【作者】 赵玉果；

【导师】 张春霖；

【作者基本信息】 郑州大学 ， 骨外科， 2009， 硕士

【摘要】 背景脊柱疾患的手术治疗方法很多,包括传统的开放手术以及近年来发展起来的各种微创手术,如脊柱骨折切开复位椎弓根钉内固定术、经后路脊柱畸形矫形术、脊柱肿瘤切除椎弓根螺钉固定重建术、经皮椎弓根钉置入术、经皮椎体成形术(PVP、PKP)、经皮椎体活检术、经皮齿状突骨折螺钉内固定术等。由于这些术式涉及内植物置入或注入,就必然涉及不同的穿刺路径与精度,其中以精确的经椎弓根途径最为重要。不当的经椎弓根穿刺可导致严重的并发症,如穿破椎弓根,可损伤脊髓、神经根;穿破椎体侧前方,可损伤大血管或内脏器官等。以椎弓根螺钉置入为例,文献报道其误置率可高达30%。目前引导穿刺置入的方法主要包括X线正侧位透视引导监测、辅助仪器引导监测、术中诱发电位引导监测及计算机辅助技术监测等,这些方法均存在一定的不足之处,如X线正侧位透视引导监测判断螺钉位置准确性和安全性不够高,很大程度上还要依靠手术医生的临床经验;辅助仪器引导监测不能对进钉点及进钉角度同时准确控制,且需手动控制角度,仍有较大的人为因素存在;诱发电位引导监测术中连续应用困难,椎弓根穿破后无法继续监测,而且不能直观反映螺钉的位置,发现神经损伤可能为时已晚;计算机辅助导航系统需要借助昂贵的设备和特殊的器械,操作程序繁琐,且存在不能动态监测、注册匹配失误等问题,椎弓根穿刺精度仍不理想,限制了其广泛推广。因此,探索更为安全可靠、操作简便的引导椎弓根穿刺的方法,是亟待解决的重要课题之一。目的本实验采用自行研发的脊柱微创手术机器人,用其机械手轴位引导行腰椎弓根穿刺并分析其精度,以期为临床探索一种穿刺精度高、安全可靠、简便易行的经椎弓根置入方法。方法1标本选择6具L1-L5干燥脊柱标本(共30个)。X线摄片排除发育异常及骨缺损者。2设计TSA对所选脊柱标本逐一CT扫描。在侧位像平分椎弓根的椎体横断面CT图像上,测量椎弓根导针理想轴线与椎体自身矢状线夹角(设计TSA)。3操作方法与步骤(1)锁定导针矢状面角:将C型臂X线机调整至固定好的目标椎体的标准侧位像,移动机械手使导针投影的延长线通过椎弓根投影中心且与椎体上终板平行,限制机械手头尾方向移动并锁定矢状面倾斜角;(2)确定“0点”:透视确定椎体标准正位像,以此作为“0点”;(3)匹配C臂投射轴线与椎弓根设计轴线:根据设计TSA,按该角度值向目标椎弓根一侧旋转C型臂,使其投射轴线与椎弓根设计轴线一致;(4)匹配机械手轴线与椎弓根设计轴线:调整机械手至导针投影为一圆点并位于椎弓根投影中心(即机械手轴位,导针轴位),使机械手轴线与椎弓根设计轴线一致;(5)监测导针置入:启动机械手正反转旋转导针,使其经椎弓根进入椎体内约35mm,实时透视监测导针置入过程,确保其投影不偏离椎弓根投影中心。4测量指标用C臂摄椎体标准侧位像或CT扫描导针针道图像分别确定:(1)导针矢状面夹角(SSA),导针与上终板平行为0°,斜向上终板记为正,反之记为负;(2)导针实际TSA;(3)狭部平面针道偏离中心的距离b,到内外侧骨皮质的距离d1、d2。5统计学处理所有参数用均数加减标准差((?)±s)表示,用SPSS10.0统计软件进行统计分析,腰椎各节段术前设计TSA与术后导针实际TSA采用配对设计资料t检验,检验水准α=0.05。结果共60个椎弓根,均成功置入导针。(1) L1-L5导针与椎体上终板夹角(矢状面角,SSA)为-0.13±0.83°(-2～1°);(2) L1-L5术前设计TSA分别为13.11±1.75°、14.63±2.18°、16.79±2.38°、19.25±2.79°、29.67±4.58°,导针实际TSA分别为13.42±2.13°、14.83±1.72°、16.45±2.45°、19.70±3.19°、30.33±4.94°,两者相差最大不超过2度。各节段两者差异均无统计学意义(P＞0.05)。(3) L1-L5导针针道在椎弓根狭部平面偏离中心的距离分别为0.17±0.16mm(0～0.5mm)、0.18±0.22mm(0～0.6mm)、0.16±0.17mm(0～0.5mm)、0.58±0.49mm(0～1.2mm)、0.86±0.68mm(0～1.7mm),到内侧骨皮质的距离分别为1.85±0.47mm(1.0～2.6mm)、1.90±0.42mm(1.6～2.9mm)、2.12±0.36mm(1.6～2.6mm)、3.02±0.97mm(1.8～4.9mm)、4.67±1.40mm(2.2～6.9mm),到外侧骨皮质的距离分别为1.61±0.35mm(1.0～2.3mm)、1.80±0.29mm(1.6～2.5mm)、2.27±0.41mm(1.7～3.1mm)、3.09±0.83mm(1.7～4.2mm)、5.22±1.41mm(3.0～7.1mm)。导针在椎体侧位像及CT扫描横断面图像中无一例接触或穿破椎弓根骨皮质。结论机械手轴位法引导脊柱微创手术机器人腰椎弓根导针置入,可使导针准确地沿设计轴线穿过椎弓根,是一种安全可靠、简便易行的椎弓根导针置入方法,具有推广应用价值。更多还原

【Abstract】 BackgroundThere are many surgical methods in the treatment of spinal diseases, including traditional open surgery, as well as a variety of minimally invasive surgery which have developed in recent years, such as with open reduction and pedicle screw fixation for spinal fractures, posterior scoliosis surgery, spinal reconstruction with pedicle screw fixation after tumor resection, minimally invasive percutaneous pedicle screw osteosynthesis, percutaneous vertebropiasty (PVP), percutaneous kyphoplasty (PKP), percutaneous transpedicular biopsy, percutaneous anterior screw fixation for treatment of odontoid process fracture. As a result of these surgical procedures involving implantation of instrumentation, it will inevitably involve puncture accuracy and different path, especially transpedicular surgery which requests the highest puncture accuracy. Improper transpedicular puncture may lead to neurovascular damage or suboptimal biomechanical spinal stabilization. A number of studies have reported up to a 30% rate of screw misplacement. Currently there are several methods to monitor the process of pedicle screw placement, including X-ray, guide device, stimulus-evoked electromyography, computer-assisted image-guided technology and so on. However, these methods have some shortcomings. The accuracy and security is not high enough by X-ray guiding and guide device guiding, which depend on the clinical experience of the surgeon to a large extent; stimulus-evoked electromyography can not continue to monitor after the pedicle perforation; computer-assisted image-guided technology has been advanced to improve accuracy. However, these systems need expensive and special equipments with the disadvantage of cumbersome procedures. Some technical problems remain fully unresolved, such as dynamic monitoring, registration errors, unsatisfactory precision of screw implantation. Because of the suboptimal reliability and complexity, the frequency of use of the computer-assisted surgery technologies is relatively low. Therefore, to explore a more secure and reliable, simple and effective way to guide percutaneous pedicle puncture is urgent.PurposeTo evaluate the feasibility and accuracy of pedicle guide wire placement by MISS robot with manipulator axial position guiding, with a view to researching a method of minimally invasive pedicle guide wire implantation safely and reliably with high puncture precision.Methods1. Specimen selection.Six dry human cadaveric lumbar spines (L1 to L5) were used and inspected visually and radiographically to exclude abnormal morphology and bone defects.2. Preoperative determination.Spine specimens underwent pre-intervention CT scanning, and ideal transverse section angle (TSA) was measured according to the lateral cross-sectional image of each vertebral body.3. Operating methods and procedures.(1)The vertebral body specimen was fixed and C-arm was adjusted till the standard lateral image was obtained. The manipulator was lowered and its direction was adjusted, so that the guide wire could project through the center of the pedicle’s projection , and parallel upper endplate of the vertebral.(2)C-arm was adjusted till a standard posteroanterior image was obtained and the projection was in the center of the screen.(3) C-arm was rotated at a certain angle (design TSA) to obtain the projection of the target pedicle.(4) The robot manipulator was adjusted, so that the projection of the guide wire was at the projection center of target pedicle.(5) The manipulator was lowered. The robot set 0, when the guide wire reached the pedicle posterior cortex. The whole process was monitored to make sure the projection of the guide wire will not deviate from the center of pedicle projection until the guide wire was within the vertebral body.4. Measurement of indicators.(1) Sagital section angle (SSA) on standard lateral images;(2) Transverse section angle (the actual TSA) on post-procedural CT scans.(3) Deviation of the actual position from the center at the pedicle isthmus plane, and the distance between the guide wire track and medial cortical or lateral cortical on post-procedural CT scans.5. Statistical analysis.The results were expressed as (x|-)±s. Paired t test was used to analyze the difference between preoperative TSA and postoperative TSA with SPSS 10.0. Statistical significance was determined at the 0.05 Alpha level.ResultsA total of 60 guide wires were successfully inserted.(1) Sagital section angles (SSA) of L1-5 were -0.13±0.83°(range, -2-1°).(2) The designed transverse section angles of Ll-5 were 13.11±1.75°, 14.63±2.18°,16.79±2.38°,19.25±2.79°,29.67±4.58°, and the actual transverse section angles were 13.42±2.13°,14.83±1.72°,16.45±2.45°,19.70±3.19°,30.33±4.94°. There were no significant difference (P > 0.05) between actual TSA and designed TSA in all leves, no more than 2 degrees.(3) Deviation of the guide wire track from the center at the pedicle isthmus plane of Ll-5 was 0.17±0.16mm(0～0.5mm), 0.18±0.22mm(0～0.6mm), 0.16±0.17mm(0～0.5mm), 0.58±0.49mm(0～1.2mm), 0.86±0.68mm(0～1.7mm). The distance between the guide wire track and medial cortical was 1.85±0.47mm(1.0～ 2.6mm), 1.90±0.42mm(1.6～2.9mm), 2.12±0.36mm(1.6～2.6mm), 3.02±0.97mm(1.8～4.9mm), 4.67±1.40mm(2.2～6.9mm). The distance between the guide wire track and lateral cortical was 1.61±0.35mm(1.0～2.3mm), 1.80±0.29mm(1.6～2.5mm), 2.27±0.41mm(1.7～3.1mm), 3.09±0.83mm(1.7～4.2mm), 5.22±1.41mm(3.0～7.1mm).None of the guide wire track was found to have contracted or perforated the pedicle wall.ConclusionLumbar pedicle puncture is performed perfectly by MISS robot with manipulator axial position guiding, which can accurately guide the wire through the pedicle axis. This method can guide the pedicle wire plantation safely and reliably with the promotion of application value.更多还原