术中螺旋CT与导航系统在胸腰椎爆裂骨折个性化治疗中的临床应用
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摘要
目的：
本研究旨在通过术中三维CT （Intraoperative computedtomography;iCT）扫描与导航系统对胸腰椎爆裂骨折采用个体化治疗方案，探索术中CT与导航系统的在使用过程中标准化流程，利用两组患者术后结果评价其可行性及安全性，分析导航系统的准确性，并对患者预后进行系统的回顾性分析，探讨在胸腰椎爆裂骨折个体化手术治疗中术中CT与导航系统的应用价值。同时，针对胸腰椎椎弓根钉易损伤脊髓和血管，导致术后严重后果的缺陷，建立术中CT重建技术辅助胸腰椎椎弓根固定的方法，重建术中实现三维图像的虚拟手术系统，实现术中三维影像引导手术，为下一步机器人参与手术打下基础。
方法：
1.术前评估制定手术方案
纳入2009年3月至2012年3月腰椎爆裂骨折患者90例，所有患者均在术前进行X线检查、三维CT检查，核磁共振检查，三位高年资副主任以上医师根据手术标准制定手术计划，包括后路撑开间接复位术、后路撑开复位直接减压术、后路撑开复位经椎弓根前路减压术、后路撑开复位前路植骨内固定术。并提出可行的具体方案和技术路线。
2.建立术中CT观测组和术中X线观测组
利用西门子和BrainLab公司联合推出的整体手术室，将所有入组病例按照就诊顺序进行单双号分组，所有患者均在术前、术中间接复位后、术后进行CT扫描。按术中具体不同的手术方式将其分为A、B两组：A组（n=45）术中根据三维重建CT结果判断评估手术复位结果，包括A3.1型11例，A3.2型25，A3.3型9例（AO分型）；B组（n=45）术中根据传统X线正侧位判断手术复位结果，包括A3.115例，A3.224例，A3.36例。记录两组手术时间、出血量，并按照ASIA神经功能评定标准对两组患者神经功能恢复情况评定，随访6-16个月。
3.建立椎弓根螺钉术中CT导航置入组和术中X线置入组
A组行实时导航下椎弓根钉内固定术，即通过螺旋CT三维重建技术中的容积重建VR和多平面重建MPR技术对置入椎弓根钉的相关参考指标进行个体化测量并在导航下置入螺钉，男27例，女18例，年龄（19～59）岁，平均年龄（35.3±8.2）岁，按照受伤原因分类：坠落伤15例，砸伤5例，交通事故伤25例；按照损伤部位分类：T1115例，T1213例，L1112例，L25例。
B组行传统X线透视法椎弓根螺钉内固定术，男28例，女17例，年龄（17~55）岁，平均年龄（37.4±9.5）岁，按照受伤原因分类：坠落伤9例，砸伤8例，交通事故伤28例；按照损伤部位分类：TI116例，T1213例，L1113例，L23例。记录两组手术时间、出血量，并按照ASIA神经功能评定标准对两组患者神经功能恢复情况评定，随访时间6-16个月。
结果：
1.手术疗效：实验中发现A组患者中24例（53.3%）通过间接复位椎管内骨块回复良好，达到既定要求，无需进一步处理；6例（13.3%）患者首次复位后椎管内骨块复位欠佳，调整复位方法后重新复位，iCT重新扫描后显示复位良好；11例（24.4%）患者多次复位欠佳，根据骨块形态及占位大小进行直接减压或间接减压，椎管达到既定要求；4例（8.9%）患者复位后仍显示椎体骨块持续压迫脊髓及马尾，改变体位后行前路减压并融合；全部患者中21例（46.7%患者根据术中复位后情况改变术前手术计划，达到良好疗效，所有患者均无需进行二次手术。B组患者中17例（37.8%）根据术前计划间接复位后行减压手术，但根据术后CT扫描结果显示，4例患者经复位后骨块已复位良好，无需进一步行减压手术，占比23.5%，15例（33.3%）患者根据术前计划间接复位后无需减压的患者中有2例术后CT扫描结果显示骨块复位不理想，需后路减压，占比13.3%，治疗欠当者共6例，占比13.3%，2例需进行二次手术，占比4.4%。两组手术时间、出血量、术后神经功能恢复情况比较差异均有统计学意义（P<0.05）。
2.螺钉置入准确率：利用导航验证的准确度平均为1.6mm（1.2-2.0mm）；A组共置入螺钉204枚，置入准确度为98.8％，其中2枚（2例患者）侵入椎弓根皮质，均位于胸椎，1例为右单侧T11螺钉，虽然突破了皮层内侧但只有螺纹部分侵入椎弓根皮质，未超过2mm也未损伤邻近神经血管；另一例为左侧的T12螺钉微创椎弓根外侧壁，未损伤邻近神经血管，因此仍保留螺丝初始位置，未进行二次手术；B组共置入螺钉198枚，置入准确率为96.5%，其中7枚螺钉出现差错，占比3.5％。其中1例病例侵入椎管，术中CT扫描后认为无需二次手术；此外，B组中发生术后伤口感染1例，行清创术后痊愈。两组手术时间和螺钉平均置入时间均有统计学差异（P<0.05）。
结论：
1.术中采用CT扫描系统进行实时检测复位效果能够显著提高复位准确率并可指导医生随时调整手术方案，避免二次手术，不增加血管和神经损伤，显著改善了患者生活质量；
2.对于必须减压的病例，iCT可提供清晰的图像以帮助判断减压是否彻底，从而从根本上提高腰椎手术的治疗效果。与无iCT相比，iCT可以帮助医生实时掌握治疗效果，判断是否需要改变手术方案或进一步治疗，有助于获得最佳疗效，对于提高手术定位精确度、降低手术损伤、优化手术路径和治疗方案、提高手术成功率等均具有十分重要的意义；
3.术中CT导航与传统X线透视法相比，采用影像导航技术辅助椎弓根螺钉置入，不仅降低了医患所受的X线辐射，更大大降低了因螺钉误值所造成手术的失误率，使椎弓根螺钉置入更精确，同时还缩短了手术时间、减少了术中的出血量，有效地降低了术后并发症的发生；
4.导航的实时监测追踪功能、内固定物精确制导，能使操作多维化，形象化、实时感强，避免胸腰段骨折患者因旋转脱位变化而带来的误差，是微创理念在脊柱手术中的临床应用，为胸腰椎爆裂骨折个性化治疗提供技术支持。
本论文创新性研究成果：
1.首次通过术中CT及导航系统对胸腰椎爆裂骨折治疗进行研究，不但可以在术中判断减压是否彻底，并可以根据椎管复位程度进一步改变术式，从根本上提高胸腰椎手术的治疗效果；
2.探索性地将胸腰椎爆裂骨折复位后骨块形态进行分型和整合，对不同类型骨折块进行不同方法进行处理，可能启发基于CT分型方法在的治疗上的新思路；
3.总结了建立术中CT重建技术辅助胸腰椎椎弓根固定的方法，重建术中实现三维图像的虚拟手术系统，实现术中三维影像引导手术，提高手术效果，为下一步机器人参与手术纵深研究提供了重要科学证据。
Objective：
Our study investigate how the intraoperative computed tomography(iCT) using amobile scanner with integrated navigation system (NS) wasapplied for individualized treatment for thoracolumbar burst fractures.The aim of this article is to determine the standard workflow ofintraoperative CT integrated with NS in microsurgery, to estimate thefeasibility and safety, as well as the accuracy of the NS. Retrospectiveanalysis of the prognosis of patients was used to investigate the clinicalapplication of iCT and integrated NNS in congenital thoracolumbar burstfractures. Meanwhile, since there’s a high risk was in the fix of thepedicle screws in thoracolumbar vertebra, which may induce injuries ofspinal cord and vascellum around pedicle, the method of intraoperativecomputed tomography (iCT) scan and navigation system (NS) reconstruction assisting thoracolumbar pedicle fixation was established,with which the reconstruct in the virtual surgery system with realisticthree-dimensional images and the3-D would improve the prognosis
Methods：
This study was divided into three parts.
1. Preoperative assessment of patients after surgical planning. Into thelumbar burst fractures in patients90cases from March2009toMarch2012, all patients in the preoperative X-ray examination of thethree-dimensional CT scan, MRI, three high qualification, deputy directorof the above physician surgical standard for surgical plan, including theposterior distraction reduction surgery decompression the posteriordistraction reset directly, and posterior distraction reset indirectdecompression, posterior distraction reset transpedicular anteriordecompression, posterior distraction reduction anterior interbody fixation.And propose feasible specific programs and technical route.
2. Establish the the intraoperative CT observation group and X-rayobservations surgery group. Siemens and BrainLab jointly launched the whole operating room, through retrospective analysis of the hospitalhospital from the composition of the90cases from March2009to March2013, odd and even numbers grouped according to the treatmentsequence,90patients were in indirect reduction surgery, preoperative,intraoperative CT scan after the completion of surgery. Surgical reductionresults according to the three-dimensional reconstruction of CT to assesshow their specific surgery surgical divided into A, B groups: A group thatsurgery A group of45patients, according to the AO classification, whichthe A3.1type of11cases, A3.2type25, A3.3type nine cases; accordingto the traditional X-ray group B that surgery is lateral to judge the resultsof surgical reduction A3.115cases, A3.224cases A3.36cases. Thestatistical analysis of the two sets of data are comparable, and aftersurgery were retrospectively analyzed by the same group of surgeons,recording two surgical time, blood loss. The two groups were16monthsof follow-up June1postoperative neurologic recovery assessed inaccordance with the ASIA neurological function evaluation.
3. Establish pedicle screw intraoperative CT navigation placement group and intraoperative X-ray placement group.45routine real-timenavigation of pedicle screw fixation (A group),27males and18females,aged19-59years old, with an average age of35, the cause of his injuries:15cases of fall injury, injured five cases, traffic The accident injury25cases; injury site: T119cases, T1214cases, Lll6cases, L28cases.45traditional routine X-ray fluoroscopy pedicle volume reconstruction byspiral CT technology in VR and multi-planar reconstruction the MPRtechnique of pedicle screw reference indicators individualizedmeasurement and screw placed in the navigation screw fixation (B group),26males and14females, aged17to55years old, with an average of37years of age, cause of injury: fall injury cases, injured six cases,26casesof traffic accident injury; injury site: TI16cases、T1213cases、L114cases、L29cases、L33cases. statistical analysis, the two sets of data arecomparable, and after surgery were retrospectively analyzed by the samegroup of surgeons, recorded two surgical time, blood loss, evaluation ofplacement quality. The two groups were16months of follow-up June1postoperative neurologic recovery assessed in accordance with the ASIA neurological function evaluation.
Results：
1.Experiment found that24patients in group A patients by indirectreduction and spinal bone Replies to achieve the established requirements,without further processing;6patients first reset spinal bone imperfectreduction, adjust the reset method re-Reset, iCT re-scan display goodreduction;11patients imperfect reduction, based on direct decompressionbone morphology and placeholder size or indirect decompression of thespinal canal to reach the established requirements;4patients after resetvertebral bone block sustained spinal cord compression and cauda equinachange postural underwent anterior decompression and fusion;22patients in all patients under surgery after reset change preoperativesurgical planning.17cases of group B patients preoperative planningindirect reduction underwent decompression surgery, but CT scansshowed postoperative evaluation after reset,4patients was reset afterbone has good reduction, no need for further decompression, false Thepositive rate of23%.2patients CT scans showed postoperative evaluation after reset the bone reset unsatisfactory in15cases of patientsaccording to the preoperative plan indirect reduction withoutdecompression required posterior decompression, the false-negative rateof13%.16patients in all patients should be changed according to thesituation after the surgery reset preoperative surgical planning. Differencebetween two groups in operative time, blood loss, postoperative recoveryof neurological function was significant (P <0.05)
2. Navigation verify accuracy average of1.6mm (1.6:1.2-2.0mm);navigation Steering Group204, placed screws, two screws (1.2%) inviolation of the pedicle cortex. The two screws in the thoracic spine.1case, right unilateral T11screws breakthrough the cortical medial,because only the threaded portion invasive pedicle cortex, not more than2mm not close to the nerve, vascular damage. The second patient the leftof the T-12screws minimally invasive pedicle outer sidewall, the twocases none of the spinal canal and adjacent structures damage, there is nodanger therefore decided screws remain in its initial position. TheSteering Group of the picture, the overall accuracy of98.8%. X-ray fluoroscopic guidance group, placed screws198errors (3.5%) observedseven screws. The screw dislocation in the distribution of each group arelisted in Table1according to statistics, X-ray guided group than in thefrequent occurrence of the screw in the wrong place than navigationguidance group (P <0.05, χ2test). Cases invasive spinal surgery CT scandoes not require revision.(Table2). The perspective group apostoperative wound infection healed after requiring surgicaldebridement. Screws average placement in operative time, the timedifference between the two groups was significant (P <0.05)
Conclusions：
1. Intraoperative CT scanning system for real-time detection reset effectcan significantly improve the reset accuracy rate and the guidance of adoctor at any time to adjust to the surgery program, to avoid secondarysurgery does not increase the blood vessels and nerve injury, a significantimprovement in the quality of life of the patients;
2. Cases must be decompression, iCT can also provide a clear imagevacuum to help determine whether a thorough and fundamentally improve the therapeutic effect of lumbar spine surgery. Compared with nointraoperative CT, iCT allows doctors treatment effect can be captured inreal time, to determine whether surgery program needs to be changed orfurther treatment, helps to get the best effect for improving surgicalpositioning accuracy and reduce surgical injury, optimize the surgicalpath and treatment programs, improve the success rate of surgery, etc. hasa very important significance;
3. Using image-guidance technology the auxiliary push pedicle screwplacement relative to conventional X-ray fluoroscopy, navigationtechnology reduces the patient and surgeon X-ray radiation, to favorsurgery smoothly; greatly reduce the failure rate of surgery; make pediclescrew surgery more accurate, simple, fast, safe, reduce operative time andblood loss, can reduce the incidence of postoperative complications;
4. Navigation instantaneous tracking capabilities, real-time monitoring,precision-guided within the plant to enable the operator to image,multi-dimensional, real strong sense of to avoid the error ofthoracolumbar fractures in patients with postural changes brought navigation is an ideal plant boot mode, the clinical application of theconcept of minimally invasive spine surgery.Contributions and innovations：
1. The first time by intraoperative CT and navigation systems ofthoracolumbar burst fractures study, not only was whether the judgmentdecompression surgery completely, and further changes may be based onthe degree of spinal reset surgical, and fundamentally improve thethoracolumbar spine surgery the therapeutic effect;
2. Exploration of thoracolumbar burst the bone morphology typing andintegration fractures, different methods of fracture fragments of thedifferent types of treatment, may inspire new ideas in the treatmentCT-based typing methods;
3. Summed up the establishment of intraoperative CT reconstructiontechnique assisted thoracolumbar pedicle fixation, virtual surgery systemfor three-dimensional image reconstruction, intraoperative3Dimaging-guided surgery, improving the efficacy involved in the surgery in depth for the next robot The study provides important scientific evidence.
本研究旨在通过术中三维CT （Intraoperative computedtomography;iCT）扫描与导航系统对胸腰椎爆裂骨折采用个体化治疗方案，探索术中CT与导航系统的在使用过程中标准化流程，利用两组患者术后结果评价其可行性及安全性，分析导航系统的准确性，并对患者预后进行系统的回顾性分析，探讨在胸腰椎爆裂骨折个体化手术治疗中术中CT与导航系统的应用价值。同时，针对胸腰椎椎弓根钉易损伤脊髓和血管，导致术后严重后果的缺陷，建立术中CT重建技术辅助胸腰椎椎弓根固定的方法，重建术中实现三维图像的虚拟手术系统，实现术中三维影像引导手术，为下一步机器人参与手术打下基础。
方法：
1.术前评估制定手术方案
纳入2009年3月至2012年3月腰椎爆裂骨折患者90例，所有患者均在术前进行X线检查、三维CT检查，核磁共振检查，三位高年资副主任以上医师根据手术标准制定手术计划，包括后路撑开间接复位术、后路撑开复位直接减压术、后路撑开复位经椎弓根前路减压术、后路撑开复位前路植骨内固定术。并提出可行的具体方案和技术路线。
2.建立术中CT观测组和术中X线观测组
利用西门子和BrainLab公司联合推出的整体手术室，将所有入组病例按照就诊顺序进行单双号分组，所有患者均在术前、术中间接复位后、术后进行CT扫描。按术中具体不同的手术方式将其分为A、B两组：A组（n=45）术中根据三维重建CT结果判断评估手术复位结果，包括A3.1型11例，A3.2型25，A3.3型9例（AO分型）；B组（n=45）术中根据传统X线正侧位判断手术复位结果，包括A3.115例，A3.224例，A3.36例。记录两组手术时间、出血量，并按照ASIA神经功能评定标准对两组患者神经功能恢复情况评定，随访6-16个月。
3.建立椎弓根螺钉术中CT导航置入组和术中X线置入组
A组行实时导航下椎弓根钉内固定术，即通过螺旋CT三维重建技术中的容积重建VR和多平面重建MPR技术对置入椎弓根钉的相关参考指标进行个体化测量并在导航下置入螺钉，男27例，女18例，年龄（19～59）岁，平均年龄（35.3±8.2）岁，按照受伤原因分类：坠落伤15例，砸伤5例，交通事故伤25例；按照损伤部位分类：T1115例，T1213例，L1112例，L25例。
B组行传统X线透视法椎弓根螺钉内固定术，男28例，女17例，年龄（17~55）岁，平均年龄（37.4±9.5）岁，按照受伤原因分类：坠落伤9例，砸伤8例，交通事故伤28例；按照损伤部位分类：TI116例，T1213例，L1113例，L23例。记录两组手术时间、出血量，并按照ASIA神经功能评定标准对两组患者神经功能恢复情况评定，随访时间6-16个月。
结果：
1.手术疗效：实验中发现A组患者中24例（53.3%）通过间接复位椎管内骨块回复良好，达到既定要求，无需进一步处理；6例（13.3%）患者首次复位后椎管内骨块复位欠佳，调整复位方法后重新复位，iCT重新扫描后显示复位良好；11例（24.4%）患者多次复位欠佳，根据骨块形态及占位大小进行直接减压或间接减压，椎管达到既定要求；4例（8.9%）患者复位后仍显示椎体骨块持续压迫脊髓及马尾，改变体位后行前路减压并融合；全部患者中21例（46.7%患者根据术中复位后情况改变术前手术计划，达到良好疗效，所有患者均无需进行二次手术。B组患者中17例（37.8%）根据术前计划间接复位后行减压手术，但根据术后CT扫描结果显示，4例患者经复位后骨块已复位良好，无需进一步行减压手术，占比23.5%，15例（33.3%）患者根据术前计划间接复位后无需减压的患者中有2例术后CT扫描结果显示骨块复位不理想，需后路减压，占比13.3%，治疗欠当者共6例，占比13.3%，2例需进行二次手术，占比4.4%。两组手术时间、出血量、术后神经功能恢复情况比较差异均有统计学意义（P<0.05）。
2.螺钉置入准确率：利用导航验证的准确度平均为1.6mm（1.2-2.0mm）；A组共置入螺钉204枚，置入准确度为98.8％，其中2枚（2例患者）侵入椎弓根皮质，均位于胸椎，1例为右单侧T11螺钉，虽然突破了皮层内侧但只有螺纹部分侵入椎弓根皮质，未超过2mm也未损伤邻近神经血管；另一例为左侧的T12螺钉微创椎弓根外侧壁，未损伤邻近神经血管，因此仍保留螺丝初始位置，未进行二次手术；B组共置入螺钉198枚，置入准确率为96.5%，其中7枚螺钉出现差错，占比3.5％。其中1例病例侵入椎管，术中CT扫描后认为无需二次手术；此外，B组中发生术后伤口感染1例，行清创术后痊愈。两组手术时间和螺钉平均置入时间均有统计学差异（P<0.05）。
结论：
1.术中采用CT扫描系统进行实时检测复位效果能够显著提高复位准确率并可指导医生随时调整手术方案，避免二次手术，不增加血管和神经损伤，显著改善了患者生活质量；
2.对于必须减压的病例，iCT可提供清晰的图像以帮助判断减压是否彻底，从而从根本上提高腰椎手术的治疗效果。与无iCT相比，iCT可以帮助医生实时掌握治疗效果，判断是否需要改变手术方案或进一步治疗，有助于获得最佳疗效，对于提高手术定位精确度、降低手术损伤、优化手术路径和治疗方案、提高手术成功率等均具有十分重要的意义；
3.术中CT导航与传统X线透视法相比，采用影像导航技术辅助椎弓根螺钉置入，不仅降低了医患所受的X线辐射，更大大降低了因螺钉误值所造成手术的失误率，使椎弓根螺钉置入更精确，同时还缩短了手术时间、减少了术中的出血量，有效地降低了术后并发症的发生；
4.导航的实时监测追踪功能、内固定物精确制导，能使操作多维化，形象化、实时感强，避免胸腰段骨折患者因旋转脱位变化而带来的误差，是微创理念在脊柱手术中的临床应用，为胸腰椎爆裂骨折个性化治疗提供技术支持。
本论文创新性研究成果：
1.首次通过术中CT及导航系统对胸腰椎爆裂骨折治疗进行研究，不但可以在术中判断减压是否彻底，并可以根据椎管复位程度进一步改变术式，从根本上提高胸腰椎手术的治疗效果；
2.探索性地将胸腰椎爆裂骨折复位后骨块形态进行分型和整合，对不同类型骨折块进行不同方法进行处理，可能启发基于CT分型方法在的治疗上的新思路；
3.总结了建立术中CT重建技术辅助胸腰椎椎弓根固定的方法，重建术中实现三维图像的虚拟手术系统，实现术中三维影像引导手术，提高手术效果，为下一步机器人参与手术纵深研究提供了重要科学证据。
Objective：
Our study investigate how the intraoperative computed tomography(iCT) using amobile scanner with integrated navigation system (NS) wasapplied for individualized treatment for thoracolumbar burst fractures.The aim of this article is to determine the standard workflow ofintraoperative CT integrated with NS in microsurgery, to estimate thefeasibility and safety, as well as the accuracy of the NS. Retrospectiveanalysis of the prognosis of patients was used to investigate the clinicalapplication of iCT and integrated NNS in congenital thoracolumbar burstfractures. Meanwhile, since there’s a high risk was in the fix of thepedicle screws in thoracolumbar vertebra, which may induce injuries ofspinal cord and vascellum around pedicle, the method of intraoperativecomputed tomography (iCT) scan and navigation system (NS) reconstruction assisting thoracolumbar pedicle fixation was established,with which the reconstruct in the virtual surgery system with realisticthree-dimensional images and the3-D would improve the prognosis
Methods：
This study was divided into three parts.
1. Preoperative assessment of patients after surgical planning. Into thelumbar burst fractures in patients90cases from March2009toMarch2012, all patients in the preoperative X-ray examination of thethree-dimensional CT scan, MRI, three high qualification, deputy directorof the above physician surgical standard for surgical plan, including theposterior distraction reduction surgery decompression the posteriordistraction reset directly, and posterior distraction reset indirectdecompression, posterior distraction reset transpedicular anteriordecompression, posterior distraction reduction anterior interbody fixation.And propose feasible specific programs and technical route.
2. Establish the the intraoperative CT observation group and X-rayobservations surgery group. Siemens and BrainLab jointly launched the whole operating room, through retrospective analysis of the hospitalhospital from the composition of the90cases from March2009to March2013, odd and even numbers grouped according to the treatmentsequence,90patients were in indirect reduction surgery, preoperative,intraoperative CT scan after the completion of surgery. Surgical reductionresults according to the three-dimensional reconstruction of CT to assesshow their specific surgery surgical divided into A, B groups: A group thatsurgery A group of45patients, according to the AO classification, whichthe A3.1type of11cases, A3.2type25, A3.3type nine cases; accordingto the traditional X-ray group B that surgery is lateral to judge the resultsof surgical reduction A3.115cases, A3.224cases A3.36cases. Thestatistical analysis of the two sets of data are comparable, and aftersurgery were retrospectively analyzed by the same group of surgeons,recording two surgical time, blood loss. The two groups were16monthsof follow-up June1postoperative neurologic recovery assessed inaccordance with the ASIA neurological function evaluation.
3. Establish pedicle screw intraoperative CT navigation placement group and intraoperative X-ray placement group.45routine real-timenavigation of pedicle screw fixation (A group),27males and18females,aged19-59years old, with an average age of35, the cause of his injuries:15cases of fall injury, injured five cases, traffic The accident injury25cases; injury site: T119cases, T1214cases, Lll6cases, L28cases.45traditional routine X-ray fluoroscopy pedicle volume reconstruction byspiral CT technology in VR and multi-planar reconstruction the MPRtechnique of pedicle screw reference indicators individualizedmeasurement and screw placed in the navigation screw fixation (B group),26males and14females, aged17to55years old, with an average of37years of age, cause of injury: fall injury cases, injured six cases,26casesof traffic accident injury; injury site: TI16cases、T1213cases、L114cases、L29cases、L33cases. statistical analysis, the two sets of data arecomparable, and after surgery were retrospectively analyzed by the samegroup of surgeons, recorded two surgical time, blood loss, evaluation ofplacement quality. The two groups were16months of follow-up June1postoperative neurologic recovery assessed in accordance with the ASIA neurological function evaluation.
Results：
1.Experiment found that24patients in group A patients by indirectreduction and spinal bone Replies to achieve the established requirements,without further processing;6patients first reset spinal bone imperfectreduction, adjust the reset method re-Reset, iCT re-scan display goodreduction;11patients imperfect reduction, based on direct decompressionbone morphology and placeholder size or indirect decompression of thespinal canal to reach the established requirements;4patients after resetvertebral bone block sustained spinal cord compression and cauda equinachange postural underwent anterior decompression and fusion;22patients in all patients under surgery after reset change preoperativesurgical planning.17cases of group B patients preoperative planningindirect reduction underwent decompression surgery, but CT scansshowed postoperative evaluation after reset,4patients was reset afterbone has good reduction, no need for further decompression, false Thepositive rate of23%.2patients CT scans showed postoperative evaluation after reset the bone reset unsatisfactory in15cases of patientsaccording to the preoperative plan indirect reduction withoutdecompression required posterior decompression, the false-negative rateof13%.16patients in all patients should be changed according to thesituation after the surgery reset preoperative surgical planning. Differencebetween two groups in operative time, blood loss, postoperative recoveryof neurological function was significant (P <0.05)
2. Navigation verify accuracy average of1.6mm (1.6:1.2-2.0mm);navigation Steering Group204, placed screws, two screws (1.2%) inviolation of the pedicle cortex. The two screws in the thoracic spine.1case, right unilateral T11screws breakthrough the cortical medial,because only the threaded portion invasive pedicle cortex, not more than2mm not close to the nerve, vascular damage. The second patient the leftof the T-12screws minimally invasive pedicle outer sidewall, the twocases none of the spinal canal and adjacent structures damage, there is nodanger therefore decided screws remain in its initial position. TheSteering Group of the picture, the overall accuracy of98.8%. X-ray fluoroscopic guidance group, placed screws198errors (3.5%) observedseven screws. The screw dislocation in the distribution of each group arelisted in Table1according to statistics, X-ray guided group than in thefrequent occurrence of the screw in the wrong place than navigationguidance group (P <0.05, χ2test). Cases invasive spinal surgery CT scandoes not require revision.(Table2). The perspective group apostoperative wound infection healed after requiring surgicaldebridement. Screws average placement in operative time, the timedifference between the two groups was significant (P <0.05)
Conclusions：
1. Intraoperative CT scanning system for real-time detection reset effectcan significantly improve the reset accuracy rate and the guidance of adoctor at any time to adjust to the surgery program, to avoid secondarysurgery does not increase the blood vessels and nerve injury, a significantimprovement in the quality of life of the patients;
2. Cases must be decompression, iCT can also provide a clear imagevacuum to help determine whether a thorough and fundamentally improve the therapeutic effect of lumbar spine surgery. Compared with nointraoperative CT, iCT allows doctors treatment effect can be captured inreal time, to determine whether surgery program needs to be changed orfurther treatment, helps to get the best effect for improving surgicalpositioning accuracy and reduce surgical injury, optimize the surgicalpath and treatment programs, improve the success rate of surgery, etc. hasa very important significance;
3. Using image-guidance technology the auxiliary push pedicle screwplacement relative to conventional X-ray fluoroscopy, navigationtechnology reduces the patient and surgeon X-ray radiation, to favorsurgery smoothly; greatly reduce the failure rate of surgery; make pediclescrew surgery more accurate, simple, fast, safe, reduce operative time andblood loss, can reduce the incidence of postoperative complications;
4. Navigation instantaneous tracking capabilities, real-time monitoring,precision-guided within the plant to enable the operator to image,multi-dimensional, real strong sense of to avoid the error ofthoracolumbar fractures in patients with postural changes brought navigation is an ideal plant boot mode, the clinical application of theconcept of minimally invasive spine surgery.Contributions and innovations：
1. The first time by intraoperative CT and navigation systems ofthoracolumbar burst fractures study, not only was whether the judgmentdecompression surgery completely, and further changes may be based onthe degree of spinal reset surgical, and fundamentally improve thethoracolumbar spine surgery the therapeutic effect;
2. Exploration of thoracolumbar burst the bone morphology typing andintegration fractures, different methods of fracture fragments of thedifferent types of treatment, may inspire new ideas in the treatmentCT-based typing methods;
3. Summed up the establishment of intraoperative CT reconstructiontechnique assisted thoracolumbar pedicle fixation, virtual surgery systemfor three-dimensional image reconstruction, intraoperative3Dimaging-guided surgery, improving the efficacy involved in the surgery in depth for the next robot The study provides important scientific evidence.
引文
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