【作者】 申才良；

【导师】 唐天驷；

【作者基本信息】 苏州大学 ， 骨科学， 2001， 博士

【摘要】 腰骶部融合是治疗下腰痛的常用方法之一，通过融合，消除退变或/和不稳定的脊柱运动节段，从而解除症状。但融合可导致邻近节段的退变和腰椎前凸的减少，最终导致症状再发，本研究首先对后外侧融合治疗崩裂性滑脱进行随访，发现这种方法的不足之处，并应用三维有限元分析融合后邻近节段的退变机制。为减轻或延缓融合对邻近节段的影响，提高临床疗效。我们对椎间融合支架进行改进，设计制作了同种皮质骨融合支架，并对其生物力学性能进行测试。并首次提出保留腰椎终板的椎间融合术，并将ACFC应用于临床，同时还对不同的加工处理同种骨的方法，对同种骨的生物力学性能和骨诱导活性的影响进行了研究。第一部分 腰骶部后外侧融合治疗崩裂性滑脱的远期疗效 目的：研究后外侧融合治疗腰椎滑脱的远期疗效及影响疗效因素。方法：对自1990年至1996年在本院行steffee钢板复位固定后外侧融合的35例病人进行研究，随访内容包括：（1）采用日本矫形外科学会制定的《腰椎疾患治疗成绩评定标准》，对手术的远期疗效进行评定。（2）对术前、术后及随访过程中拍摄的腰骶部正侧位片进行测量，观察腰骶部融合情况，融合区及融合区上下方椎间隙高度，以及腰椎前凸角的改变。结果：35例病人获长期随访，随访时间4-10年，平均6.7年，手术疗效优良率为77.4％，31例病人术后达到骨性融合，融合率为91.4％，4例病人未融合，其中2例无症状，另2例病人出现假关节。腰椎前凸角由术前的41.72°减少到术后的39.23°，未次随访时为37.37°。融合区椎间隙变窄，融合区上方椎间隙变小。结论：（1）后外侧融合及腰椎前凸角的改变，可以加速邻近节段的退变。（2）后外侧融合不能有效地控制融合区椎体的运动，椎体有继续滑移的趋向，在行腰椎滑脱治疗时，应增加对脊柱前中柱的修复。 腰骰部融合的实验和临床研究 摘 要 第二部分 腰骰部融合的三维有限元分析 目的 研究三种不同融合方式对融合段和融合邻近节段的影 响，探讨腰椎融合后的退变机制。方法 采用三维有限元法，建立 腰椎的三维力学模型，利用MSCrpATRAN软件，分析保留终板与 否，不同椎间植入物的椎间融合，后外侧融合以及后侧融合后融合 节段及邻近节段的应力水平，并与正常腰椎的应力水平相比较。结 果 单节段椎间融合、后外侧融合和后侧融合分别使邻近节段的应 力水平升高 28．8O、20．l0和 35．5O。双节段融合后，应力水平分别 增加 49．9O、35．2o和 68．7o。椎间融合，保留终板时，三种不同的 椎间植入物，以融合支架的稳定性最好，ACFC次之，髓骨最差， 对邻近节段的应力水平，从大到小依次是Cage＞ACFC入lica，不保 留终板时，邻近节段的应力水平较保留终板时高。结论 脊柱融合 导致邻近节段的退变，以后侧椎板融合最严重，后外侧融合影响最 小。融合节段愈多，邻近节段应力水平愈大；椎间融合时，植入材 料的强度愈大，对邻近节段的影响愈大；保留终板对应力有均化作 用，使融合段对邻近节段的应力水平降低。 第三部分 同种皮质骨融合支架的制备及生物力学稳定评价 目的：比较三种椎间植入物行椎间融合的生物力学性能，为临 床应用提供科学依据。方法：用16具新鲜小牛脊柱，行保留终扳的 椎间融合术，用实验应力分析方法进行生物力学系统实验，分析比 较它们在不同生理运动状态下脊柱的强度性能及稳定性。结果：门） 钛合金支架、同种皮质骨融合支架，髓骨块三种椎间融合植入物在脊 柱强度、刚度和稳定性方面具有显著性差异中．of人 前两者比 后者的强度、刚度优越，更加稳定。Q）加用后路椎弓根内固定后， 前屈、后伸、侧屈、旋转稳定性均有显著增强。结论：采取保留终 板施行椎间融合更加有利于脊柱稳定；三种融合植入物以钛合金支 架和同种皮质骨融合支架明显优于髓骨块植骨融合；采用后路椎弓 根内固定，增强了脊柱的强度和刚度提高了脊柱的承载能力。 第四部分 同种皮质骨融合支架的临床应用 目的：研究同种皮质骨融合支架b。fi COniC31 fusioflC昭C 互豆 3 腰骰部融台的实验和临床研究 摘 要 ACFC）行后路椎间融合术治疗腰椎滑脱的临床疗效。方法：对 12 例腰椎滑脱病人，用ACFC行保留终板的后路椎体间融合，y内固 定术；其中男性3性，女性9例；年龄3253岁，平均412岁；L。 滑脱8例，L。?更多还原

【Abstract】 Lumbosacral spinal fusion is one of the common surgical procedures for low-back pain. Symptoms can be relieved by elimination of motion in the degenerative and br unstable spinal motion segments by fusion. However, Fusion can cause degeneration in the adjacent segments, and lumbar lordosis angles can be decreased at last, Fusion cause recurrent symptoms. So, in this paper. A retrospective study about spondylolsthesis treated by posterolateral fusion was conducted. Expecting to find some shortcomings of this treatment. The degenerative mechanism in the adjacent segments after fusion was researched by 3D-finite element analysis. In order to alleviate and/or postpone the effect of fusion to the adjacent segments. We design allograft cortical fusion cage (ACFC), and biomechanical properties of ACFC were tested. And we use it in the clinical practice. It was the first time that we offer interbody vertebral fusion with preseving endplate. The effect of different processed methods on biomechanical character and osteoinductive of allograft was also investigated. Part I. Long-term effects of lumbar spondylolisthesis treated with Iumbosacral posterolateral spinal fusion. Objective To investigate the long-term effects and influence factors of posterolateral fusion for spondylolisthesis. Methods From 1990 to 1996,35 patients with lumbar spondylolisthesis were followed up after underwent reducing and fixing with steffee system and posterolateral fusion. The contents followed up included: (1) Evaluating the long-term effect of the operation with JOA score.(2) Measuring the lumbosacral anteroposterior and lateral x-ray films in pre-operation, post-operation and the following-up course, mostly observing the fusion state, the intervertebral height in fusion segments and its upper and lower segment, and the changes of lumbar cobb?s angle.Results: 35 patients were followed up, the mean follow-up period was 6.7 years (range,4 to 10 year) The excellent and good rate of operation was 77.4%, 31 patients showed V bony fusion, The fusion rate was 91 .4%.4 patients had not fusion,2 patients without symptoms, another two with pseudarthrodesis. lumbar cobb?s angle decreased from 41.720 pro-operation to 39.23 0 post- operation. and it was 37,370 in the last. Intervertebral height in fusion segments and adjacent segments was decreased.Conclusion (1): posterolateral fusion and lumbar lordosis changing can accelerate degeneration in the adjacent segments. (2): Posterolateral fusion can not effectively curbed motion of the vertebral in the fusion segment. The vertebra tending to continuous slip, thus. The anterior and medial column should be repaired when lumbar spordylolisthesis was treated. Part II Three-dimensional finite element analysis of lumbar fusion. Objective Effects of three various fusion ways on fusion segments and adjacent segments were studied. The degenerative mechanism of lumbar fusion was investigated. Methods: The three-dimensional mechanical model of the intact lumbar spine was developed with 3-D finite element method. The stresses on the fusion segments and adjacent segments with three different types of spinal fusion (posterior, bilateral- lateral and interbody fusion) and various interbody implants, and preserving endplate were analysed by MSC/PATRAN software, and the stress was compared with that of the intact lumbar spine. Results: The stresses of the adjacent segme更多还原