胸椎椎弓根螺钉内固定术后植入准确性的CT评价
摘要
目的：采用术后CT回顾性分析置入的68枚胸椎椎弓根镙钉来决定胸椎椎弓根镙钉内固定术在脊柱外科应用（包括脊柱侧凸中）中的总体准确性和危险性，以及椎弓根内外、前方皮质穿破的关联因素.
方法：本组病人均采用中华富乐椎弓根螺钉系统进行手感法内固定，由同一位有多年腰椎椎弓根镙钉内固定经验的医师植入，所有螺钉的植入均通过术中x线荧屏正侧位辅助判断位置，术中均采用了脊髓监测。T1~T10的进钉点采用横突水平线上缘与小关节突竖直中线的交点，T11～T12采用横突水平中线与小关节水平中线的交点。T1~T10采用4.5mm直径的螺钉，T11~T12采用5.5或6.5mm直径的螺钉。采用徒手法植入椎弓根镙钉，利用术后CT评价植入胸椎椎弓根和锥体的钉的准确性，由三名脊柱外科医师配合一名放射医师来通过术后CT观测椎弓根的皮质移位移位情况。同时也测量了横向螺钉角度 (TSA) ，椎弓根皮质移位分成两大组四类：有侧凸组和无侧凸组，椎弓根皮质移位程度按2mm为级别进行分类，根据移位程度分I，II，III，IV四类：I.0~2.0mm，II.2.1~4.0mm, III.4.1~6.0mm, IV.6.1~8.0mm。对镙钉进行了区域性的分类对比（上中下胸椎），植入的镙钉于是也被按照是否内侧皮质移位<2mm,外侧皮质移位<6mm，分为可接受镙钉，即AP镙钉，指内侧皮质移位<2mm,外侧皮质移位<6mm的镙钉；和完全植入镙钉，即TC镙钉。前方椎体皮质穿破通过沿着螺钉中轴来测量判断其穿出的具体mm数值，对比分析了无皮质移位时与有各种皮质移位时的椎弓根横向镙钉角度（TSA）。以椎体横断面的中线为参考来测量横向螺钉角度TSA，即其与椎弓根镙钉轴线的夹角。并对比了有侧凸组和无侧凸组的准确性差异。
结果：在采用脊柱后路固定融合的手术中共植入68枚胸椎椎弓根镙钉，
它们分布于有脊柱侧凸畸形或无脊柱侧凸的10位患者中。镙钉直径范围（4.5mm～6.5mm），97％基本完全植入椎弓根（即为可接受镙钉），60％完全植入椎弓根（完全包容的镙钉）。内侧椎弓根皮质移位率为12％，但只有2枚(2.9%)侵犯椎管程度>2mm,外侧皮质移位率相对最高19％，明显高于内侧皮质移位（p<0.05）。前方皮质移位平均1.5mm。在27枚移位椎弓根皮质的螺钉中，50％移位外侧，明显高于内侧30%.(p<0.05)和前方皮质移位20%. 在内侧皮质移位的螺钉中，8.8％（6枚）为I类，2.9％（2枚）为II类，III，IV类为0枚；在外侧皮质移位的螺钉中，10.2％（7枚）为I类，7.4％（5枚）为II类，1％（1枚）为III类，IV类0枚。值得一提的是，内侧皮质移位为II类，即>2mm的只有2枚。完全植入的镙钉平均TSA为14.5度，与有内外侧移位有显著差异(p<0.05)，内侧皮质移位者平均TSA17度，外侧11度。前方皮质移位者平均TSA最小（10.0），且常常于外侧皮质移位同时伴随发生(p<0.05)。按区域划分，其中上（T1～T4）17枚，中段（T5～T8）23枚，下段（T9～T12）28枚，在各段完全植入的比率无明显差异（分别为59%，61%，60%）。位置可接受镙钉(AP镙钉)在有侧凸组和无侧凸组均为97%，完全植入的镙钉（TC镙钉）准确率在有侧凸组（58%）稍低，无侧凸组（62%），但也无统计学上的差异（p>0.05）。均无血管和脊髓损伤并发症。
结论：97%的螺钉为可接受的准确镙钉(AP镙钉). 皮质有无移位组均无血管神经并发症。经胸椎椎弓根镙钉内固定术总体上安全可靠。螺钉的准确性在有侧凸组和无侧凸组没有显著差异，螺钉的准确性在胸椎各段亦无明显差异。完全植入的螺钉与有内外侧皮质移位的螺钉TSA有统计学上的差异(p<0.05)。前方皮质移位通常伴有外侧皮质移位，而且平均TSA角度
更小。
Study Design:A prospective observational study to evaluate the accuracy of 68 transpedicular thoracic screws placed in patients with and without idiopathic scoliosis using postoperative computed tomography (CT) and to establish its risks and benefits.
Summary of Background Data:. Lumbar pedicle screw instrumentation has proven tobe reliable and effective in the spine surgical management of scoliosis. No domestic reports exist on the accuracy and benefits of pedicle screw instrumentation of the thoracic spine including in scoliosis surgery.
Materials and Methods:In all the 68 thoracic pedicle screws placed in 10 patients,we use chinese fule pedicle screw system,and pedicle screws were by the same surgeon who has many years of experences on pedicle screw implantion,during opertion we use c armed x-ray to see the position of the screws.with regards to the entry site,we use the intersection of a vertical line bisecting the facet joint and a horizontal line located at the superior border of the transverse process for T1-T10 or the midline of the transverse process at T11-T12 defined the pedicle entrance point. 68 thoracic pedicle screws in 10 patients with and without idiopathic scoliosis were investigated shortly after surgery by computed tomography. The accuracy of thoracic screw placement within the pedicle and vertebral body were assessed by postoperative CT. Cortical perforations of the pedicle were graded in 2-mm increments. and grouped into 4 groups:I.0~2.0mm，II.2.1~4.0mm,
III.4.1~6.0mm, IV.6.1~8.0mm . And defined “acceptably positioned (AP) screws” includes:<= 2 mm of medial or <= 6 mm of lateral pedicle perforation. Screws were regionally grouped for analysis. upper thoracic,middle thoracic and lower thoracic..The transverse screw angle (TSA) between with-penetration group and without-penetration group were measured and analysed. The accuracy of thoracic screw placement between with-deformity group and without coronal deformity group were compared and analysed.
Results:68 titanium thoracic pedicle screws of various diameters (4.5-6.5mm)were placed in ten patients who underwent instrumented posterior spinal fusion. The regional distribution of the screws was 17 screws at T1-T4, 23 screws at T5-T8, and 28screws at T9-T12. 97% of the screws are mainly-totally within pedicles(acceptable positioned screws), 60% of screws were totally confined within the pedicle. Although medial perforation of the pedicle wall occurred in 12% of screws, in <1% there was > mm of canal intrusion. Lateral pedicular perforation occurred in 50% of perforating screws and was significantly more common than medial perforation (P < 0. 05). 6 screws penetrated the anterior vertebral cortex by an average of 1.7 mm. Screws inserted between T1 and T4 had no difference in the incidence of full containment within the pedicle and vertebral body (P >0.05) compared with T9–T12. The mean TSA for screws localized within the pedicle was 14.5° and was significantly different from screws with either medial (mean 17°) or lateral (mean 11.0°) pedicle perforation (P < 0. 05). Anterior vertebral penetration was associated with a
smaller mean TSA of 10.0° (P <0.05) and with lateral pedicle perforation (P < 0.05). There was no statistic difference between the overall percentages of acceptably positioned screws (<= 2 mm of medial or <= 6 mm of lateral pedicle perforation) in patients with coronal plane spinal deformities (97%) versus patients without coronal plane spinal deformities (97%) (P>0.05).There were no neurologic or vascular complications.
Conclusions:Ninety-Seven percent of screws were fully contained or were inserted with either <=2 mm of medial cortical perforation or an acceptable lateral breech. there is no neurologic and vascular compromise in both with-penetration and without-penetration groups. Thoracic pedicle screw fixation is a reliable method including treating spinalde formities. Anterior cortical penetration occurred significantly more often with lateral pedicle perforation and with a smaller mean
方法：本组病人均采用中华富乐椎弓根螺钉系统进行手感法内固定，由同一位有多年腰椎椎弓根镙钉内固定经验的医师植入，所有螺钉的植入均通过术中x线荧屏正侧位辅助判断位置，术中均采用了脊髓监测。T1~T10的进钉点采用横突水平线上缘与小关节突竖直中线的交点，T11～T12采用横突水平中线与小关节水平中线的交点。T1~T10采用4.5mm直径的螺钉，T11~T12采用5.5或6.5mm直径的螺钉。采用徒手法植入椎弓根镙钉，利用术后CT评价植入胸椎椎弓根和锥体的钉的准确性，由三名脊柱外科医师配合一名放射医师来通过术后CT观测椎弓根的皮质移位移位情况。同时也测量了横向螺钉角度 (TSA) ，椎弓根皮质移位分成两大组四类：有侧凸组和无侧凸组，椎弓根皮质移位程度按2mm为级别进行分类，根据移位程度分I，II，III，IV四类：I.0~2.0mm，II.2.1~4.0mm, III.4.1~6.0mm, IV.6.1~8.0mm。对镙钉进行了区域性的分类对比（上中下胸椎），植入的镙钉于是也被按照是否内侧皮质移位<2mm,外侧皮质移位<6mm，分为可接受镙钉，即AP镙钉，指内侧皮质移位<2mm,外侧皮质移位<6mm的镙钉；和完全植入镙钉，即TC镙钉。前方椎体皮质穿破通过沿着螺钉中轴来测量判断其穿出的具体mm数值，对比分析了无皮质移位时与有各种皮质移位时的椎弓根横向镙钉角度（TSA）。以椎体横断面的中线为参考来测量横向螺钉角度TSA，即其与椎弓根镙钉轴线的夹角。并对比了有侧凸组和无侧凸组的准确性差异。
结果：在采用脊柱后路固定融合的手术中共植入68枚胸椎椎弓根镙钉，
它们分布于有脊柱侧凸畸形或无脊柱侧凸的10位患者中。镙钉直径范围（4.5mm～6.5mm），97％基本完全植入椎弓根（即为可接受镙钉），60％完全植入椎弓根（完全包容的镙钉）。内侧椎弓根皮质移位率为12％，但只有2枚(2.9%)侵犯椎管程度>2mm,外侧皮质移位率相对最高19％，明显高于内侧皮质移位（p<0.05）。前方皮质移位平均1.5mm。在27枚移位椎弓根皮质的螺钉中，50％移位外侧，明显高于内侧30%.(p<0.05)和前方皮质移位20%. 在内侧皮质移位的螺钉中，8.8％（6枚）为I类，2.9％（2枚）为II类，III，IV类为0枚；在外侧皮质移位的螺钉中，10.2％（7枚）为I类，7.4％（5枚）为II类，1％（1枚）为III类，IV类0枚。值得一提的是，内侧皮质移位为II类，即>2mm的只有2枚。完全植入的镙钉平均TSA为14.5度，与有内外侧移位有显著差异(p<0.05)，内侧皮质移位者平均TSA17度，外侧11度。前方皮质移位者平均TSA最小（10.0），且常常于外侧皮质移位同时伴随发生(p<0.05)。按区域划分，其中上（T1～T4）17枚，中段（T5～T8）23枚，下段（T9～T12）28枚，在各段完全植入的比率无明显差异（分别为59%，61%，60%）。位置可接受镙钉(AP镙钉)在有侧凸组和无侧凸组均为97%，完全植入的镙钉（TC镙钉）准确率在有侧凸组（58%）稍低，无侧凸组（62%），但也无统计学上的差异（p>0.05）。均无血管和脊髓损伤并发症。
结论：97%的螺钉为可接受的准确镙钉(AP镙钉). 皮质有无移位组均无血管神经并发症。经胸椎椎弓根镙钉内固定术总体上安全可靠。螺钉的准确性在有侧凸组和无侧凸组没有显著差异，螺钉的准确性在胸椎各段亦无明显差异。完全植入的螺钉与有内外侧皮质移位的螺钉TSA有统计学上的差异(p<0.05)。前方皮质移位通常伴有外侧皮质移位，而且平均TSA角度
更小。
Study Design:A prospective observational study to evaluate the accuracy of 68 transpedicular thoracic screws placed in patients with and without idiopathic scoliosis using postoperative computed tomography (CT) and to establish its risks and benefits.
Summary of Background Data:. Lumbar pedicle screw instrumentation has proven tobe reliable and effective in the spine surgical management of scoliosis. No domestic reports exist on the accuracy and benefits of pedicle screw instrumentation of the thoracic spine including in scoliosis surgery.
Materials and Methods:In all the 68 thoracic pedicle screws placed in 10 patients,we use chinese fule pedicle screw system,and pedicle screws were by the same surgeon who has many years of experences on pedicle screw implantion,during opertion we use c armed x-ray to see the position of the screws.with regards to the entry site,we use the intersection of a vertical line bisecting the facet joint and a horizontal line located at the superior border of the transverse process for T1-T10 or the midline of the transverse process at T11-T12 defined the pedicle entrance point. 68 thoracic pedicle screws in 10 patients with and without idiopathic scoliosis were investigated shortly after surgery by computed tomography. The accuracy of thoracic screw placement within the pedicle and vertebral body were assessed by postoperative CT. Cortical perforations of the pedicle were graded in 2-mm increments. and grouped into 4 groups:I.0~2.0mm，II.2.1~4.0mm,
III.4.1~6.0mm, IV.6.1~8.0mm . And defined “acceptably positioned (AP) screws” includes:<= 2 mm of medial or <= 6 mm of lateral pedicle perforation. Screws were regionally grouped for analysis. upper thoracic,middle thoracic and lower thoracic..The transverse screw angle (TSA) between with-penetration group and without-penetration group were measured and analysed. The accuracy of thoracic screw placement between with-deformity group and without coronal deformity group were compared and analysed.
Results:68 titanium thoracic pedicle screws of various diameters (4.5-6.5mm)were placed in ten patients who underwent instrumented posterior spinal fusion. The regional distribution of the screws was 17 screws at T1-T4, 23 screws at T5-T8, and 28screws at T9-T12. 97% of the screws are mainly-totally within pedicles(acceptable positioned screws), 60% of screws were totally confined within the pedicle. Although medial perforation of the pedicle wall occurred in 12% of screws, in <1% there was > mm of canal intrusion. Lateral pedicular perforation occurred in 50% of perforating screws and was significantly more common than medial perforation (P < 0. 05). 6 screws penetrated the anterior vertebral cortex by an average of 1.7 mm. Screws inserted between T1 and T4 had no difference in the incidence of full containment within the pedicle and vertebral body (P >0.05) compared with T9–T12. The mean TSA for screws localized within the pedicle was 14.5° and was significantly different from screws with either medial (mean 17°) or lateral (mean 11.0°) pedicle perforation (P < 0. 05). Anterior vertebral penetration was associated with a
smaller mean TSA of 10.0° (P <0.05) and with lateral pedicle perforation (P < 0.05). There was no statistic difference between the overall percentages of acceptably positioned screws (<= 2 mm of medial or <= 6 mm of lateral pedicle perforation) in patients with coronal plane spinal deformities (97%) versus patients without coronal plane spinal deformities (97%) (P>0.05).There were no neurologic or vascular complications.
Conclusions:Ninety-Seven percent of screws were fully contained or were inserted with either <=2 mm of medial cortical perforation or an acceptable lateral breech. there is no neurologic and vascular compromise in both with-penetration and without-penetration groups. Thoracic pedicle screw fixation is a reliable method including treating spinalde formities. Anterior cortical penetration occurred significantly more often with lateral pedicle perforation and with a smaller mean
引文
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noted that the malposition of the screws could not be clearly established.
Danesh-Clough T, Taylor P, Hodgson B, et al.: The use of evoked EMG in detecting misplaced thoracolumbar pedicle screws. Spine 2001, 26:1313–6. The authors have studied the efficacy of evoked electromyographic stimulation in determining the position of thoracic pedicle screws in a sheep model and noted a sensitivity of 94% and a specificity of 90% when using a threshold of 10 volts.
Reidy D, Houlden D, Nolan P, et al.: Evaluation of electromyographic monitoring during insertion of thoracic pedicle screws. J Bone Joint Surg Br 2001, 83:1009–14. The authors investigated the use of intercostal electromyographic monitoring as an indicator of malpositioned thoracic pedicles in 17 patients (95 screws) and noted the electromyographic monitoring did not improve the reliability of screw placement.
Faraj A, Webb J: Early complications of spinal pedicle screw. Eur Spine J 1997, 6:324–6. The authors retrospectively reviewed the position of 279 transpedicular thoracic screws using postoperative CT and noted a 43% malposition rate without neurologic or vascular complication.
Liljenqvist U, Halm H, Link T: Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine 1997, 22:2239–45.
Halm H, Niemeyer T, Link T, et al.: Segmental pedicle screw instrumentation in idiopathic thoracolumbar and lumbar scoliosis. Eur Spine J 2000, 9:191–7.
Belmont Jr, PJ Klemme WR, Dhawan A, et al.: In vivo accuracy of thoracic pedicle screws. Spine 2001, 26:2340–6.
Suk S, Kim W, Lee S, et al.: Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine 2001, 26:2049–57. The authors retrospectively reviewed the rate of complications associated with 4604 thoracic pedicle screws and noted a 0.8% rate of neurologic complications.
Suk S, Kim W, Kim J, et al.: Restoration of thoracic kyphosis in the hypokyphotic spine: a comparison between multiple-hook and segmental pedicle screw fixation in
adolescent idiopathic scoliosis. J Spinal Disord 1999, 12:489–95.
Jonsson B, Sjostrom L, Olerud C, et al.: Outcome after limited posterior surgery for thoracic and lumbar spine metastases. Eur Spine J 1996, 5:36–44.
Parker JW, Lane JR, Karaikovic EE, et al.: Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 4 1/2-year series. Spine 2000, 25:1157–70.
李振宇，候树勋：胸椎经椎弓根镙钉内固定的相关问题.[J]中国脊柱脊髓杂志,2002,12(1),60-62.
Deepak Awasthi, MD and Najeeb Thomas, MD:pedicle screw placement.Department of Neurosurgery; Louisiana State University Health Sciences Center; New Orleans, Louisiana; USA.http://www.medschool.lsumc.edu/Nsurgery.
Whitecloud TS, Skalley T, Cook SD, et al. Roentgenographic measurement of pedicle screw penetration. Clin Orthop 1989; 245: 57-68.
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 1991; 5: 576-9.
Michael,K,Rosner,M.D.et al.thoracic pedicle screw fixation for spinal deformity.[J]Neurosur Focus,2003,14(1).
O’Brien MF，Lenke LG，et,al.Pedicle morphology in thoracic adolescent idiopathic scoliosis:is pedicle fixation an anatomically viable technique.[j].Spine,2000,25(18).2285-2293.
Liljenqvist UR,Link TM:Morphometric analysis of thoracic and lumbar vertebrae in idiopathic scoliosis.Spine 2000,25,1247-1253.
Rauschning w.Anterior surgery of the thoracolumbar junction and the lumbar spine:Anatomy complications,safe guards[c]Berlin,Germany,1995,October 25-27.
Cotrel Y,Dubousset J,New universal instrumentation in spinal surgery[j].Clinorthop,1988,227:10-23.
温晓阳,廖世文等：椎弓根镙钉技术在中上胸椎中的应用.[J]the journey of bone and joint injury.2003.18(8),556-557。
LILJENQVIST, ULF R. MD. ALLKEMPER, THOMAS MD. HACKENBERG, LARS MD. LINK, THOMAS M. MD. STEINBECK, JORN MD. HALM, HENRY F.H. MD. ANALYSIS OF VERTEBRAL MORPHOLOGY IN IDIOPATHIC SCOLIOSIS WITH USE OF MAGNETIC RESONANCE IMAGING AND MULTIPLANAR RECONSTRUCTION. Journal of Bone & Joint Surgery - American Volume. 84-A(3):359-368, March 2002.
Carl AL,pedicle screw instrumentation for thoracolumbar burst fractures and fracture dislocations.Spine 1992,17:317S-323S.
Sim E. Location of transpedicular screws for fixation of the lower thoracic and lumbar spine: computed tomography of 45 fracture cases. Acta Orthop Scand 1993; 64: 28-32.
Sasso RC, Cotler HB, Reuben JD. Posterior fixation of thoracic and lumbar spine fractures using DC plates and pedicle screws. Spine 1991; 16 (suppl): 134-9.
Sjostrom L, Jacobsson O, Karlstrom G, et al. CT analysis of pedicles and screw tracts after implant removal in thoracolumbar fractures. J Spinal Disord 1993; 6: 225-31.
Esses SI, Botsford DJ, Wright T, et al. Operative treatment of spinal fractures with the AO internal fixator. Spine 1991; 16 (suppl): 146-50.
Jonsson B, Sjostrom L, Olerud C, et al. Outcome after limited posterior surgery for thoracic and lumbar spine metastases. Eur Spine J 1996; 5: 36-44.
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; 5: 606-14.
Chang K. Oligosegmental correction of post-traumatic thoracolumbar angular kyphosis. Spine 1993; 18: 1909-15.
Wu SS, Hwa SY, Lin LC, et al. Management of rigid post-traumatic kyphosis. Spine 1996; 21: 2260-7.
Delorme S, Labelle H, Aubin C, et al. A three-dimensional radiographic comparison of Cotrel-Dubousset and Colorado instrumentation for the correction of idiopathic scoliosis. Spine 2000; 25: 205-10.
Cheung KM,et al.Radiographic assessment of pedicle hook placement [j]. Spine, 1997, 22(18):2106-2111.
Phillips JH ,et al:the radiographic anatomy fo the thoracic pedicle. Spine, 1994, 19(4):446-449.
Kothe R,et al:International architechure of the thoracic pedicle :an anatomy study. Spine,1996,21(3):264-270.
Ebraheim NA,et al: Anatomic relations of the thoracic pedicle to the adjacent neural structures.Spine,1997,22(14):1553-1557.
潘显明,谭映军,张波,等.胸椎经椎弓根内固定的解剖学研究与内固定器的研制[Ｊ].骨与关节损伤杂志,2000,15(3):202-205.
Louis R,Spine internal fixation with louis instrumentation. InAnHs, CotlerJmeds. Spine Instrumentation [m].Baltimore:Wiliamsand Wilkins,1992:183-196.
AnHs,GordinR,Anatomic considerations ofr plate screw fixation of the cervical spine.Spine,1991,16(suppl):S548-551.
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附图
图1术后CT显示椎管内侵犯
图2 术后CT显示外侧皮质穿破
图3.在T9的外侧皮质合并前皮质穿破（TSA=7度）
图4 完全置入椎弓根的T4镙钉
图5.挤开外侧皮质植入的螺钉
图6. 外侧皮质穿破
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Krag M, Weaver D, Beynnon B, et al.: Morphometry of the thoracic and lumbar spine related to transpedicular screw placement for surgical spinal fixation. Spine 1988, 13:27–32.
Misenhimer G, Peek R, Wiltse L, et al.: Anatomic analysis of pedicle cortical and cancellous diameter as related to screw size. Spine 1989, 14:367–72.
Vaccaro A, Rizzolo S, Allardyce T, et al.: Placement of pedicle screws in the thoracic spine. Part I: Morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am 1995, 77:1193–9.
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Ebraheim N, Xu R, Ahmad M, et al.: Projection of the thoracic pedicle and its morphometric analysis. Spine 1997, 22:233–8.
Kothe R, O'Holleran J, Liu W, et al.: Internal architecture of the thoracic pedicle: an anatomic study. Spine 1996, 21:264–70.
Ebraheim N, Jabaly G, Xu R, et al.: Anatomic relations of the thoracic pedicle to the adjacent neural structures. Spine 1997, 22:1553–6.
Weinstein JN, Rydevik BL, Rauschning W: Anatomic and technical considerations of pedicle screw fixation. Clin Orthop Rel Res 1992, X:34–46.
Ugur H, Attar A, Uz A, et al.: Thoracic pedicle: surgical anatomic evaluation and relations. J Spinal Disord 2001, 14:39–45. The authors have reported a comprehensive anatomic study of the adult thoracic pedicle.
Zindrick M, Knight G, Sartori M, et al.: Pedicle morphology of the immature thoracolumbar spine. Spine 2000, 25:2726–35.?
Roy-Camille R, Saillant G, Mazel C: Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Rel Res 1986:7–17.
Louis R: Fusion of the lumbar and sacral spine by internal fixation with screw plates. Clin Orthop Rel Res 1986:18–33.
Roy-Camille R, Saillant G, Mazel C: Plating of thoracic, thoracolumbar, and lumbar injuries with pedicle screw plates. Orthop Clin North Am 1986, 17:147–59.
Vaccaro AR, Rizzolo SJ, Balderston RA, et al.: Placement of pedicle screws in the thoracic spine. Part II: An anatomic and radiographic assessment. J Bone Joint Surg Am 1995, 77:1200–6.
Xu R, Ebraheim N, Ou Y, et al.: Anatomic considerations of pedicle screw placement in the thoracic spine: Roy-Camille technique versus open-lamina technique. Spine 1998, 23:1065–8.
Xu R, Ebraheim N, Shepherd M, et al.: Thoracic pedicle screw placement guided by computed tomographic measurements. J Spinal Disord 1999, 12:222–6.
Magerl FP: Stabilization of the lower thoracic and lumbar spine with external skeletal fixation. Clin Orthop Rel Res 1984:125–141.
Cinotti G, Gumina S, Ripani M, et al.: Pedicle instrumentation in the thoracic spine: a morphometric and cadaveric study for placement of screws. Spine 1999, 24:114–9.
Schwend R, Dewire P, Kowalski T: Accuracy of fluoroscopically assisted laser targeting of the cadaveric thoracic and lumbar spine to place transpedicular screws. J Spinal Disord 2000, 13:412–8.?
Jang J, Lee W, Yuan H: Use of a guide device to place pedicle screws in the thoracic spine: a cadaveric study. Technical note. J Neurosurg 2001, 94:328–33. The authors have reported a malposition rate of 5.8% in a cadaveric model using a specially designed external guide.?
Merloz P, Tonetti J, Eid A, et al.: Computer assisted spine surgery. Clin Orthop Rel Res 1997, 337:86–96.
Merloz P, Tonetti J, Pittet L, et al.: Pedicle screw placement using image guided techniques. Clin Orthop Rel Res 1998, 35439–48.
Foley KT, Smith MM: Image-guided spine surgery. Neurosurg Clin North Am 1996, 7:171–86.
Nolte LP, Visarius H, Arm E, et al.: Computer-aided fixation of spinal implants. J Image Guid Surg 1995, 1:88–93. .
Nolte L, Zamorano L, Arm E, et al.: Image-guided computer-assisted spine surgery: a pilot study on pedicle screw fixation. Stereotact Funct Neurosurg 1996, 66:108–17.
Schwarzenbach O, Berlemann U, Jost B, et al.: Accuracy of computer-assisted pedicle screw placement. An in vivo computed tomography analysis. Spine 1997, 22:452–8.
Kim K, Patrick JJ, Bloch BO, et al.: Computer-assisted thoracic pedicle screw placement: an in vitro feasibility study. Spine 2001, 26:360–4. The authors have reported their experience in thoracic pedicle screw placement in a cadaveric model using streotactic navigation. They have
noted a 19.2% malposition rate. They have also noted a progressive learning curve.
Kamimura M, Ebara S, Itoh H, et al.: Accurate pedicle screw insertion under the control of a computer-assisted image guiding system: laboratory test and clinical study. J Orthop Sci 1999, 4:197–206.
Youkilis A, Quint D, McGillicuddy J, et al.: Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery 2001, 48:771–8. The authors have reported a malposition rate of 14% in 266 thoracic pedicle screws placed using streotactic navigation.
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, 25:606–14.
Assaker R, Reyns N, Vinchon M, et al.: Transpedicular screw placement: image-guided versus lateral-view fluoroscopy:in vitro simulation. Spine 2001, 26:2160–64. The authors have compared streotactic navigation with traditional biplanar fluoroscopy and have noted a much longer time needed to place pedicle screws using computer-assisted devices (13.5 minutes per screw) versus biplanar fluoroscopy (4 minutes per screw).
Lenke LG, Padberg AM, Russo MH, et al.: Triggered electromyographic threshold for accuracy of pedicle screw placement: an animal model and clinical correlation. Spine 1995, 20:1585–91.
Calancie B, Lebwohl N, Madsen P, et al.: Intraoperative evoked EMG monitoring in an animal model: a new technique for evaluating pedicle screw placement. Spine 1992, 17:1229–35.?
Lewis S, Lenke L, Raynor B, et al.: Triggered electromyographic threshold for accuracy of thoracic pedicle screw placement in a porcine model. Spine 2001, 26:2485–9. The authors have studied the efficacy of triggered electromyographic stimulation in determining the position of thoracic pedicle screws in a porcine model and
noted that the malposition of the screws could not be clearly established.
Danesh-Clough T, Taylor P, Hodgson B, et al.: The use of evoked EMG in detecting misplaced thoracolumbar pedicle screws. Spine 2001, 26:1313–6. The authors have studied the efficacy of evoked electromyographic stimulation in determining the position of thoracic pedicle screws in a sheep model and noted a sensitivity of 94% and a specificity of 90% when using a threshold of 10 volts.
Reidy D, Houlden D, Nolan P, et al.: Evaluation of electromyographic monitoring during insertion of thoracic pedicle screws. J Bone Joint Surg Br 2001, 83:1009–14. The authors investigated the use of intercostal electromyographic monitoring as an indicator of malpositioned thoracic pedicles in 17 patients (95 screws) and noted the electromyographic monitoring did not improve the reliability of screw placement.
Faraj A, Webb J: Early complications of spinal pedicle screw. Eur Spine J 1997, 6:324–6. The authors retrospectively reviewed the position of 279 transpedicular thoracic screws using postoperative CT and noted a 43% malposition rate without neurologic or vascular complication.
Liljenqvist U, Halm H, Link T: Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine 1997, 22:2239–45.
Halm H, Niemeyer T, Link T, et al.: Segmental pedicle screw instrumentation in idiopathic thoracolumbar and lumbar scoliosis. Eur Spine J 2000, 9:191–7.
Belmont Jr, PJ Klemme WR, Dhawan A, et al.: In vivo accuracy of thoracic pedicle screws. Spine 2001, 26:2340–6.
Suk S, Kim W, Lee S, et al.: Thoracic pedicle screw fixation in spinal deformities: are they really safe? Spine 2001, 26:2049–57. The authors retrospectively reviewed the rate of complications associated with 4604 thoracic pedicle screws and noted a 0.8% rate of neurologic complications.
Suk S, Kim W, Kim J, et al.: Restoration of thoracic kyphosis in the hypokyphotic spine: a comparison between multiple-hook and segmental pedicle screw fixation in
adolescent idiopathic scoliosis. J Spinal Disord 1999, 12:489–95.
Jonsson B, Sjostrom L, Olerud C, et al.: Outcome after limited posterior surgery for thoracic and lumbar spine metastases. Eur Spine J 1996, 5:36–44.
Parker JW, Lane JR, Karaikovic EE, et al.: Successful short-segment instrumentation and fusion for thoracolumbar spine fractures: a consecutive 4 1/2-year series. Spine 2000, 25:1157–70.
李振宇，候树勋：胸椎经椎弓根镙钉内固定的相关问题.[J]中国脊柱脊髓杂志,2002,12(1),60-62.
Deepak Awasthi, MD and Najeeb Thomas, MD:pedicle screw placement.Department of Neurosurgery; Louisiana State University Health Sciences Center; New Orleans, Louisiana; USA.http://www.medschool.lsumc.edu/Nsurgery.
Whitecloud TS, Skalley T, Cook SD, et al. Roentgenographic measurement of pedicle screw penetration. Clin Orthop 1989; 245: 57-68.
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 1991; 5: 576-9.
Michael,K,Rosner,M.D.et al.thoracic pedicle screw fixation for spinal deformity.[J]Neurosur Focus,2003,14(1).
O’Brien MF，Lenke LG，et,al.Pedicle morphology in thoracic adolescent idiopathic scoliosis:is pedicle fixation an anatomically viable technique.[j].Spine,2000,25(18).2285-2293.
Liljenqvist UR,Link TM:Morphometric analysis of thoracic and lumbar vertebrae in idiopathic scoliosis.Spine 2000,25,1247-1253.
Rauschning w.Anterior surgery of the thoracolumbar junction and the lumbar spine:Anatomy complications,safe guards[c]Berlin,Germany,1995,October 25-27.
Cotrel Y,Dubousset J,New universal instrumentation in spinal surgery[j].Clinorthop,1988,227:10-23.
温晓阳,廖世文等：椎弓根镙钉技术在中上胸椎中的应用.[J]the journey of bone and joint injury.2003.18(8),556-557。
LILJENQVIST, ULF R. MD. ALLKEMPER, THOMAS MD. HACKENBERG, LARS MD. LINK, THOMAS M. MD. STEINBECK, JORN MD. HALM, HENRY F.H. MD. ANALYSIS OF VERTEBRAL MORPHOLOGY IN IDIOPATHIC SCOLIOSIS WITH USE OF MAGNETIC RESONANCE IMAGING AND MULTIPLANAR RECONSTRUCTION. Journal of Bone & Joint Surgery - American Volume. 84-A(3):359-368, March 2002.
Carl AL,pedicle screw instrumentation for thoracolumbar burst fractures and fracture dislocations.Spine 1992,17:317S-323S.
Sim E. Location of transpedicular screws for fixation of the lower thoracic and lumbar spine: computed tomography of 45 fracture cases. Acta Orthop Scand 1993; 64: 28-32.
Sasso RC, Cotler HB, Reuben JD. Posterior fixation of thoracic and lumbar spine fractures using DC plates and pedicle screws. Spine 1991; 16 (suppl): 134-9.
Sjostrom L, Jacobsson O, Karlstrom G, et al. CT analysis of pedicles and screw tracts after implant removal in thoracolumbar fractures. J Spinal Disord 1993; 6: 225-31.
Esses SI, Botsford DJ, Wright T, et al. Operative treatment of spinal fractures with the AO internal fixator. Spine 1991; 16 (suppl): 146-50.
Jonsson B, Sjostrom L, Olerud C, et al. Outcome after limited posterior surgery for thoracic and lumbar spine metastases. Eur Spine J 1996; 5: 36-44.
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; 5: 606-14.
Chang K. Oligosegmental correction of post-traumatic thoracolumbar angular kyphosis. Spine 1993; 18: 1909-15.
Wu SS, Hwa SY, Lin LC, et al. Management of rigid post-traumatic kyphosis. Spine 1996; 21: 2260-7.
Delorme S, Labelle H, Aubin C, et al. A three-dimensional radiographic comparison of Cotrel-Dubousset and Colorado instrumentation for the correction of idiopathic scoliosis. Spine 2000; 25: 205-10.
Cheung KM,et al.Radiographic assessment of pedicle hook placement [j]. Spine, 1997, 22(18):2106-2111.
Phillips JH ,et al:the radiographic anatomy fo the thoracic pedicle. Spine, 1994, 19(4):446-449.
Kothe R,et al:International architechure of the thoracic pedicle :an anatomy study. Spine,1996,21(3):264-270.
Ebraheim NA,et al: Anatomic relations of the thoracic pedicle to the adjacent neural structures.Spine,1997,22(14):1553-1557.
潘显明,谭映军,张波,等.胸椎经椎弓根内固定的解剖学研究与内固定器的研制[Ｊ].骨与关节损伤杂志,2000,15(3):202-205.
Louis R,Spine internal fixation with louis instrumentation. InAnHs, CotlerJmeds. Spine Instrumentation [m].Baltimore:Wiliamsand Wilkins,1992:183-196.
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附图
图1术后CT显示椎管内侵犯
图2 术后CT显示外侧皮质穿破
图3.在T9的外侧皮质合并前皮质穿破（TSA=7度）
图4 完全置入椎弓根的T4镙钉
图5.挤开外侧皮质植入的螺钉
图6. 外侧皮质穿破
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