胸腰椎椎弓根螺钉植入钉道准备系统的研制和实验研究
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摘要
【背景】椎弓根螺钉内固定技术已被广泛地用于脊柱外科,用以矫正畸形、重建脊柱的稳定性。但是随着临床上的广泛应用,人们发现椎弓根螺钉植入位置的不良率高达20%至40%。螺钉误植将会导致椎弓根骨折、神经损伤等一系列严重的并发症,同时植入的准确性也影响着内固定的稳定性。因此,关于椎弓根螺钉准确植入方法的研究一直是人们倍受关注的课题。
【目的】设计椎弓根螺钉植入钉道准备系统,通过与常规椎弓根钉道准备的方法相比较,以评估钉道准备系统植入椎弓根螺钉的准确性。
【方法】选用7具经防腐处理后的成人胸腰段脊柱标本(T10～L5),经检查未发现畸形及骨性病变,分为实验组(n=56)和对照组(n=56)。胸椎采用Ebraheim法确定进钉点;腰椎采用杜心如“人字形骨嵴”顶点作为进钉点。实验组:椎弓根螺钉钉道准备系统准备好椎弓根钉道(Pilot Hole),确认钉道无误后植入螺钉;对照组:直径1.5mm克氏针钝头凭手感钻探出椎弓根孔道,扩孔后植入螺钉。术中螺钉植入后,摄正侧位片了解螺钉位置,判断并记录误植螺钉。术后解剖椎体,直视下观察螺钉位置,记录误植螺钉,测量螺钉侵入椎管的距离。
【结果】经直视下观察发现:112侧椎弓根中有14例(占12.5%)螺钉误植。钉道准备系统组56侧椎弓根3例发生误植(T111例、T12 2例),成功率达94.6%。植入过程中,有3例在定位测深器的帮助下发现钉道位置欠佳,调整后植入。对照组56侧椎弓根有11例螺钉植入位置不佳(T10 3例、T11 2例、T12 3例、L1 2例、L2 1例),成功率仅80.4%。
[Background] Pedicle screw placement is a commonly used technique in the field of spinal surgery for procedures requiring spinal stabilization and deformity correction. However, Pedicle screws are reportedly misplaced at a high rate of 20% to 40%. Transpedicular screw placement is associated with complications including pedicle fracture, and temporary or permanent neurologic injury. The accuracy with which such instrumentation can be placed is constantly under study.
[Objective] The objective of the study was to design a system of preparing the pilot hole of pedicle screw placement and to evaluate the accuracy of this device in comparison with techniques commonly used for pedicle cannulation.
[Methods] Seven spine specimens were cleaned of muscle and overlying soft tissue. These specimens included T10～L5. Preoperative anteroposterior and lateral radiographs were taken and inspected to rule out underlying osseous pathology or deformity. The entry site for each pedicle was identified using anatomic landmarks based on estimation of the pedicle projection dorsally, our routine method in clinical practice. For each spine specimen, the pedicles of one side were cannulated with the conventional placement technique using Kirschner wire, then were placed pedicle screws. For the other side of each spine specimen, the pedicles were cannulated with the system of preparing the pilot hole of
【目的】设计椎弓根螺钉植入钉道准备系统,通过与常规椎弓根钉道准备的方法相比较,以评估钉道准备系统植入椎弓根螺钉的准确性。
【方法】选用7具经防腐处理后的成人胸腰段脊柱标本(T10～L5),经检查未发现畸形及骨性病变,分为实验组(n=56)和对照组(n=56)。胸椎采用Ebraheim法确定进钉点;腰椎采用杜心如“人字形骨嵴”顶点作为进钉点。实验组:椎弓根螺钉钉道准备系统准备好椎弓根钉道(Pilot Hole),确认钉道无误后植入螺钉;对照组:直径1.5mm克氏针钝头凭手感钻探出椎弓根孔道,扩孔后植入螺钉。术中螺钉植入后,摄正侧位片了解螺钉位置,判断并记录误植螺钉。术后解剖椎体,直视下观察螺钉位置,记录误植螺钉,测量螺钉侵入椎管的距离。
【结果】经直视下观察发现:112侧椎弓根中有14例(占12.5%)螺钉误植。钉道准备系统组56侧椎弓根3例发生误植(T111例、T12 2例),成功率达94.6%。植入过程中,有3例在定位测深器的帮助下发现钉道位置欠佳,调整后植入。对照组56侧椎弓根有11例螺钉植入位置不佳(T10 3例、T11 2例、T12 3例、L1 2例、L2 1例),成功率仅80.4%。
[Background] Pedicle screw placement is a commonly used technique in the field of spinal surgery for procedures requiring spinal stabilization and deformity correction. However, Pedicle screws are reportedly misplaced at a high rate of 20% to 40%. Transpedicular screw placement is associated with complications including pedicle fracture, and temporary or permanent neurologic injury. The accuracy with which such instrumentation can be placed is constantly under study.
[Objective] The objective of the study was to design a system of preparing the pilot hole of pedicle screw placement and to evaluate the accuracy of this device in comparison with techniques commonly used for pedicle cannulation.
[Methods] Seven spine specimens were cleaned of muscle and overlying soft tissue. These specimens included T10～L5. Preoperative anteroposterior and lateral radiographs were taken and inspected to rule out underlying osseous pathology or deformity. The entry site for each pedicle was identified using anatomic landmarks based on estimation of the pedicle projection dorsally, our routine method in clinical practice. For each spine specimen, the pedicles of one side were cannulated with the conventional placement technique using Kirschner wire, then were placed pedicle screws. For the other side of each spine specimen, the pedicles were cannulated with the system of preparing the pilot hole of
引文
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7 Youkilis AS, Quint DJ, McGillicuddy JE, et al. Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery, 2001,48(4): 771-778.
8 Seller K, Wild A, Urselmann L, et al. Prospective screw misplacement analysis after conventional and navigated pedicle screw implantation. Biomed Tech, 2005, 50(9):287-292.
9 周云, 唐天驷. 胸腰椎椎弓根螺钉植入技术的研究进展. 中华创伤骨科杂志, 2004,6(1):118-120.
10 Ebraheim NA, Xu R, Ahmad M, et al. Projection of the thoracic pedicle and its morphometric analysis. Spine, 1997,2(2):233-238.
11 杜心如, 叶启彬,张一模,等. 腰椎椎弓根螺钉人字嵴顶点进钉方法的放射解剖
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2 Roy-Camille R, Saillant G, Mazel C, at al. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res, 1986,203:7-17.
3 Steffee AD, Biscup RS, Sitkowski DJ,et al. Segmental spine plates with pedicle screw fixation. A new internal fixation device for disorders of the lumbar and thoracolumbar spine. Clin Orthop Relat Res, 1986,203:45-53.
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6 Ebraheim NA, Xu R, Ahmad M, et al. Projection of the thoracic pedicle and its morphometric analysis. Spine, 1997,22(3):233-238.
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12 Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine, 1990,15(1):11-14.
13 Weinstein JN, Spratt KF, Spengler D, et al. Spinal pedicle fixation: reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine, 1988,13(9):1012-1018.
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28 Myles RT, Fong B, Esses SI, et al. Radiographic verification of pedicle screw pilot hole placement using Kirshner wires versus beaded wires. Spine, 1999,24(5):476-480.
29 宁漱岩, 苗巍巍, 刘一,等. 螺旋式导针法准确判断胸椎椎弓根螺钉植入. 吉林大学学报(医学版), 2002,28(5):515-517.
30 Liu Y, Zhang SK, Miao WW, et al. Radiographic verification of pedicle screw pilot hole placement in thoracic spine using Kirschner wires versus spiral wires. Chin J Traumatol, 2003,6(5):288-91.
31 谭军, 万年宇,左金良,等. 胸腰段椎弓根螺钉准确植入方法的实验和临床研究. 中国脊柱脊髓杂志, 1996,6(3):99-102.
32 陈光磊, 江汉, 朱剑华,等. 胸腰段椎弓根螺钉植入的节段性变化及坐标法研究. 中国骨伤, 2001,14(11):643-645.
33 Steinmann JC, Herkowitz HN, el-Kommos H, et al. Spinal pedicle fixation. Confirmation of an image-based technique for screw placement. Spine, 1993,18 (13):1856-61.
34 陈永铵, 姚汉刚, 李佛保,等. 对称性可调节式椎弓根钻孔导向器的研制及应用. 中国脊柱脊髓杂志, 2003,13(6):328-331.
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36 Amiot LP, Lang K, Putzier M, et al. Comparative results between conventional and computer-assisted pedicle screw installation in the thoracic, lumbar, and sacral spine.Spine, 2000,25(5):606-614.
37 Youkilis AS, Quint DJ, McGillicuddy JE, et al. Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery, 2001,48(4): 771-778.
38 山卫东,龚耀成,吴文坚,等. 诱发肌电图对椎弓根螺钉植入的术中监测. 中国脊柱脊髓杂志, 2001,11(2):85-88.
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42 Christensen FB, Thomsen K, Eiskjaer SP, et al. Functional outcome after posterolateral spinal fusion using pedicle screws: comparison between primary and salvage procedure. Eur Spine, 1998,7(4):321-327.
2 Odgers CJ, Vaccaro AR, Pollack ME, et al. Accuracy of pedicle screw placement with the assistance of lateral plain radiography. J Spinal Disord, 1996,9(4): 334- 338.
3 Vaccaro AR, Rizzolo SJ, Balderston RA, 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):1200-1206.
4 Belmont PJ Jr, Klemme WR, Dhawan A, et al. In vivo accuracy of thoracic pedicle screws. Spine, 2001,26(21):2340-2346.
5 Carbone JJ, Tortolani PJ, Quartararo LG, et al. Fluoroscopically assisted pedicle screw fixation for thoracic and thoracolumbar injuries: technique and short-term complications. Spine, 2003,28(1):91-97.
6 Xu R, Ebraheim NA, Shepherd ME, et al. Thoracic pedicle screw placement guided by computed tomographic measurements. J Spinal Disord,1999,12(3): 222-226.
7 Youkilis AS, Quint DJ, McGillicuddy JE, et al. Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery, 2001,48(4): 771-778.
8 Seller K, Wild A, Urselmann L, et al. Prospective screw misplacement analysis after conventional and navigated pedicle screw implantation. Biomed Tech, 2005, 50(9):287-292.
9 周云, 唐天驷. 胸腰椎椎弓根螺钉植入技术的研究进展. 中华创伤骨科杂志, 2004,6(1):118-120.
10 Ebraheim NA, Xu R, Ahmad M, et al. Projection of the thoracic pedicle and its morphometric analysis. Spine, 1997,2(2):233-238.
11 杜心如, 叶启彬,张一模,等. 腰椎椎弓根螺钉人字嵴顶点进钉方法的放射解剖
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