摘要
目的：比较单、双侧椎弓根螺钉固定经椎间孔椎体间融合术治疗腰椎退行性疾病的临床疗效。方法：2006年10月至2010年10月采用经椎间孔椎体间融合椎弓根螺钉固定治疗60例腰椎退行性疾病患者，根据固定方式分为A，B两组。A组28例应用单侧椎弓根螺钉经椎间孔椎体间融合，男16例，女12例；年龄40--56岁，平均48岁。术前诊断：腰椎椎间盘脱出4例，腰椎椎间盘术后复发6例，腰椎管狭窄症6例，腰椎退行性不稳8例，退行性腰椎滑脱症4例。B组32例应用双侧椎弓根螺钉经椎间孔椎体间融合，男18例，女14例；年龄42--67岁，平均52岁。术前诊断：腰椎椎间盘脱出5例，腰椎椎间盘术后复发6例，腰椎管狭窄症7例，腰椎退行性不稳6例，退行性腰椎滑脱症8例。使用ODI评分、VSA视觉模拟评分对两组患者术前评分及术后评分，并比较两组的手术时间、失血量、融合率、医疗费用、手术优良率、并发症发生率等情况。结果：两组患者ODI评分、VSA视觉模拟评分术前与术后3个月、6个月比较差异有统计学意义（P＜0.05）；手术时间、出血量、医疗费用比较差异有统计学意义（P＜0.05），单侧组少于双侧组；融合率、优良率、并发症发生率比较差异无统计学意义（P＞0.05），两组融合率分别为92％、94％。结论：单、双侧椎弓根螺钉经椎间孔椎体间融合术治疗腰椎退行性疾病临床疗效均满意，单侧椎弓根螺钉椎体间融合术创伤小，经济简便，是治疗腰椎退行性疾病的较好选择；长期疗效尚需进一步临床研究。
目的：探讨单侧椎弓根固定联合单枚椎间融合器行经椎间孔椎体间融合术后对侧腰部疼痛原因及发生率。方法：2008年10月至2011年10月，30例资料完整的患者(男16例，女14例，年龄40岁-56岁)行单侧椎弓根固定联合单枚椎间融合器行经椎间孔椎体间融合术。分析术前及术后ODI评分及VSA评分，通过术后影像学表现分析椎间高度及对侧关节突的改变。结果：术前及术后3m、6m、12m ODI评分、VSA评分明显改善，有统计学意义（P<0.05）。融合率为92%，临床满意率为89%，5例患者术后出现对侧腰骶部疼痛。三维CT扫描提示：单侧固定的对侧椎间隙的高度及腰椎生理前凸恢复欠佳；其他影像学表现包括对侧关节突关节间隙的增宽，融合节段的相对旋转。结论：单侧固定术后椎间高度两侧恢复不对称及对侧关节突关节紊乱应引起重视。
目的:研究腰椎三角固定装置的生物力学特性，并与常规椎弓根螺钉固定方法比较。方法:建立L3-5TLIF三维有限元模型，分别用双侧椎弓根螺钉固定（BPSF）、单侧椎弓根螺钉固定（UPSF）、三角固定装置固定（TCF）。L3表面施加500N预载荷，再施加10N·m的力距模拟腰椎前屈、后伸、左右侧屈、轴向旋转等生理活动，测试不同工况下L4-L5节段角位移，椎弓根螺钉或经椎板关节突螺钉、融合器应力分布情况。结果：BPSF与TCF L4-L5节段角位移小于UPSF；UPSF的螺钉应力峰值明显高于BPSF、TCF；UPSF椎间融合器的应力峰值在各种工况下高于BPSF、TCF，BPSF与TCF基本相似。结论：TCF生物力学稳定性优于UPSF，与BPSF相似。
目的：研究单侧椎弓根螺钉+经关节椎弓根螺钉固定装置的生物力学特性。方法：建立L4-5节段TLIF三维有限元模型，分别用双侧椎弓根螺钉（BPSF组）、单侧椎弓根螺钉（UPSF组）、单侧椎弓根螺钉+经关节椎弓根螺钉固定（UPSF+TPSF组）固定。L3表面施加500N预载荷，再施加10N·m的力距模拟腰椎前屈、后伸、左右侧方屈曲、轴向旋转等生理活动，测试不同工况下每组L4-L5节段角位移，椎弓根螺钉或经关节椎弓根螺钉、融合器应力分布情况。结果：与UPSF组及UPSF+TPSF组比较，BPSF组可获得更少角位移。UPSF组在所有载荷负载实验模型中最不稳定；尤其与BPSF相比，UPS组在侧弯实验更不稳定。UPSF组的螺钉应力峰值明显高于BPSF组及UPS+TPSF组，与以左方屈曲及后伸时螺钉应力峰值最大； UPS+TPSF组高于BPSF组。UPSF组椎间融合器的应力峰值在各种工况下高于BPSF组及UPS+TPSF组；及UPS+TPFS与BPSF组基本相似。
结论：UPS+TPSF组的生物力学稳定性优于UPSF组，可作为腰椎后路固定方式的另一种选择。
目的：探讨腰椎上下关节突与相应骨性终板解剖关系，为经关节椎弓根螺钉准确经皮植入提供影像解剖学参考。方法：研究L3--S1节段干燥标本20具及200位21-44岁健康成人体检腰椎正侧位X片，测量关节突关节的高度，分别测量上、下关节突超出相应骨性终板的比例。进一步确定下终板作为进针点的标志。结果：L3--L5/S1的上、下关节突高度几乎相等，约14.5mm。L3及L4下关节突关节超出L3、L4下终板约74%and78%，L5超出约67%。在所有节段，上关节突关节超出上终板约35%--40%。结论：在冠状面上椎体骨性下终板可作为经皮植入经关节椎弓根螺钉进针点的参考。
目的：探讨经皮腰椎经关节椎弓根螺钉理想的进针点及进针角度，为螺钉准确植入提供解剖学参考。方法：研究20具L3—S1节段干燥标本及200位21-44岁健康成人体检腰椎正侧位X片，测量关节突关节的高度、宽度及角度，并在直视下应用Boucher技术进行固定，分析螺钉在矢状面及轴位的角度及进针点与与上位椎体解剖标志的关系。进一步确定合适的进针点及终点的放射学参数。结果：L3, L4, L5的上关节突最大宽度分别为11,13, and15mm，L3到S1最大上关节突宽度逐渐增大，S1最大约16mm。L3到L5/S1的上、下关节突高度几乎相等，约14.5mm。关节突关节的外倾角自L3至S1逐渐增大，分别为18°,27°,35°,及44°。进针点在冠状面内外方向应当以棘突与下关节突边缘连线中点为参考，头尾方向应当以固定节段的下终板为参考标准。在轴位片上，理想的进针角度应为15-18°；在矢状位的尾倾角为30-35°。在前后X片上，螺钉应终止于椎弓根的下1/4，侧位X片上，应在椎弓根椎体连接处。结论：通过测量获得腰椎关节突关节准确的解剖学数值，为经皮植入经关节椎弓根螺钉操作提供了较为可靠的数据支持。
Objective: To compare clinical effects of lumbar interbody fusion withunilateral pedicle screw fixation and bilateral pedicle screw fixation in treating lumbardegenerative disease. Methods: Form October2006to October2010，sixty cases weretreated with lumbar interbody fusion with unilateral pedicle screw fixation or bilateralpedicle screw fixation, and were divided into two groups according to internal fixationmode. There were28cases of which underwent lumbar interbody fusion with unilateralpedicle screw fixation,16males and12females with an average of48years(range,40-56). The preoperative diagnosis consisted of lumbar disc herniation (n=4), postoperative recurrent lumbar disc herniation (n=6), spinal stenosis (n=6),degenerative lumbar instability (n=8), degenerative spondylolisthesis (n=4). Therewere32cases of which underwent lumbar interbody fusion with bilateral pedicle screwfixation,18males and14females with an average of52years(range,42-67). Thepreoperative diagnosis consisted of lumbar disc herniation (n=5), postoperative recurrentlumbar disc herniation (n=6), spinal stenosis (n=7), degenerative lumbarinstability (n=6), degenerative spondylolisthesis (n=8). Pre-and postoperativescores measured by Oswestry Disability Index (ODI), Visual Analog Scale (VAS), andJOA scores were analyzed and compared between the two groups. Comparison wasconducted between two groups in terms of operation duration, intraoperative blood loss,fusion rates, operative cost, excellence rate, incidence rate of complications. Results:Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) in two groups showedstatistical significance between preoperation and3months,6months（P<0.05. Compared with B group, A group had shorter operation duration, less intraoperative blood loss andlower operative cost,with statistical difference （P<0.05）. No significant difference wasfound between two groups in the fusion rates,excellence rate, incidence rate ofcomplications（P>0.05）.The fusion rate of two groups were92%、94%respectively.Conclusion: Lumbar interbody fusion with unilateral pedicle screw fixation is as effectiveas with bilateral pedicle screw fixation. It is demonstrated that lumbar interbody fusionwith unilateral pedicle screw fixation was an effective and convenient method with littlesurgical trauma as well as a satisfactory method in treating lumbar degenerative disease.But the operation indications must be strictly defined and long-term clinical studies arerequired.
Objective: The purpose of this study was to explore the possible causesand incidence of the postoperative back pain in the opposite lumbosacral area. Methods:Form October2008to October2011，thirty consecutive patients (16men and14womenwith age ranged from40to56years) underwent diagonal cage-instrumented lumbarinterbody fusion with unilateral fixation. Pre-and postoperative scores measured byOswestry Disability Index (ODI), Visual Analog Scale (VAS) were analyzed. Fusionstatuses, condition of intervertebral height and opposite facets were investigated withX-ray and CT scans. Results: Oswestry Disability Index (ODI),Visual Analog Scale (VAS)showed statistical significance between peri-operation and3months,6months,12monthspostoperatively(P<0.05). The fusion rates were92%, The clinical results were89%satisfactory, five patients complained recent postoperative back pain in the oppositelumbosacral area.Conclusion: Due attention should pay to the postoperative back painarised from the restore intervertebral height asymmetrically and the opposite facetsdisfunction.The operation indications must be strictly defined and long-term clinicalstudies are required.
Objective: To investigate the biomechanical stability of triangleconstruct fixation (TCF). Comparisons were made with conventional pedicle screwfixation. Methods: Three-dimensional finite element models were established bysimulating bilateral pedicle screw fixation (BPSF), unilateral pedicle screw fixation(UPSF), and triangle construct fixation (TCF).500N pre-load was added on the superiorsurface of the L3vertebral body, followed by load of10N·m torque to simulate L4-L5flexion, extension, lateral bending, and axial rotation. The stress changes and distributionsof the three kinds of fixation and cage, the L4-L5angular variation under different loadwere compared and analyzed using software. Results: Both TCF and BPSF were able toachieve more reduction in angular variation compared with UPSF. The pedicle peak stressin UPSF was markedly higher than that in BPSF and TCF. The cage peak stress in theUPSF was higher than that in BPS F and TCF, BPSF was similar toTCF.Conclusion:.Biomechanical stability of the TCF was superior to UPSF, similar to
[Objective]: Identify the biomechanical effects of unilateral pedicle screwcombine transfacet pedicle screw fixation (TPSF). Comparisons were made withUPS+TPSF, BPSF and UPSF.[Method]: Three-dimensional finite element models wereestablished by simulating bilateral pedicle screws fixation (BPSF), unilateral pediclescrews fixation (UPSF) and (UPSF+TPSF).500N preload was added on the superiorsurface of the L3vertebral body, followed by load of10N·m torque to simulate L4-L5flexion, extension, lateral bending, and axial rotation. The stress changes and distributionof the three kinds of fixation, the L4-L5angular variation, cage under different load werecompared and analyzed using software.[Result]: The group UPSF+TPSF was able to achieve more reduction in angular variation compared with group UPSF. Group UPSF wasthe least stable in all loading modes and was significantly different than group BPSF inlateral bending. The pedicle peak stress in group UPSF was markedly higher than that ingroup UPSF+TPSF and group BPSF, especially high on left lateral bending and extension,the group UPS+TPSF was higher than the group BPSF. The cage peak stress in the groupUPSF was higher than that in group UPS+TPSF and group BPSF. And group UPS+TPSFwas similar to group BPSF.[Conclusion]: The group UPS+TPSF was superior to groupUPSF. It may offer the potential for percutaneous fixation in order to decrease themorbidity and complications associated with open procedures and decrease costs ofimplants. TPSF can be considered as a good alternative to lumbar posterior stabilizationmethods.
Objective: To explore the relationship of the lumbar facets and thecorresponding bony endplate, providing anatomic and radiographic guidelines for safepercutaneous placement of the transfacet pedicle screws.Methods: Twenty normal drycadaveric lumbar vertebra specimens and lumbar spinal radiograph of anteroposterior,lateral views of200adult21-44years old who undergoing physical examination werechosen to research. Depth of the facets in the sagittal and axial plane and ratio of the facetsbeyond the bony end plate were were measured.The relationship of the starting pointrelative to landmarks of the inferior bony endplate was measured. Results: Both inferiorand superior facet heights were14.5mm at L3-L5/S1levels. The percentage of inferiorfacet extending below the L3and L4bony end plates was74%and78%respectively anddecreased at L5to67%. The percentage of superior facet extending above the bony endplate ranged from35%to40%at all levels.
Conclusions: The starting point of the percutaneous placement of lumbar transfacetpedicle screw should be centered on the inferior bony endplate in the coronal plane.
Objective: To explore the ideal starting point and trajectory forpercutaneous lumbar trans-facet pedicle screws fixation, providing anatomic guidelines forsafe placement of the screws. Methods: Twenty normal dry cadaveric lumbar vertebraspecimens and lumbar spinal radiograph of anteroposterior and lateral views of200adult21-44years old that undergoing physical examination were chosen to research. Linear andangular measurements of the facets including the length, width, depth and degrees ofangulation in the sagittal and axial plane were recorded. Under direct visualization, thesegments were pinned with Boucher technique. The relationship of the starting pointrelative to landmarks of the superior body was measured. Under fluoroscopy, radiographicparameters for ideal starting point and ending point of the pin were determined. Results:There was progressive increase in maximum superior facet depth from L3to S1, with S1being the largest at16mm. Both the inferior and superior facet heights from L3to L5orS1were approximately14.5mm at all levels. The increasingly extroversion angle of facetjoint measuring18°,27°,35°, and44°from L3to S1with caudal progression. The startingpoint in the coronal plane is based on the superior body of the instrumented segment andshould be in line with the the midpoint of the spinous process and the inferior articularprocess edge connection in the medial-lateral direction and in line with the inferior endplate in the cranial-caudal direction.The pin should be laterally angulated approximately15-18°in the axial plane approximately30-35°caudally in the sagittal plane. The pinshould end in the inferolateral quadrant of the pedicle on the AP radiograph and at thepedicle vertebral body junction on the lateral radiograph. Conclusions: The accurateanatomical date of lumbar facet articular acquired by measurement can be used to supportthe percutaneous placement of lumbar transfacet pedicle screw fixation.
引文
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[1]毛路，沈忆新，王磊.椎间盘源性下腰痛临床治疗研究.中国矫形外科杂志,2007,15:39-41.
[2毛路，刘栋，郝剑等.腰椎动力固定装置治疗下腰痛的研究进展.中国骨与关节损伤杂志，2007,22：262-264.
[3] Chou JH,Chan CC. Validation of the Chinese version of the Oswestry DisabilityIndex [J].Work,2005,25(4):307-314.
[4] Huskisson EC. Measurement of pain [J].Lancet,1974,2(7889):1127-1131.
[5] Goel VK,Lim TH,Gwon J.et al.Effects of an internal fixation device:a comprehensivebiomechanical investigation. Spine,1991,16(3Suppl):S155-161.
[6] Kabins MB, Weinstein JN, Spratt KF, et a1. Isolated L4-L5fusions using the variablescrew placement system: unilateral versus bilateral. Spinal Disord,1992,5:39-49.
[7] Suk KS, Lee HM, Kim NH, et al.Unilateral versus bilateral pedicle screw fixation inlumbar spinal fusion. Spine,2000,25:1843-1847.
[8] Chen HH, Cheung HH, Wang WK, et al.Biomechanical analysis of unilateral fixationwith interbody cages.Spine,2005,30: E92-E96.
[9]何蔚，张桦，何海龙，等.腰椎单侧及双侧椎弓根螺钉固定椎间融合的生物力学研究[J].解放军医学杂志，2009,34：405-408.
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[17] Schleicher P, Beth P,Ottenbacher A et al.Biomechanical evaluation of differentasymmetrical posterior stabilization methods for minimally invasive transforaminallumbar interbody fusion.Neurosurg spine,2008,9(4):363-371
[18] Zhao J, Zhang F,Chen X,et al. Posterior interbody fusion using a diagonal cage withunilateral transpedicular screw fixation for lumbar stenosis. Clin Neurosci.2011，18:324-328.
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