改进型腰骶椎前路钢板的研制及生物力学测试
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摘要
研究背景和目的：
脊柱前路内固定是针对脊柱肿瘤、结核、椎体骨折以及椎间盘病变等各种脊柱疾病的有效内固定方式，在各种脊柱前路内固定器械中，由法国SCIENT’X公司设计制造的腰骶椎前路安全钢板(PACH)是近年来在脊柱外科领域应用的较多的内固定器械之一，适用于腰椎前路融合后的前方或侧前方固定，具有以下特点：1、其形状符合椎体前侧的水平曲度，有助于提高水平与矢状面的稳定性；2、双侧固定提供立体三维稳定性；3、拥有螺钉安全系统：焊接在钢板上的弹性钛条可弯曲以使螺钉通过后复原以避免螺钉退出；4、表面刻痕可使其完美贴附于椎体。但我们在临床应用中也逐渐发现该钢板存在一些不足：1、该钢板为单体双孔钢板，手术一般需植入2块钢板过程复杂，若只植入1块钢板固定的牢固性可能不足；2、该钢板是依据国外人种脊柱解剖特点设计，不能完全符合国人脊柱解剖特点；3、术中2块钢板放置的间距及角度无明确标准，生物力学稳定性无法保证。本研究的目的在于通过对国人腰骶椎解剖结构的统计分析，在现有PACH内固定钢板的基础上，将其改进为整体复合四孔钢板，并使其弧度、长度及角度能完全适应国人腰骶椎解剖结构，并在脊柱标本上进行生物力学测试，各项生物力学指标达到预期结果。
研究方法：
1、通过对约350例正常成人腰骶椎侧位X线片腰骶角、腰5骶1椎体及椎间盘高度的测量并进行统计分析，得出正常国人腰骶椎结构的数值范围。
2、在对国人腰骶椎结构测量结果的基础上，结合腰5骶1节段脊柱前侧血管分布特点，设计出改进型腰骶椎前路钢板高度、宽度、角度、弧度等各项参数，使其符合国人腰骶椎解剖特点。
3、生产钢板样品，并在人体脊柱标本上进行生物力学测试，比较改进型钢板组、PACH钢板组、对照组的生物力学特点。
研究结果：
1、通过对350例正常成人站立位腰骶椎正位侧位X线片腰骶角、腰5及骶1椎体、椎间盘高度的测量，得出正常国人腰骶椎结构的数值统计结果：腰5椎体高度(27.1±2.3)mm，骶1椎体高度(22.3±2.8)mm，腰5骶1椎间盘高度(8.2±0.3)mm，腰骶角(129°±5.9°)。
2、依据对国人腰骶椎部位解剖结构的研究结果，我们制定了改进型腰骶椎前路钢板内固定系统的设计参数，钢板高度：28、32 mm 2种，钢板宽度：20 mm，钢板角度：125°、130°、135°3种，钢板弧度：弧长22 mm，弦长20 mm，螺钉长度：30、32.5、35、37.5、40、42.5、45mm，螺钉直径：5 mm。球形头全螺纹自攻螺钉,螺钉自然状态下偏向头尾两侧，与头尾侧之间夹角18°。
3、试验试件先进行弯曲测试，持续加载至设定桡度，记录载荷-位移曲线，选取500N载荷下测定对照组和试验组在后伸、侧屈条件下位移变化比较，结果显示改进型钢板组抗弯能力优于PACH组(P<0.05 )。再进行压缩实验，根据载荷-位移曲线，计算出各组在载荷400N下刚度值，PACH组为87.4N/mm，改进型钢板组为105.8N/mm，两者相差21％，有统计学差异(P<0.05)。最后进行扭转实验，当达到5°的转角时，改进型钢板组和PACH组的脊柱试件所需的扭矩较对照组分别增加54.6%和53.7%，且两者扭转刚度相似，没有统计学差异(P＞0.05)。
研究结论：
1、本研究针对国人腰骶椎部位包括腰骶角、L5及S1椎体高度、L5S1椎间盘高度的等解剖结构测量统计，得出国人腰骶椎解剖结构具体数值范围，并分析腰骶椎前侧血管结构的分布特点，设计出改进型腰骶椎前路钢板的参数指标。
2、按照设计参数生产钢板样品，安装在人体脊柱标本后完全符合国人腰骶椎解剖结构特点，且位于腰骶椎前侧手术的“安全空间”内，对腹侧血管不会造成影响和损伤。
3、改进型腰骶椎前路钢板经系统的生物力学测试，其在前屈、后伸、侧屈、旋转四种生理运动状态上生物力学稳定性均优于或接近现有的PACH钢板，且操作方便灵活，完全适合国人腰骶椎部位ALIF手术内固定的需要。
Background and Purpose：
Anterior spina l fixa tion is an effective interna l fixa tion for spina l diseases such asspina l tumors, tuberculosis, vertebra l fractures and spina l disc disease . In various anteriorspina l fixa tion devices, PACH designed and ma nufactured by French SCIENT’X Companyis a widely used interna l fixa tion device in the field of spine surgery in recent years. Thisdevice is used for anterior fixa tion after anterior Lumbosacra l intervertebra l fusion. It hasthe following features : 1. Proper shape to agree with the horizontal curvature of anteriorvertebra l body can help to improve the stability of level pla ne and sagittal pla ne; 2. bila tera lfixa tion provide s three-dimensiona l stability; 3. with a screw security system: elastictitanium bar welded on the steel pla te can bent to allow screw restored after crossingthrough and avoid the screw’s exit; 4. the surface notch allows the pla te attached in thevertebra l body perfectly. However, we gradua lly find some shortcomings of the pla te inclinica l applica tion: 1. This pla te is a single steel pla te with two holes . It needs to impla nttwo steel sheets in the surgica l operation, which makes the process become complica ted. Ifonly one steel sheet is impla nted, the fastness of fixa tion ma y be inadeq uate; 2. the pla te isdesigned on the basis of anatomica l characteristics of foreign race’s spine, and it could notfully conform to the anatomica l characteristics of Chinese spine; 3. no definite standard sare given for the spacing and angle between two impla nted steel sheets, which mea ns thatthe biomecha nica l stability could not be guaranteed. The purpose of this study is to improvethe pla te into an integrated composite pla te with four hole s on the basis of present PACHinterna l fixa tion pla te after statistica l ana lysis of the anatomica l structure of ChineseLumbosacra l vertebrae. Curva ture, length and angle of the improved/mod ified pla te willagree with the anatomica l structure of Chinese Lumbosacra l vertebrae. Biomecha nica l testwill be performed on spine specimens and the biomecha nica l properties sha ll achieve the desired results.
MethodMethods
1. Measure lumbosacra l angle and the heights of L5 and S1 vertebra l bodies andintervertebra l discs on latera l X-rays of 350 cases of norma l adults’Lumbosacra l vertebrae.Perform statistica l ana lysis upon results of the measurement and obtain usua l numerica lrange of Chinese lumbosacra l structure.
2. Design parameters such as height, width, angle and curvature of improved/mod ifiedPACH pla te accord ing to vascular distribution of anterior L5 and S1 vertebra l bodies , so asto have the pla te conform to anatomica l characteristics of Chinese Lumbosacra l vertebrae.
3. Manufacture pla te samples and do biomecha nica l tests on huma n spine specimens .Compare biomecha nica l characteristics of improved/mod ified pla te group, PACH pla tegroup and the control group.
Results
1. After measuring lumbosacra l angle and the heights of L5 and S1 vertebra l bodiesand intervertebra l discs on anteroposterior and latera l films of 350 cases of norma l adults’Lumbosacra l vertebrae, the researchers obtained usua l numerica l range of Chineselumbosacra l structure: height of L5 vertebra l body - (27.06±2.30) mm, height of S1vertebra l body - (22.3±2.8) mm, height of L5 S1 disc - (8.2±0.3) mm, lumbosacra l angle -(129°±5.9°).
2. Based on the find ings of anatomica l structure of Chinese Lumbosacra l vertebrae, theresearchers developed optiona l parameters for mod ified PACH interna l fixa tion system:pla te height - 28/32 mm, pla te width - 30 mm, pla te angle - 125°/130°/135°, pla te curvature- arc length 22 mm and chord length 20 mm, screw length - 30/32.5/35/37.5/40/42.5/45 mm,screw dia meter - 5 mm. Ballhead full thread tapping screws are used. And screws tend tohead and tail sides in natural state, with an angle of 18°between the side s.
3. The researchers performed bend ing test before testing the specimens : continuingload ing till the set deflection, record ing load - shift curve, and determining shift cha nge ofcontrol group and experimental group under cond itions of anteflexion, postextension andlatera l flexion with 500N load . The results ind ica ted that resista nce to bend ing of mod ified pla te group was superior to the PACH group (P <0.05). Then compression experiment wasperformed. The researchers calcula ted stiffness mea ns of each group under 400N load :PACH group - (87.4±4.2) N/mm, mod ified pla te group - (105.8±7.6) N/mm. The differenceof 20% was statistica lly significa nt (P<0.05). Torsion test was performed in the end. Whenthe turn angle reached 5°, the required torque of spine specimens of mod ified pla te groupand PACH group increased 54.6% and 53.7% respectively compared to control group. Andtorsiona l stiffness of the two was simila r, which mea nt no statistica l difference (P>0.05).
Conclusion
The improved/mod ified pla te applies to fusing and fixa tion of tumor, tuberculosis anddisc diseases at L5S1, especia lly suitable for dama ged disc structure and slightly dama ge dsclerotin of vertebra l body. Compared to PACH pla te under the same cond itions, thismod ified pla te has obviously increased resista nce to bend ing and compress ion. In addition,flexion shift and vertica l compression stiffness in all directions of the two groups underlinear load also ind ica tes significa ntly differen ce (P<0.05). This pla te has a reliablebiomecha nica l stability, provid ing an idea l mecha nica l environment for lumbosacra l area .So it is very ind ica ted for fusing and fixa tion at this site.
脊柱前路内固定是针对脊柱肿瘤、结核、椎体骨折以及椎间盘病变等各种脊柱疾病的有效内固定方式，在各种脊柱前路内固定器械中，由法国SCIENT’X公司设计制造的腰骶椎前路安全钢板(PACH)是近年来在脊柱外科领域应用的较多的内固定器械之一，适用于腰椎前路融合后的前方或侧前方固定，具有以下特点：1、其形状符合椎体前侧的水平曲度，有助于提高水平与矢状面的稳定性；2、双侧固定提供立体三维稳定性；3、拥有螺钉安全系统：焊接在钢板上的弹性钛条可弯曲以使螺钉通过后复原以避免螺钉退出；4、表面刻痕可使其完美贴附于椎体。但我们在临床应用中也逐渐发现该钢板存在一些不足：1、该钢板为单体双孔钢板，手术一般需植入2块钢板过程复杂，若只植入1块钢板固定的牢固性可能不足；2、该钢板是依据国外人种脊柱解剖特点设计，不能完全符合国人脊柱解剖特点；3、术中2块钢板放置的间距及角度无明确标准，生物力学稳定性无法保证。本研究的目的在于通过对国人腰骶椎解剖结构的统计分析，在现有PACH内固定钢板的基础上，将其改进为整体复合四孔钢板，并使其弧度、长度及角度能完全适应国人腰骶椎解剖结构，并在脊柱标本上进行生物力学测试，各项生物力学指标达到预期结果。
研究方法：
1、通过对约350例正常成人腰骶椎侧位X线片腰骶角、腰5骶1椎体及椎间盘高度的测量并进行统计分析，得出正常国人腰骶椎结构的数值范围。
2、在对国人腰骶椎结构测量结果的基础上，结合腰5骶1节段脊柱前侧血管分布特点，设计出改进型腰骶椎前路钢板高度、宽度、角度、弧度等各项参数，使其符合国人腰骶椎解剖特点。
3、生产钢板样品，并在人体脊柱标本上进行生物力学测试，比较改进型钢板组、PACH钢板组、对照组的生物力学特点。
研究结果：
1、通过对350例正常成人站立位腰骶椎正位侧位X线片腰骶角、腰5及骶1椎体、椎间盘高度的测量，得出正常国人腰骶椎结构的数值统计结果：腰5椎体高度(27.1±2.3)mm，骶1椎体高度(22.3±2.8)mm，腰5骶1椎间盘高度(8.2±0.3)mm，腰骶角(129°±5.9°)。
2、依据对国人腰骶椎部位解剖结构的研究结果，我们制定了改进型腰骶椎前路钢板内固定系统的设计参数，钢板高度：28、32 mm 2种，钢板宽度：20 mm，钢板角度：125°、130°、135°3种，钢板弧度：弧长22 mm，弦长20 mm，螺钉长度：30、32.5、35、37.5、40、42.5、45mm，螺钉直径：5 mm。球形头全螺纹自攻螺钉,螺钉自然状态下偏向头尾两侧，与头尾侧之间夹角18°。
3、试验试件先进行弯曲测试，持续加载至设定桡度，记录载荷-位移曲线，选取500N载荷下测定对照组和试验组在后伸、侧屈条件下位移变化比较，结果显示改进型钢板组抗弯能力优于PACH组(P<0.05 )。再进行压缩实验，根据载荷-位移曲线，计算出各组在载荷400N下刚度值，PACH组为87.4N/mm，改进型钢板组为105.8N/mm，两者相差21％，有统计学差异(P<0.05)。最后进行扭转实验，当达到5°的转角时，改进型钢板组和PACH组的脊柱试件所需的扭矩较对照组分别增加54.6%和53.7%，且两者扭转刚度相似，没有统计学差异(P＞0.05)。
研究结论：
1、本研究针对国人腰骶椎部位包括腰骶角、L5及S1椎体高度、L5S1椎间盘高度的等解剖结构测量统计，得出国人腰骶椎解剖结构具体数值范围，并分析腰骶椎前侧血管结构的分布特点，设计出改进型腰骶椎前路钢板的参数指标。
2、按照设计参数生产钢板样品，安装在人体脊柱标本后完全符合国人腰骶椎解剖结构特点，且位于腰骶椎前侧手术的“安全空间”内，对腹侧血管不会造成影响和损伤。
3、改进型腰骶椎前路钢板经系统的生物力学测试，其在前屈、后伸、侧屈、旋转四种生理运动状态上生物力学稳定性均优于或接近现有的PACH钢板，且操作方便灵活，完全适合国人腰骶椎部位ALIF手术内固定的需要。
Background and Purpose：
Anterior spina l fixa tion is an effective interna l fixa tion for spina l diseases such asspina l tumors, tuberculosis, vertebra l fractures and spina l disc disease . In various anteriorspina l fixa tion devices, PACH designed and ma nufactured by French SCIENT’X Companyis a widely used interna l fixa tion device in the field of spine surgery in recent years. Thisdevice is used for anterior fixa tion after anterior Lumbosacra l intervertebra l fusion. It hasthe following features : 1. Proper shape to agree with the horizontal curvature of anteriorvertebra l body can help to improve the stability of level pla ne and sagittal pla ne; 2. bila tera lfixa tion provide s three-dimensiona l stability; 3. with a screw security system: elastictitanium bar welded on the steel pla te can bent to allow screw restored after crossingthrough and avoid the screw’s exit; 4. the surface notch allows the pla te attached in thevertebra l body perfectly. However, we gradua lly find some shortcomings of the pla te inclinica l applica tion: 1. This pla te is a single steel pla te with two holes . It needs to impla nttwo steel sheets in the surgica l operation, which makes the process become complica ted. Ifonly one steel sheet is impla nted, the fastness of fixa tion ma y be inadeq uate; 2. the pla te isdesigned on the basis of anatomica l characteristics of foreign race’s spine, and it could notfully conform to the anatomica l characteristics of Chinese spine; 3. no definite standard sare given for the spacing and angle between two impla nted steel sheets, which mea ns thatthe biomecha nica l stability could not be guaranteed. The purpose of this study is to improvethe pla te into an integrated composite pla te with four hole s on the basis of present PACHinterna l fixa tion pla te after statistica l ana lysis of the anatomica l structure of ChineseLumbosacra l vertebrae. Curva ture, length and angle of the improved/mod ified pla te willagree with the anatomica l structure of Chinese Lumbosacra l vertebrae. Biomecha nica l testwill be performed on spine specimens and the biomecha nica l properties sha ll achieve the desired results.
MethodMethods
1. Measure lumbosacra l angle and the heights of L5 and S1 vertebra l bodies andintervertebra l discs on latera l X-rays of 350 cases of norma l adults’Lumbosacra l vertebrae.Perform statistica l ana lysis upon results of the measurement and obtain usua l numerica lrange of Chinese lumbosacra l structure.
2. Design parameters such as height, width, angle and curvature of improved/mod ifiedPACH pla te accord ing to vascular distribution of anterior L5 and S1 vertebra l bodies , so asto have the pla te conform to anatomica l characteristics of Chinese Lumbosacra l vertebrae.
3. Manufacture pla te samples and do biomecha nica l tests on huma n spine specimens .Compare biomecha nica l characteristics of improved/mod ified pla te group, PACH pla tegroup and the control group.
Results
1. After measuring lumbosacra l angle and the heights of L5 and S1 vertebra l bodiesand intervertebra l discs on anteroposterior and latera l films of 350 cases of norma l adults’Lumbosacra l vertebrae, the researchers obtained usua l numerica l range of Chineselumbosacra l structure: height of L5 vertebra l body - (27.06±2.30) mm, height of S1vertebra l body - (22.3±2.8) mm, height of L5 S1 disc - (8.2±0.3) mm, lumbosacra l angle -(129°±5.9°).
2. Based on the find ings of anatomica l structure of Chinese Lumbosacra l vertebrae, theresearchers developed optiona l parameters for mod ified PACH interna l fixa tion system:pla te height - 28/32 mm, pla te width - 30 mm, pla te angle - 125°/130°/135°, pla te curvature- arc length 22 mm and chord length 20 mm, screw length - 30/32.5/35/37.5/40/42.5/45 mm,screw dia meter - 5 mm. Ballhead full thread tapping screws are used. And screws tend tohead and tail sides in natural state, with an angle of 18°between the side s.
3. The researchers performed bend ing test before testing the specimens : continuingload ing till the set deflection, record ing load - shift curve, and determining shift cha nge ofcontrol group and experimental group under cond itions of anteflexion, postextension andlatera l flexion with 500N load . The results ind ica ted that resista nce to bend ing of mod ified pla te group was superior to the PACH group (P <0.05). Then compression experiment wasperformed. The researchers calcula ted stiffness mea ns of each group under 400N load :PACH group - (87.4±4.2) N/mm, mod ified pla te group - (105.8±7.6) N/mm. The differenceof 20% was statistica lly significa nt (P<0.05). Torsion test was performed in the end. Whenthe turn angle reached 5°, the required torque of spine specimens of mod ified pla te groupand PACH group increased 54.6% and 53.7% respectively compared to control group. Andtorsiona l stiffness of the two was simila r, which mea nt no statistica l difference (P>0.05).
Conclusion
The improved/mod ified pla te applies to fusing and fixa tion of tumor, tuberculosis anddisc diseases at L5S1, especia lly suitable for dama ged disc structure and slightly dama ge dsclerotin of vertebra l body. Compared to PACH pla te under the same cond itions, thismod ified pla te has obviously increased resista nce to bend ing and compress ion. In addition,flexion shift and vertica l compression stiffness in all directions of the two groups underlinear load also ind ica tes significa ntly differen ce (P<0.05). This pla te has a reliablebiomecha nica l stability, provid ing an idea l mecha nica l environment for lumbosacra l area .So it is very ind ica ted for fusing and fixa tion at this site.
引文
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11. Rajara man V, Vinga n R, Roth P, et al. iscera l and vascular complica tions resulting fromanterior lumbar interbod y fusion. J Neurosurg 1999;91(Suppl1):60–4.
12. Nezha t C, Childers J, Nezha t F, et al. Major retroperitonea l vascular injury duringlaparoscopic surgery. Hum Reprod 1997;12:480–3.
13. Vraney RT, Phillips FM, Wetzel FT, et al. Predisca l vascula r anatomy of the lowerlumbar spine. An endoscopic perspective[ J ]. Spine, 1999, 24 (21) : 2183-2187.
14.凌云志，刘振华，周建生等.腰骶椎前路手术“有效工作区”血管应用解剖学研究[J].蚌埠医学院学报，2009，34(2):110-114.
15.钱太保、周健生.腰5椎体和骶椎的应用解剖学研究，解剖与临床杂志，2007，12(3)：163-166.
16.中国解剖学体质调查委员会.中国人解剖学数值，北京：人民卫生出版社，2002；70
17.魏梅洋，谭军，贾连顺，等.国人下腰椎前方血管解剖结构特点和入路分型[J].中国矫形外科杂志，2004,25(6):385.
18. Heth JA, Hitchon PW, Goel VK, et al. A biomecha nica l comparison between anteriorand transverse interbod y fusion cages. Spine, 2001 26:E261–E267.
19. Nibu K, Panjabi MM, Oxla nd T, et al. Multid irectiona l stabilizing potentia l of BAKinterbod y spina l fusion system for anterior surgery. J Spina l Disord, 1997 10:357–62.
20. Gla zer PA, Colliou O, Klisch SM, et al. Biomecha nica l ana lysis of multilevel fixa tionmethods in the lumbar spine. Spine, 1997 22:171–82.
21. Gill K, O’Brien PO. Observations of resorption of the posterior latera l bone graft incombined anterior and posterior lumbar fusion. Spine, 1993 18:1885–9.
22. Oxla nd TR, Hoffer Z, Nydegger T, et al. A comparative biomecha nica l investiga tion ofanterior lumbar interbod y cages: central and bila tera l approaches.J Bone Joint Surg Am,2000 82:383–93.
23. Anjarwalla NK, Morcom RK, Fraser RD. Supplementary stabiliza tion with anteriorlumbar interbod y fusion—a radiologic review. Spine, 2006 31:1281–7.
24. Beaubien BP, Derincek A, LewWD, et al. In vitro, biomecha nica l comparison of ananterior lumbar interbod y fusion with an anteriorlyp lac ed, lowp rofile lumbar pla teand posteriorly placed pedicle screwsor transla mina r screws[ J ]. Spine, 2005, 30 (16) :1846-1851.
25. Fraser RD. Interbody, posterior and combined fusions. Spine, 1995 20(24S):167–77.
26. Naffis K. Anjarwalla, MS, FRCS.Supplementary Stabiliza tion With Anterior LumbarIntervertebra l Fusion–A Radiologic Review.Spine,2006 33(11): 1281–87
27. Fredrickson BE , Edwards WT , Rauschning W, et al. Vertebra l burst fractures : anexperimental , morphologic , and radiographicstudy[J ] . Spine ,1992 ,17 :1012– 1017.
28. Paul RL ,Michael RH ,Dunn J ,et al. Anterior transthoracic surgica l decompression ofacute spina l cord injuries[J ] . J Neurosurg ,1975 ,43 :299 - 302.
29. Zdeblick TA ,Shirado O ,McAfee PC ,et al. Anterior spina l fixa tion after lumbarcorpectomy [J ] . J Bone Joint Surg (Am) ,1991 ,73: 527 - 531.
30. Gla zerPA, Colliou O, Klisch SM, et al.Biomecha nica lana lysis of multilevel fixa tionmethods in the lumbar spine. Spine,1997 22(2):171-187.
31. WilkeI-U, WengerK, ClaesL. Testing criteria for spina l impla nts: recommenda tions forthe standard iza tion of in vitro stability testing of spina l impla nts.J Eur Spine,1998,7:148.
32. Dick JC, BrodkeDS , ZdeblickTA, et al. Anterior instrumentation of the thoracolumbarspine: a biomecha nica l comparison . Spine,1997 22:744.
33. Panjabi MM. Biomecha nica l eva luation of spina l fixa tion devices: IA comceptua l framework.Spine,1988 13:1129.work.Spine,1988 13:1129.
34. Kotani Y, Cunningha m BW, Parker LM, et al. Statica nd fatigue biomecha nica lproperties of anterior thoracolumbar instrumentation systems. Spine,1999 24(14):1406-13.
35.戴力扬.脊柱内固定的生物力学.医用生物力学, 2001, 16 (2) :123～128
36. Nachemson A,Vivo measurements of intradisca l pressure.J Bone joint Surg(Am),1964,46A:1077
37. Boden SD, Riew KD, Yamguchi K, et al. Orinetetion of the lumbar facet joints:associa tion with degenera tive disc disease. J Bone Joint Surg(Am), 1996, 78: 403-411.
38. Grobler LJ, Robertson PA, Novotny JE, et al. Decompression for degenera tivespond ylolisthesis and spina l stenosis at L4、5: The effects on facet joint morphology,Spine, 1993, 18: 1475-1482.
39. Greene LB. Radiographic measurement of the lumbosacra l angle. ArchPhysMed1967 ;48 :240
40. Splithoff CA.Lumbosacra l junction : roent genographic compareison of patients withnd without back ache. JAMA 1953 ;152 (10) :1610
41. Hellems HK.Measurement of the norma l lumbosacra la ngle. AmJ Roent 1971 ; 113:642
42.郑丰欲.慢性下腰痛患者立位X线侧位片测量及相关分析.中华骨科杂志1996 ;16 (7) :435
43. Wile HJ, Krischa S, Claes LE, et al. Forma lin fixa tion strongly influencesbiomecha nica l properties of the spine. J Biomech,1996 9(12):1629-1631.
44. Pool-Goud zwaa rd A, Hoek van Dijke G,Mulder P, et al.The iliolumbar liga ment:itsinfluence on stability of the sacroiliac joint. Clin Biomech, 2003 18(2):99-105.
45. Hasega wa K, Abe M, Washio T, et al. An experimental study on the interface strengthbetween titanium mesh cage and vertebra in reference to vertebra l bone minera l density.Spine,2001 26(8):957-63.
46. Ishia wa N. Strain distribution in the L1vertebra under axia l load and load transmittingbeha vior between the bertebra l body and posterior elements.Nippon Seikeigea GakkaiZasshi,1995 69(11):1136-46.
47.齐向北,张英泽,等.新鲜与防腐椎体标本生物力学差异性的试验研究,临床生物力学.2005 23(2):202-205.
48. Lee SH, Kong BU, Jeon SH, et al. Revision surgery of the lumbar spine: anterior lumbarinterbod y fusion follow by perutaneous pedicle screw fixa tion. J Neurosurg Spine, 20065:228-233 .
49. Jang JS, SH. Clinica l ana lysis of percutanrous facet screw fixa tion after anterior lumbarinterbod y fusion, J Neurosurg Spine, 2005 3:40-46.
50. Jutte PC, Castelein RM. Complications of pedicle screw in lumbar and la mbosacra lfusion in 105 consecutive prima ry operations. Eur Spine J, 2002 11:594-8.
51. Mark Gerber,Neil R. Crawford, Robert H. Chamberla in. et al. Biomecha nica lAssessment of Anterior Lumbar Interbod y Fusion With an Anterior Lumbosacra lFixa tion Screw-Pla te: Comparison to Stand-Alone Anterior Lumbar Interbod y Fusionand Anterior Lumbar Interbod y Fusion With Pedicle Screws in an Unstable Huma nCadaver Model. Spine,2006 31(7):762–8.
52. Beaubien BP, Derincek A, Lew WD, et al. In vitro biomecha nica l comparison of ananterior lumbar interbod y fusion with an anteriorly placed low-profile lumbar pla te andposteriorly placed pedicle screws or transla minar screws. Spine, 2005 30:1846-51.
53. Michael N. Tzermiad ianos, Anis Mekhail, Enha ncing the Stability of Anterior LumbarInterbod y Fusion.Spine,2008 33(2):E38–E43.
1. Peretz AM, Hipp JA, Heggeness MH. The interna l bony architecture of thesacrum.Spine . 1998;23:971-974.
2. Drefuss P, Dreyer SJ, Cole A, Mayo K. Sacroiliac joint pain. J Am Acad OrthopSurg.2004 ;12:255-265.
3. Mirkovic S, Abitbol JJ, Steinma n J, etyal. Anatomic considerations for sacra lscrewplacement. Spine.1991,16:289.
4. Nachemson A, Vivo measurements of intradisca l pressure . J Bone joint Surg(Am),1964,46A:1077 .
5. Boden SD, Riew KD, Yamguchi K, et al. Orinetetion of the lumbar facet joints:associa tion with degenera tive disc disease. J Bone Joint Surg(Am), 1996, 78: 403-411.
6. Grobler LJ, Robertson PA, Novotny JE, et al. Decompression for degenera tivespond ylolisthesis and spina l stenosis at L4-5: The effects on facet joint morphology,Spine, 1993, 18: 1475-1482.
7. Mark G, Neil RC, Robert H, et al. Biomecha nica l assessment of anterior lumbarinterbod y fusion with an anterior lumbosacra l fixa tion screw- pla te: Comparison tostand-alone anterior lumbar interbod y fusion and anterior lumbar interbod y fusion withpedicle screws in an unstable huma n cadaver model. Spine ,2006,31:7:762-768.
8. Aftab Karim，Debi Mukherjee，Murali Ankem，Jorge Gonza lez-Cruz，Dona ld Smith，Anil Nanda etal, Augmention of anterior lumbar interbod y fusion with anteriorpedicle screw fixa tion:Demonstration of novel constructs and eva luation ofbiomecha nica l stability in cadaveric pecimens. Neuro- surgery. 2006.58：522-527.
9. Brid well KH, Edwards CC II, Lenke LG.The pros and cons to saving the L5-S1motionsegment in a long scoliosis fusion construct.Spine. 2003:28:S234-S242.
10. Rosner MK, Ondra SL. Sacropelvic fixa tion in adult deformity Seminars in SpineSurgery, 2004:16：107-113.
11. Schwend RM, Sluyters R, Najdzionek J. The pylon concept of pelvic anchora ge forspina l instrumentation in the huma n cadaver. Spine, 2003,28 (6) : 542～547.
12. Gla zer PA, ColliouO,Lotz JC, et al. Biomecha nica l ana lysis of lumbosacra l fixa tion.Spine, 1996, 21 (10) : 1211～1222.
13. Dewa ld CJ, Millikan KW, Hammerberg KW, et al. An open, minima llyinvasiveapproach to the lumbar spine. Am Surg 1999;65:61–8.
14. Obencha in TE. Laproscopic lumbar discectomy: Case report. J Laproendosc Surg1991;1:1459.
15. Nezhat C, Childers J, Nezhat F, et al. Major retroperitonea l vascular injury duringlaparoscopic surgery. Hum Reprod 1997;12:480–3.
16. Kowalsk i RJ, Ferrara LA, Benzel EC. Biomecha nics of bone fusion. Neurosurg Focus ,2001,10 (4) : E2 .
17. Keith DK, FRCSED, FHKAM, et al. A stronger bicortica l sacra l pedicle screw fixa tionthrough the S1 endplate: An in vitro cyclic load ing and pull-out force eva luation. Spine ,2005,30,5:525-529.
18. Mina mide A, Akama ru T, Yoon ST, et al. Tra nsdisca l L5-S1screws for the fixa tion ofisthmic spond ylolisthesis , a biomecha nica l eva luation. J Spina l Disord Tech ,2003;16:144-149.
19. Schwend RM, Sluyers R, Nsjdzionek J. The pylon concept of pelvic anch- orage forspina l instrumentation en the huma n cadaver.Spine 2003;28:542-547.
20. Cunningha m BW, Lewis SJ, Long J, et al. Biomecha nica l eva luation of lumbo sacra lreconstruction techniq ues for spond ylolisthesis. An in vitro por- cine model. Spine2002;27:2321-2327.
21. Timothy R. Kuklo , Keith H. Brid well, et al, Minimum 2-Year Analysis of SacropelvicFixa tion and L5– S1 Fusion Using S1 and Iliac Screws . Spine ,2001;26:18:1976-1983.
22. Kuniyoshi T, Keith H, Brid well, et al. Minimum 5-year ana lysis of L5-S1 fusion usingsacropelvic fixa tion (bila tera l S1 and iliac screws) for spina l deformity.Spine.2006 ;31:3:303-308.
23. Gerber M, Crawford NR, Chamberla in RH, et al. Biomecha nica l assessment of anteriorlumbar interbod y fusion with an anterior lumbosacra l fixa tion screwpla te: comparisonto stand -alone anterior lumbar interbod y fusion and anterior lumbar interbod y fusionwith pedicle screws in an unstable huma n cadavermodel[J]. Spine , 2006, 31 (7) : 762-768.
24. Beaubien BP, Derincek A, Lew WD, et al. In vitro, biomecha nica l comparison of ananterior lumbar interbod y fusion with an anteriorlyp lac ed, lowp rofile lumbar pla teand posteriorly placed pedicle screwsor transla mina r screws[ J ]. Spine, 2005, 30 (16) :1846-1851.
2. Wicke L. Atlas of Radiologic Anatomy. 2nd, Vrba n & Schwargenberg, 1979. 58～60
3. Schwend RM, Sluyters R, Najdzionek J. The pylon concept of pelvic anchora ge forspina l instrumentation in the huma n cadaver. Spine, 2003,28 (6) : 542～547
4. Lebwohl NH, Cunningha m BW,Dmitriev A, et al. Biomecha nica l comprarison oflumbosacra l fixa tion techniq ues in a calf spine model.Spine, 2002, 27 (21) : 2312～2320.
5. Gla zer PA, ColliouO,Lotz JC, et al. Biomecha nica l ana lysis of lumbosacra l fixa tion.Spine, 1996, 21 (10) : 1211～1222.
6. Kowalsk i RJ, Ferrara LA, Benzel EC. Biomecha nics of bone fusion.Neurosurg Focus,2001, 10 (4) : E2.
7. Dewa ld CJ, Millikan KW, Hammerberg KW, et al. An open, minima lly invasiveapproach to the lumbar spine. Am Surg 1999;65:61–8.
8. Obencha in TE. Laproscopic lumbar discectomy: Case report. J Laproendosc Surg1991;1:1459.
9. Hellems HK.Measurement of the norma l lumbosacra la ngle. Am J Roent 1971 ;113:642
10. Regan JJ, Aronoff RJ, Ohnmeiss DD, et al. Laparoscopic approach to L4–L5 forinterbod y fusion using BAK cages: experience in the first 58 cases. Spine1999;24:2171–4.
11. Rajara man V, Vinga n R, Roth P, et al. iscera l and vascular complica tions resulting fromanterior lumbar interbod y fusion. J Neurosurg 1999;91(Suppl1):60–4.
12. Nezha t C, Childers J, Nezha t F, et al. Major retroperitonea l vascular injury duringlaparoscopic surgery. Hum Reprod 1997;12:480–3.
13. Vraney RT, Phillips FM, Wetzel FT, et al. Predisca l vascula r anatomy of the lowerlumbar spine. An endoscopic perspective[ J ]. Spine, 1999, 24 (21) : 2183-2187.
14.凌云志，刘振华，周建生等.腰骶椎前路手术“有效工作区”血管应用解剖学研究[J].蚌埠医学院学报，2009，34(2):110-114.
15.钱太保、周健生.腰5椎体和骶椎的应用解剖学研究，解剖与临床杂志，2007，12(3)：163-166.
16.中国解剖学体质调查委员会.中国人解剖学数值，北京：人民卫生出版社，2002；70
17.魏梅洋，谭军，贾连顺，等.国人下腰椎前方血管解剖结构特点和入路分型[J].中国矫形外科杂志，2004,25(6):385.
18. Heth JA, Hitchon PW, Goel VK, et al. A biomecha nica l comparison between anteriorand transverse interbod y fusion cages. Spine, 2001 26:E261–E267.
19. Nibu K, Panjabi MM, Oxla nd T, et al. Multid irectiona l stabilizing potentia l of BAKinterbod y spina l fusion system for anterior surgery. J Spina l Disord, 1997 10:357–62.
20. Gla zer PA, Colliou O, Klisch SM, et al. Biomecha nica l ana lysis of multilevel fixa tionmethods in the lumbar spine. Spine, 1997 22:171–82.
21. Gill K, O’Brien PO. Observations of resorption of the posterior latera l bone graft incombined anterior and posterior lumbar fusion. Spine, 1993 18:1885–9.
22. Oxla nd TR, Hoffer Z, Nydegger T, et al. A comparative biomecha nica l investiga tion ofanterior lumbar interbod y cages: central and bila tera l approaches.J Bone Joint Surg Am,2000 82:383–93.
23. Anjarwalla NK, Morcom RK, Fraser RD. Supplementary stabiliza tion with anteriorlumbar interbod y fusion—a radiologic review. Spine, 2006 31:1281–7.
24. Beaubien BP, Derincek A, LewWD, et al. In vitro, biomecha nica l comparison of ananterior lumbar interbod y fusion with an anteriorlyp lac ed, lowp rofile lumbar pla teand posteriorly placed pedicle screwsor transla mina r screws[ J ]. Spine, 2005, 30 (16) :1846-1851.
25. Fraser RD. Interbody, posterior and combined fusions. Spine, 1995 20(24S):167–77.
26. Naffis K. Anjarwalla, MS, FRCS.Supplementary Stabiliza tion With Anterior LumbarIntervertebra l Fusion–A Radiologic Review.Spine,2006 33(11): 1281–87
27. Fredrickson BE , Edwards WT , Rauschning W, et al. Vertebra l burst fractures : anexperimental , morphologic , and radiographicstudy[J ] . Spine ,1992 ,17 :1012– 1017.
28. Paul RL ,Michael RH ,Dunn J ,et al. Anterior transthoracic surgica l decompression ofacute spina l cord injuries[J ] . J Neurosurg ,1975 ,43 :299 - 302.
29. Zdeblick TA ,Shirado O ,McAfee PC ,et al. Anterior spina l fixa tion after lumbarcorpectomy [J ] . J Bone Joint Surg (Am) ,1991 ,73: 527 - 531.
30. Gla zerPA, Colliou O, Klisch SM, et al.Biomecha nica lana lysis of multilevel fixa tionmethods in the lumbar spine. Spine,1997 22(2):171-187.
31. WilkeI-U, WengerK, ClaesL. Testing criteria for spina l impla nts: recommenda tions forthe standard iza tion of in vitro stability testing of spina l impla nts.J Eur Spine,1998,7:148.
32. Dick JC, BrodkeDS , ZdeblickTA, et al. Anterior instrumentation of the thoracolumbarspine: a biomecha nica l comparison . Spine,1997 22:744.
33. Panjabi MM. Biomecha nica l eva luation of spina l fixa tion devices: IA comceptua l framework.Spine,1988 13:1129.work.Spine,1988 13:1129.
34. Kotani Y, Cunningha m BW, Parker LM, et al. Statica nd fatigue biomecha nica lproperties of anterior thoracolumbar instrumentation systems. Spine,1999 24(14):1406-13.
35.戴力扬.脊柱内固定的生物力学.医用生物力学, 2001, 16 (2) :123～128
36. Nachemson A,Vivo measurements of intradisca l pressure.J Bone joint Surg(Am),1964,46A:1077
37. Boden SD, Riew KD, Yamguchi K, et al. Orinetetion of the lumbar facet joints:associa tion with degenera tive disc disease. J Bone Joint Surg(Am), 1996, 78: 403-411.
38. Grobler LJ, Robertson PA, Novotny JE, et al. Decompression for degenera tivespond ylolisthesis and spina l stenosis at L4、5: The effects on facet joint morphology,Spine, 1993, 18: 1475-1482.
39. Greene LB. Radiographic measurement of the lumbosacra l angle. ArchPhysMed1967 ;48 :240
40. Splithoff CA.Lumbosacra l junction : roent genographic compareison of patients withnd without back ache. JAMA 1953 ;152 (10) :1610
41. Hellems HK.Measurement of the norma l lumbosacra la ngle. AmJ Roent 1971 ; 113:642
42.郑丰欲.慢性下腰痛患者立位X线侧位片测量及相关分析.中华骨科杂志1996 ;16 (7) :435
43. Wile HJ, Krischa S, Claes LE, et al. Forma lin fixa tion strongly influencesbiomecha nica l properties of the spine. J Biomech,1996 9(12):1629-1631.
44. Pool-Goud zwaa rd A, Hoek van Dijke G,Mulder P, et al.The iliolumbar liga ment:itsinfluence on stability of the sacroiliac joint. Clin Biomech, 2003 18(2):99-105.
45. Hasega wa K, Abe M, Washio T, et al. An experimental study on the interface strengthbetween titanium mesh cage and vertebra in reference to vertebra l bone minera l density.Spine,2001 26(8):957-63.
46. Ishia wa N. Strain distribution in the L1vertebra under axia l load and load transmittingbeha vior between the bertebra l body and posterior elements.Nippon Seikeigea GakkaiZasshi,1995 69(11):1136-46.
47.齐向北,张英泽,等.新鲜与防腐椎体标本生物力学差异性的试验研究,临床生物力学.2005 23(2):202-205.
48. Lee SH, Kong BU, Jeon SH, et al. Revision surgery of the lumbar spine: anterior lumbarinterbod y fusion follow by perutaneous pedicle screw fixa tion. J Neurosurg Spine, 20065:228-233 .
49. Jang JS, SH. Clinica l ana lysis of percutanrous facet screw fixa tion after anterior lumbarinterbod y fusion, J Neurosurg Spine, 2005 3:40-46.
50. Jutte PC, Castelein RM. Complications of pedicle screw in lumbar and la mbosacra lfusion in 105 consecutive prima ry operations. Eur Spine J, 2002 11:594-8.
51. Mark Gerber,Neil R. Crawford, Robert H. Chamberla in. et al. Biomecha nica lAssessment of Anterior Lumbar Interbod y Fusion With an Anterior Lumbosacra lFixa tion Screw-Pla te: Comparison to Stand-Alone Anterior Lumbar Interbod y Fusionand Anterior Lumbar Interbod y Fusion With Pedicle Screws in an Unstable Huma nCadaver Model. Spine,2006 31(7):762–8.
52. Beaubien BP, Derincek A, Lew WD, et al. In vitro biomecha nica l comparison of ananterior lumbar interbod y fusion with an anteriorly placed low-profile lumbar pla te andposteriorly placed pedicle screws or transla minar screws. Spine, 2005 30:1846-51.
53. Michael N. Tzermiad ianos, Anis Mekhail, Enha ncing the Stability of Anterior LumbarInterbod y Fusion.Spine,2008 33(2):E38–E43.
1. Peretz AM, Hipp JA, Heggeness MH. The interna l bony architecture of thesacrum.Spine . 1998;23:971-974.
2. Drefuss P, Dreyer SJ, Cole A, Mayo K. Sacroiliac joint pain. J Am Acad OrthopSurg.2004 ;12:255-265.
3. Mirkovic S, Abitbol JJ, Steinma n J, etyal. Anatomic considerations for sacra lscrewplacement. Spine.1991,16:289.
4. Nachemson A, Vivo measurements of intradisca l pressure . J Bone joint Surg(Am),1964,46A:1077 .
5. Boden SD, Riew KD, Yamguchi K, et al. Orinetetion of the lumbar facet joints:associa tion with degenera tive disc disease. J Bone Joint Surg(Am), 1996, 78: 403-411.
6. Grobler LJ, Robertson PA, Novotny JE, et al. Decompression for degenera tivespond ylolisthesis and spina l stenosis at L4-5: The effects on facet joint morphology,Spine, 1993, 18: 1475-1482.
7. Mark G, Neil RC, Robert H, et al. Biomecha nica l assessment of anterior lumbarinterbod y fusion with an anterior lumbosacra l fixa tion screw- pla te: Comparison tostand-alone anterior lumbar interbod y fusion and anterior lumbar interbod y fusion withpedicle screws in an unstable huma n cadaver model. Spine ,2006,31:7:762-768.
8. Aftab Karim，Debi Mukherjee，Murali Ankem，Jorge Gonza lez-Cruz，Dona ld Smith，Anil Nanda etal, Augmention of anterior lumbar interbod y fusion with anteriorpedicle screw fixa tion:Demonstration of novel constructs and eva luation ofbiomecha nica l stability in cadaveric pecimens. Neuro- surgery. 2006.58：522-527.
9. Brid well KH, Edwards CC II, Lenke LG.The pros and cons to saving the L5-S1motionsegment in a long scoliosis fusion construct.Spine. 2003:28:S234-S242.
10. Rosner MK, Ondra SL. Sacropelvic fixa tion in adult deformity Seminars in SpineSurgery, 2004:16：107-113.
11. Schwend RM, Sluyters R, Najdzionek J. The pylon concept of pelvic anchora ge forspina l instrumentation in the huma n cadaver. Spine, 2003,28 (6) : 542～547.
12. Gla zer PA, ColliouO,Lotz JC, et al. Biomecha nica l ana lysis of lumbosacra l fixa tion.Spine, 1996, 21 (10) : 1211～1222.
13. Dewa ld CJ, Millikan KW, Hammerberg KW, et al. An open, minima llyinvasiveapproach to the lumbar spine. Am Surg 1999;65:61–8.
14. Obencha in TE. Laproscopic lumbar discectomy: Case report. J Laproendosc Surg1991;1:1459.
15. Nezhat C, Childers J, Nezhat F, et al. Major retroperitonea l vascular injury duringlaparoscopic surgery. Hum Reprod 1997;12:480–3.
16. Kowalsk i RJ, Ferrara LA, Benzel EC. Biomecha nics of bone fusion. Neurosurg Focus ,2001,10 (4) : E2 .
17. Keith DK, FRCSED, FHKAM, et al. A stronger bicortica l sacra l pedicle screw fixa tionthrough the S1 endplate: An in vitro cyclic load ing and pull-out force eva luation. Spine ,2005,30,5:525-529.
18. Mina mide A, Akama ru T, Yoon ST, et al. Tra nsdisca l L5-S1screws for the fixa tion ofisthmic spond ylolisthesis , a biomecha nica l eva luation. J Spina l Disord Tech ,2003;16:144-149.
19. Schwend RM, Sluyers R, Nsjdzionek J. The pylon concept of pelvic anch- orage forspina l instrumentation en the huma n cadaver.Spine 2003;28:542-547.
20. Cunningha m BW, Lewis SJ, Long J, et al. Biomecha nica l eva luation of lumbo sacra lreconstruction techniq ues for spond ylolisthesis. An in vitro por- cine model. Spine2002;27:2321-2327.
21. Timothy R. Kuklo , Keith H. Brid well, et al, Minimum 2-Year Analysis of SacropelvicFixa tion and L5– S1 Fusion Using S1 and Iliac Screws . Spine ,2001;26:18:1976-1983.
22. Kuniyoshi T, Keith H, Brid well, et al. Minimum 5-year ana lysis of L5-S1 fusion usingsacropelvic fixa tion (bila tera l S1 and iliac screws) for spina l deformity.Spine.2006 ;31:3:303-308.
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