【作者】 朱若夫；

【导师】 杨惠林；

【作者基本信息】 苏州大学 ， 骨外科学， 2008， 博士

【摘要】 第一部分颈椎椎弓根及其毗邻神经结构的解剖学研究目的:研究国人颈椎弓根及其与毗邻神经根和硬膜囊的量化关系,为临床颈椎弓根内准确置钉提供解剖学依据,以避免或减少置钉相关的并发症。方法:经福尔马林固定的12具成人脊柱标本C1-T1,剥去周围软组织及韧带,显露颈椎两侧关节突的外缘,用咬骨钳去除棘突、椎板、相连韧带、侧块以及上下关节突,显露出椎弓根及其毗邻的神经组织,测量以下参数:椎弓根狭窄部的高度(PH),椎弓根狭窄部的宽度(PW),椎弓根狭窄部内壁间的距离(IPD),椎弓根内壁与硬膜囊之间的距离(PDSD),椎弓根上缘与相邻神经根下缘之间的距离(PSRD),椎弓根下缘与相邻神经根上缘之间的距离(PIRD),冠状面上,神经根轴线与硬膜囊后正中线之间的夹角(REA)。结果:在男性PH的均值范围从6.23~7.21mm,在女性则从5.41~6.93mm。在男性PW的均值范围从5.33~ 6.56mm,在女性则从4.22~6.07mm。在男性IPD的均值范围从22.69mm~24.14mm,在女性则从22.60~23.98mm。在男性PDSD的均值范围从0~2.83mm,在女性则从0~3.19mm。在男性PSRD的均值范围从0~1.67mm,在女性则从0~1.60mm。在男性PIRD的均值范围从1.06~2.69mm,在女性则从1.32~2.80mm。在男性REA的均值范围从75.30~80.90mm,在女性则从74.40~82.30mm。结论:正常结构的国人颈椎中,颈椎弓根与其毗邻神经的解剖结构之间存在一定距离,椎弓根的轻微穿破不会导致神经根损伤并发症的发生;国人女性C3椎弓根狭窄部相对较小,置入直径为3.5mm的椎弓根螺钉要慎重。第二部分螺旋CT多平面重建(MPR)技术下的国人颈椎椎弓根形态学研究目的:探讨应用螺旋CT三维重建国人的颈椎椎弓根,并对重建图像进行测量评估,帮助外科医生更好的理解国人的颈椎弓根解剖结构,提高置钉的准确性。方法:对60名有颈椎疾患的患者进行了颈椎CT扫描(均包括了C3~C7)。对CT重建后的图像进行测量,包括了椎弓根狭窄部的高度、宽度、相对轴线长度、有效长度、椎弓根水平面上的角度(PTA)及矢状面上的角度(PSA)、椎弓根侧块投射点到侧块外缘以及到上关节突下缘的距离。结果:颈椎的绝大部分椎弓根狭窄部的宽度小于高度。在C3及C4椎弓根狭窄部宽度的测量结果有统计学差异(独立t检验,P<0.05)。椎弓根狭窄部宽度的均值范围男性5.4~6.7 mm,女性4.4~6.3 mm。椎弓根侧块投射点到上关节突下缘的距离(从C3~C7)并无规律性,而到侧块外缘的距离从头端到尾端是不断增大的。椎弓根两个平面的角度在不同椎体平面统计学上有差异(Kendall’s检验,P<0.01)。男性与女性的椎弓根水平角(PTA)在C7均最小。结论:在国人女性患者的C3及C4椎体行经颈椎椎弓根内固定术应谨慎,术前应做椎弓根影像学的评估。大部分国人的C5~C7椎体是适合行椎弓根内固定的。但考虑到颈椎弓根个体的差异较大,术前颈椎弓根的CT扫描及重建后的评估是必要的。第三部分颈椎椎弓根置钉准确性的实验研究一、CT导航系统与螺旋CT多平面重建(MPR)辅助下个体化置钉准确性的对比研究目的:对CT导航系统与螺旋CT多平面重建(MPR)辅助下个体化置钉的准确性进行对比研究。方法:将经福尔马林固定的12具成人脊柱标本C1-T1随机分为甲、乙两组,分别采用螺旋CT多平面重建(MPR)辅助下置钉方案与CT导航系统辅助置钉进行下颈椎椎弓根螺钉置入。术后标本采用影像学评价置钉准确性。评价标准根据Richter等所提出的三类分法:①一类,优:螺钉位置满意,螺钉未穿透椎弓根皮质,或仅轻微穿透(<lmm)。②二类,可:螺钉穿透椎弓根皮质>lmm,但不需要翻修,固定稳定性好。③三类,差:螺钉穿透椎弓根皮质>1mm,需要进行翻修,固定稳定性差或者对周围的神经血管造成损伤的危险。结果:共置入螺钉120枚。甲组60枚,平均手术时间152min,优54枚(90%)、可6枚(10%)、差0枚;乙组60枚,平均手术时间272min,优51枚(85%)、可7枚(11.7%)、差2枚(3.3%)。甲组和乙组之间的手术时间均有显著性差异(P=0.003<0.05),甲组和乙组之间的椎弓根穿破率之间无显著性差异(P=0.451>0.05)。结论:螺旋CT多平面重建(MPR)下的个体化置钉,操作较简单实用,其准确性与CT导航辅助下置钉相当,但明显较少了置钉的时间,在临床更易于广泛的开展应用。二、螺旋CT多平面重建(MPR)评估椎弓根螺钉置入位置的研究目的:探讨螺旋CT多平面重建对颈椎弓根螺钉置入后位置准确性的评价及可行性分析,为临床提供一种简易、准确的评估方法。方法:对徒手置钉组及导航置钉组的共12具置钉后标本,进行螺旋CT多平面重建(MPR)和评估,并将CT扫描后置钉的标本逐节段解剖分离,直视下观察评判椎弓根螺钉置钉后的位置,评估标准根据螺钉与椎弓根壁的关系,将其分为三级:①一级,完整:螺钉位置满意,螺钉未穿透椎弓根皮质。②二级,胀破:螺钉穿透椎弓根皮质≤椎弓根螺钉直径的一半。③三级,穿出:螺钉穿透椎弓根皮质>椎弓根螺钉直径的一半。以直视下观察为标准,评价螺旋CT多平面重建(MPR)方法的准确性。结果:共置入的120枚椎弓根螺钉,采用螺旋CT多平面重建(MPR)评估,有99(82.5%)枚完整,19枚(15.8%)胀破,2枚(1.7%)穿出;解剖后直视观察,有96(80%)枚完整,22枚(18.3%)胀破,2枚(1.7%)穿出。两种评估方法对椎弓根穿破的方向及穿破节段进行配对的t检验,结果显示统计学无差异(P值分别为0.058、0.208)。结论:对于颈椎弓根内固定术后螺钉位置的评价,应用螺旋CT多平面重建(MPR)技术简单实用且评估准确性高。第四部分颈椎椎弓根钉内固定术的临床应用目的:探讨颈椎椎弓根内固定系统在临床应用的价值。方法:自2004年12月至2007年12月应用颈椎椎弓根内固定术进行治疗,并且随访资料较完整的23例颈椎疾病患者,男10例,女13例,年龄23～62岁,平均46岁。其中颈椎骨折脱位10例,颈椎肿瘤11例(血管瘤1例,神经鞘瘤4例,神经纤维瘤1例,脊索瘤1例,骨软骨瘤1例,转移性颈椎肿瘤3例),颈椎先天性畸形2例。10例创伤患者脊髓损伤的程度按美国脊髓损伤学会(ASIA)分级:A级6例,B级2例,C级1例,D级1例。非创伤患者13例患者按JOA脊髓功能评分,术前平均12.9分。结果:23例均安全地置入了椎弓根螺钉,术后无置钉相关的脊髓、神经、动脉等损伤的并发症发生。随访4~30个月,平均随访11个月,随访内容包括摄X线片,CT及MRI检查,并进行神经功能的评定。术后4~6个月,影像学提示23例患者均获良好骨性愈合。神经功能恢复情况,4例不完全性脊髓损伤患者术后按ASIA损伤分级平均提高1~2级,6例完全性脊髓损伤患者术后神经功能虽无恢复,但神经根性症状,如疼痛、麻木均有一定的缓解。非创伤患者13例患者按JOA脊髓功能评分,术后平均15.2分,优良率为56.1%。结论:颈椎椎弓根内固定系统具有经三柱固定的万向螺钉以及与之相连的可塑形棒,可以达到坚强的固定、有利于植骨的融合以及术后颈椎生理曲度的维持,是一种有效、可靠的重建颈椎稳定的方法。更多还原

【Abstract】 PartⅠStudy on Anatomic Relation Between the Cervical Pedicle and the Adjacent Neural StructuresObjectives: To determine quantitatively the anatomic relation of the cervical pedicles to the adjacent nerve roots and dural sac and avoid and minimize the complication in performing the technique.Methods: 12 cadavers were used for dissection to observe the relations of the cervical pedicles to the adjacent dural sac and nerve roots. After removal of whole posterior bony elements including the spinous processes, laminas, and lateral masses, the isthmus of the pedicles, the dural sac, and the nerve roots of C3-C7 were exposed. Direct measurements included the distance from the pedicle to the superior and inferior nerve roots and the dura(PDSD,PSRD,PIRD). Also, the pedicle height(PH) and width(PW) were measured at its isthmus.Results: In 12 cadavers, PH Male: 6.23-7.21mm, Female: 5.41-6.93mm. PW Male: 5.33-6.56mm, Female: 4.22-6.07mm. IPD Male: 22.69mm-24.14mm, Female: 22.60- 23.98mm. PDSD Male:0-2.83mm, Female:0-3.19mm. PSRD Male:0-1.67mm, Female: 0-1.60mm. PIRD Male: 1.06-2.69mm, Female: 1.32-2.80mm. REA Male: 75.30- 80.90mm, Female: 74.40-82.30mm.Conclusions: This study suggests that there are some difference in the distance between the cervical pedicle and the adjacent neural structure more frequently. Screw penetrating to the pedicle may be not caused complications. In addition, transpedicular screw placement at C3 must be caution for our female populationPartⅡClinical anatomic study of lower cervical pedicle in a Chinese Population by multiplanar reformations of spiral CTObjective: To evaluate lower Cervical pedicle (C3-C7) dimensions in a Chinese population by multiplanar reformations (MPR) of computed tomography for surgical application of transpedicular screw placement and enhance the accuracy. Methods: The dimensions of the pedicles (C3–C7) were determined in 60 patients with cervical spinal lesions from CT images. Measurements of pedicle height, width, pedicle axis length, effective length, and two angles of the pedicles, the distances from the projection point of the pedicle axis to the lateral edge of the lateral mass and the inferior edge of the superior facet were measured.Results: The outer pedicle width was smaller than the height in most of the pedicles.This measurement was significantly different between male and female patients in outer pedicle width of pedicle (P<0.05; independent samples t test) at C3 and C4. The mean values were ranging from 5.4 to 6.7 mm in male , 4.4 to 6.3 mm in female for outer pedicle width. The distances from the projection point to inferior edge of the superior facet did not show uniform pattern of change from C3 to C7, whereas the distances from the projection point to the lateral edge of the lateral mass consistently increased from cephalad to caudad. There were significant correlations (P<0.01; Kendall’s Test) between the vertebral level and both of pedicle angle (pedicle transverse angle and pedicle sagittal angle). The smallest pedicle transverse angle was at C7 in male and female.Conclusions: Transpedicular screw placement for the cervical pedicle of C3, C4 must be cautious in the Chinese female population before the exact pedicle transverse diameters are known. Most of cervical pedicle (C5-C7) in a Chinese Population was suited for pedicle fixation of 3.5mm screw. Taking into consideration some variations between individuals, this data combined with evaluation of results of preoperative computed axial tomography is must before operation.PartⅢThe study of accuracy of screw placement in lower cervical pedicle1. Accuracy of CT-based navitation of pedicle screws implantation in the cervical spine compared with multiplanar reformations (MPR) of CT assisted techniqueObjective: To evaluate the feasibility and accuracy of cervical spine pedicle screw fixation assisted by CT-based navitation system and multiplanar reformations (MPR) of CT.Method: 12 human cadaveric cervical spines were utilized and 3.5mm screws were placed into the C3-C7 pedicles following two kinds of techniques: assisted by multiplanar reformations (MPR) of CT (group 1), assisted by assisted by CT-based navitation system (group 2). Thereafter, cortical integrity of every sample was examined by imaging. Screw position of the pedicle screws was divided into 3 grades: grades 1, correct screw placement without pedicle perforation or with pedicle perforation <1.0 mm (depth of the thread); grades 2, pedicle perforation >1.0 mm without the need for screw revision; and grades 3, pedicle perforation >1.0 mm with the need for screw revision because of irritation or injury of roots or the spinal cord, or because of reduced biomechanical stability.Result: All together, there were 120 pedicles involved. Group 1, 60 pedicles, the average operation time per sample was 152 minutes.90% of the screws were placed entirely within the pedicle, 10% showed non- critical breaches, and no showed critical breaches. Group 2, 60 pedicles, the average operation time was 272 minutes.85% were placed entirely within the pedicle, 11.7% showed non-critical breaches, and 3.3% showed critical breaches. There were statistically significant difference between the two groups with respect to the average operation time(P<0.05). There were no statistically significant difference between the two groups with respect to the accuracy of screw placement(P>0.05).Conclusion: The assisted by CT-based navitation system and multiplanar reformations (MPR) of CT definitely enhance saccuracy. But the assisted by multiplanar reformations (MPR) of CT technique has a shorter operation time than CT-based navitation system. It is an extensive and easy method for pedicle screws implantation in the cervical spine2.The study of evaluation postoperative transpedicular screw of cervical pedicle by multiplanar reformations (MPR) of CTObjective: To evaluate the feasibility and accuracy of postoperative transpedicular screw of cervical assisted by multiplanar reformations (MPR) of CT.Method: 120 postoperative transpedicular screw of cervical spine were evaluated by multiplanar reformations (MPR) of CT and anatomic dissection. Screw position of the pedicle screws was divided into 3 grades. grades 1, correct screw placement without pedicle perforation; grades 2, pedicle perforation≤radius of screw; grades 3, pedicle perforation≤radius of screw.Result: All together, 120 cervical pedicle screws were evaluated. Evaluated by multiplanar reformations (MPR) of CT, 82.5% of the screws were placed entirely within the pedicle, 15.8% showed breaches of expansion, and 1.7% showed critical breaches; Evaluated by anatomic dissection, 80% of the screws were placed entirely within the pedicle, 18.3% showed breaches of expansion, and 1.7% showed critical breaches. There were no statistically significant difference between the two methods of evaluation with respect to the breaches of direction and segment(p=0.058,p=0.208).Conclusion: Postoperative transpedicular screw of cervical spine were evaluated by multiplanar reformations (MPR) of CT is accurate and easy.PartⅣThe application of cervical pedicle screw fixation in clinicalObjective: To evaluate the effects of transpedicular internal fixation system.Method: From December 2004 to December 2007, transpedicular internal fixation system was performed in 23 patients (10 male, 13 female, mean age 46years). Out of them , there were 10 fracture and dislocation of cervical spine ,11 with cervical tumor, 2 with cervical congenital malformation The clinical outcomes were investigated by clinical observations, radiologic studies and statistical analysis. According to American Spinal Injury Association grades: 6 cases were in A grade, 2 cases in B grade,1 cases in C grade,1 cases in D grade. Preoperation the JOA scores of neurofunction in 13 nontraumatic lesions of the cervical spine is 12.9.Result: Cervical pedicle screws were inserted successfully on all cases without complication.The patients were followed up for 4 to 30 months with an average of 11 months. The result of imaging showed that bony fusion was successful in 23 patients at 4-6months. 4 cases with incomplete spinal cord lesions improved on average 1-2 ASIA grade postoperation, 6 cases with complete spinal injury couldn’t recover postoperation, but the symptoms of nerve root such as pain, anesthesia relieved in a certain degree. Postoperation the JOA scores of neurofunction in 13 nontraumatic lesions of the cervical spine is 15.2, the excellent and good rate was 56.1%Conclusion: Transpedicular internal fixation system has multiaxial screw of three-column fixation and plastic rods, which offer strong fixtion and good fusion. It can also benefit the maintenance of cervical curve. It is an effective and reliable method for reconstruction of upper cervical stability.更多还原