朱青安,李鉴轶,赵卫东等.PMMA强化和修复椎弓根螺钉的生物力学研究[J].中华骨科杂志,2000,20:283-286.
[20]. Blumenthal S, Cillk. Complications of the wiltse pedicle screw fixation system[J]. Spine, 1993, 18: 1867-1871
[21].杨惠林,唐天驷,朱国良,等.胸腰椎骨折患者的椎弓根短节段脊柱内固定器治疗[J].中华外科杂志,1989,27:272-275
[22]. Stephen I, Esses MD, Barton Sachs, et al. Complications associated with the technique of pedicle screw fixation[J]. Spine, 1993, 18(15): 2231-2239
[23].杜心如,叶启彬,赵铃秀等.腰椎人字嵴顶点椎弓根螺钉进钉方法的解剖学研究[J].中国临床解剖学杂志,2002,20(2):86-88.
[24]. Arand M, Hartwig E, Hebola D, et al. Precisionanaly sisofnavigation assisted implanted thoracic and lumbar pedicle screws[J]. Unfall chir urg, 2001, 104(11): 1076～1081.
[25]. Choi WW, Green BA, Levi AD, et al. Computer assisted fluoroscopic targeting system for pedicle screw insertion[J]. Neurosurgery, 2000, 47: 872～880.
[26]. Assaker R, Reyns N, Vinchon M, et al. Transpedicular screw placement: image guided versus lateral view fluoroscopy: in vitro simulation [J]. Spine, 2001, 26: 2160～2164.
[27]. Myles RT, Fong B, Esses SI, et al. Radiographic verification of pedicle screw pilot hole placement using Kirshner wires versus beaded wires[J]. Spine, 1999, 24: 476～80.
[28].杨惠林,唐天驷,朱国良,等.钉杆角椎弓根内固定系统治疗胸腰椎骨折的研究[J].中华骨科杂志,1995,15:570-572
[29]. Mckinley TO, Mclain RF, Yerby SA, et al. Characteristics of pedicle screw loading. Effect of surgical technique on intravertebral and intrapedicular bending moments [J]. Spine, 1999, 24: 18-24.
[30].李增春,王以进.椎弓根螺钉应用于骨质疏松椎体的生物力学研究[J].医用生物力学,1997,227-230
[31]. Hirano T, Hasegawa K, Takahashi HE, et al. Structural characteristics of the pedicle and its role in screw stability [J]. Spine, 1997, 22: 2504-2510.
[32].王向阳.加强和维持椎弓根螺钉系统稳定性的研究进展[J].中国矫形外科杂志,2002,9(1):57-60.
[33]. Polly DW Jr, Orehowski JR, Ellengogen RG. Revision pedicle screws, bigger, longer shims-what is best [J]? Spine 1998, 23: 1374-1379
[34]. Hirano T, Hasegawa K, Washio T, et al. Fracture risk during pedicle screw insertion in osteoporotic Spine [J]. J Spinal Disord, 1998, 11: 493-497.
[35].王正,等.椎弓根螺钉内固定稳定性的生物力学测试[J].医用生物力学, 2002,17:80-84.
[36].王向阳.加强和维持椎弓根螺钉系统稳定性的研究进展[J].中国矫形外科杂志,2002,9(1):57-60.
[37]. Christensen FB, Dalstra M, Sejling F, et al. Titanium-alloy enhances bone-pedicle screw fixation: mechanical and histomorphometrical results of titanium-alloy versus stainless steel[J]. Eur Spine J, 2000, 9: 97-103.
[38]. Deligianni D, Korovessis P, Baikousis A, et al. Factor analysis of the effectiveness of transfixation and rod characteristics on the TSRH screw-rod instrumentation[J]. Spinal Disord, 2000, 13: 50-57
[39]. Lim TH. Eck JC, An HS, et al. Biomechanics of transfixation in pedicle screw instrumentation [J]. Spine, 1996, 21: 2224-2229
[40]. West JT, Ogilive JW, Bradford DS. Complication of the variable screw plate fixation[J]. Spine, 1991, 16: 576-579
[41]. Steffe AD, Biscup RS, Sitkowski. Segmental spine plates with pediacle screw fixation[J]. Clin Orthop, 1986, 203: 45-53
[42]. McKinley TO, McLain RF, Yerby SA, et al.Characteristics of pedicle screw loading. Effect of surgical technique on intravertebral and intrapedicular bending moments [J]. Spine, 1999; 24(1): 18-24.
[43]. Biedermann L. Biomechanics of pedicle fixation as related to imp; and design. Presented at the American-European Meeting on Pedicle fixation of the Spine and Other Advanced Techniques. Munich, Germany, 1994
[44].张光泊.浅谈脊柱内固定的应用与植骨融合[J].中国脊柱脊髓损伤杂志,2002,5:325
[45].史亚民,侯树勋,姚长海等.椎管环形减压治疗胸腰椎骨折[J].中国脊柱脊髓杂志,1999,9:89～90.
[46]. Cripton PA, Jain GM, Wittenberg RH, et al. Load-sharing characteristics of stabilized lumdar spine segments [J]. Spine, 2000, 25: 170-179.
[47].张贵林,荣国威,丁占云,等.脊柱胸腰段骨折术后椎弓根螺丝钉断裂及弯曲松动的原因分析[J].中华骨科杂志,2000,2:470-472.
[48]. Christensen FB, Dalstra M, Sejling F, et al. Titanium-alloy enhances bone-pedicle screw fixation:mechanical and histomorphometfical results of titanium-alloy versus stainless steel[J]. Eur Spine J, 2000, 9: 97-103.
[49]. Dekutoski MB, Schendel MJ, Ogilvie JW, et al. Comparison of invivo and invitro adjacent segment motion after lumbar fusion[J]. Spine, 1994, 19: 1745 1751.
[50]. Mcafee PC, Farey ID, Sutterlin TC. The effects of spinal implant rigidity on vertebral bone density: Acanine model[J]. Spine, 1991,16(suppl): 190 197.
[51]. Kotani YC, Cunningham BW, Cappuccion A, et ai. The effects of spinal fixation and destabilization on the biomechanical and histologic proper ties of spinal ligaments: A invivos study[J]. Spine, 1998, 23: 677 682.
[52]. Shono Y, Kaneda K, Abumi K, et al. Stability of posterior spinal instrumentation and its effects on adjacent motion segments in the lumbaosacral spine[J]. Spine, 1998, 23: 1550 1558.
[53]. Lim TH, Pathwardham AG, Hong JH, et al. Effect of instrumented fusion on the biomechanics of adjacent segmented at the 42nd Annual Meeting, Orthopaedic Research Society, Atlanta, GA, 1996, 19-22.
[54].黄继锋,朱青安,钟世镇.5种后路脊柱内固定器械的生物力学评价[J].中华骨科杂志,1997,17(9):539 543.
[55]. Lim TH, Eck JC, An HS, et al. Biomechanics of transfixation in pedicle screw instrumentation[J]. Spine, 1996, 21: 2224-2229.
[56]. Rahm MD, Hall BB. Adjacent-segment degeneration after lumbar fusion with instrumentation: A retrospective study[J]. J Spinal Disord, 1996, 9: 392-400.
[57]. Niu CC, Chen WJ, Chen LH, et al. Reduction-fixation spinal system in spondylolisthesis[J]. Am J Orthop, 1996, 25: 418-24.
[58]. Chow DHK, Luk KDK, Evans JJ, et al. Effects of short anterior lumbar interbody fusion on biomechanics of neighboring unfused segments[J]. Spine 1996, 21: 549-55.
[59]. Fritsch EW, Heisel J, Rupp S. The failed back surgery syndrome[J]. Spine, 1996, 21: 626-33.
[60].叶晓健,沈康平,贾连顺等.脊柱内固定返修的原因和对策[J].中国矫形外科杂志,2002,10(13):1277—1279.
[61]. David W, Joseph R, Richard G. Revision pedicle screw. Big, longer, shimswhat is best? [J]. Spine, 1998, 23 (12): 1374-1379.
[62]. Arand M, Hartwig E, Hebola D, et al. Precisionanaly sisofnavigation assisted implanted thoracic and lumbar pedicle screws[J].Unfall chir urg, 2001, 104 (11): 1076～1081.
[63]. AccaroAR, BallST. Indications for instrumentation in degenerative lumbar spinal disorders. Orthopedics, 2000; 23(3): 260
[64]. Herkowitz HN. Spine update. Degenerative lumbar spondylolis-thesis[J]. Spine, 1995, 20(9): 1084
[65]. Sjostrom L, Karlstrom G, Pech P, et al. Indirect spinal canal decompression in burst fractures treated with pedicle screw instrumentation[J].Spine, 1996, 21: 113-123.
[66]. Cripton PA, Jain GM, Wittenberg RH, et al. Load-sharing characteristics of stabilized lumdar spine segments [J]. Spine, 2000, 25: 170-179.