椎弓根螺钉内固定术中应用锥束ct扫描评估椎弓根螺钉位置及椎弓根破坏情况的准确性临床研究

1、 HYPERLINK /KNavi/JournalDetail?pcode=CJFD&pykm=ZYZG t _blank 中医正骨 2017,10(29),25-29 椎弓根螺钉内固定术中应用锥束CT扫描评估椎弓根螺钉位置及椎弓根破坏情况的准确性临床研究 HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=au&skey=%E7%8E%8B%E4%BA%9A%E6%A5%A0&code=36075901&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0

2、=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank 王亚楠 HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=au&skey=%E6%9D%8E%E9%9D%92%E6%9D%BE&code=37273386&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw!

3、t _blank 李青松 HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=au&skey=%E8%B0%A2%E6%A2%A6%E7%90%A6&code=38129227&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank 谢梦琦 HYPERLINK /kcms/detail/knetsearch.aspx?dbcode

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10、oid(0); o 收藏 收藏 HYPERLINK javascript:void(0); 打印 摘要： 目的:探讨椎弓根螺钉内固定术中应用锥束CT扫描评估椎弓根螺钉位置及椎弓根破坏情况的准确性。方法:2015年10月至2017年6月收治43例因脊柱病变需接受椎弓根螺钉内固定手术的患者, 腰椎退行性疾病21例、胸腰椎骨折9例、胸腰椎肿瘤11例、脊柱畸形2例, 分别经后路进行椎间融合、骨折复位内固定、肿瘤切除内固定和脊柱矫形手术。术中置入椎弓根螺钉后用Artis Zeego系统行锥束CT扫描, 了解螺钉位置和椎弓根破坏情况, 必要时及时进行调整。术后1周内所有患者均采用CT进行病变部位扫描, 了

11、解螺钉位置和椎弓根破坏情况。分别根据术中锥束CT扫描图像和术后CT扫描图像采用Gertzbein分级系统评估螺钉位置和椎弓根破坏情况。结果:43例患者均顺利完成手术, 手术时间 (224.247.1) min, 术中出血 (482.6471.6) m L。43例患者共置入262枚椎弓根螺钉, 胸椎置钉104枚、腰椎置钉142枚、骶骨 (S1节段) 置钉16枚。无1例患者因椎弓根螺钉误置行二次手术调整钉位, 未发生椎弓根螺钉置入导致的神经损伤。置入的262枚螺钉中, 仅10枚螺钉根据术中锥束CT图像评估的分级结果与根据术后CT图像评估的分级结果不一致。根据术中锥束CT图像评估的分级结果与根据术后

12、CT图像评估的分级结果具有非常好的一致性 (Kappa=0.804, P=0.000) 。结论:椎弓根螺钉内固定手术中, 应用锥束CT扫描评估螺钉位置和椎弓根破坏情况, 准确性较高。关键词： HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=kw&skey=%E4%BD%93%E5%B1%82%E6%91%84%E5%BD%B1%E6%9C%AF%2C%20X%E7%BA%BF%E8%AE%A1%E7%AE%97%E6%9C%BA&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkM

13、yYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank 体层摄影术, X线计算机; HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=kw&skey=%E9%94%A5%E6%9D%9FCT&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gT

14、koUKaID8j8gFw! t _blank 锥束CT; HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=kw&skey=%E6%A4%8E%E5%BC%93%E6%A0%B9%E8%9E%BA%E9%92%89&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank 椎弓根螺钉; 作者简介：王琪 E-mail:

15、收稿日期：2017-07-18基金：中国博士后科学基金面上项目 (2015M582821) Clinical study on accuracy of cone beam computed tomography scanning in evaluating location of pedicle screws and severity of damage of pedicle of vertebral arch in surgery of pedicle screw internal fixation HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=

16、CJFD&sfield=au&skey=WANG%20Yanan&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank WANG Yanan HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=au&skey=LI%20Qingsong&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2

17、lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank LI Qingsong HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=au&skey=XIE%20Mengqi&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTk

18、oUKaID8j8gFw! t _blank XIE Mengqi HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=au&skey=GUO%20Mingming&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank GUO Mingming HYPERLINK /kcms/detail/knetsearch.as

19、px?dbcode=CJFD&sfield=au&skey=MENG%20Lingzhi&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank MENG Lingzhi HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=au&skey=WANG%20Qi&code=&uid=WEEvREcwSlJHSldRa1Fh

20、dXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank WANG Qi HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=in&skey=General%20Hospital%20of%20Shenyang%20Military%20District%20of%20PLA&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYm

21、E4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank General Hospital of Shenyang Military District of PLA; Abstract： Objective: To explore the accuracy of cone beam computed tomography ( CT) scanning in evaluating the location of pedicle screws and the severity of dam

22、age of pedicle of vertebral arch in the surgery of pedicle screw internal fixation. Methods: Forty-three patients were recruited from October 2015 to June 2017 and they needed pedicle screw internal fixation for treatment of spinal lesions, including lumbar degenerative disease ( 21) , thoracolumbar

23、 vertebral fracture ( 9) , thoracolumbar tumors ( 11) and spinal deformity ( 2) . Intervertebral fusion, fracture reduction and internal fixation, tumor removal and internal fixation and spinal orthopedic surgery were performed on patients respectively through posterior approach. Cone beam CT scanni

24、ng was performed on all patients using Artis Zeego system after pedicle screws were inserted into the pedicle of vertebral arch to know about the location of pedicle screws and the severity of damage of pedicle of vertebral arch. The location of pedicle screws were adjusted in time if necessary. The

25、 diseased region was scanned in all patients by using CT within one week after surgery to know about the location of pedicle screws and the severity of damage of pedicle of vertebral arch. The location of pedicle screws and the severity of damage of pedicle of vertebral arch were evaluated by using

26、Gertzbein rating system according to the intraoperative cone beam CT scanning images and postoperative CT scanning images respectively. Results: The surgeries were finished successfully in all patients, and the operative time and intraoperative blood loss were 224. 2 +/-47. 1 min and 482. 6 +/-471.

27、6 ml respectively. A total of 262 pedicle screws were inserted into pedicles of vertebral arch in 43 patients, including thoracic pedicle screws ( 104) , lumbar pedicle screws ( 142) and sacral pedicle screws at S1 segment ( 16) . No patient underwent reoperation for pedicle screw location correctio

28、n, and no nerve injury caused by pedicle screw insertion was found. The intraoperative cone beam CT images were inconsistent with the postoperative CT images in the rating results for only 10 of 262 screws. The rating results showed very good consistency between intraoperative cone beam CT images an

29、d postoperative CT image ( Kappa = 0. 804, P = 0. 000) . Conclusion: The location of pedicle screws and the severity of damage of pedicle of vertebral arch can be evaluated accurately using cone beam CT scanning in the surgery of pedicle screw internal fixation.Keyword： HYPERLINK /kcms/detail/knetse

30、arch.aspx?dbcode=CJFD&sfield=kw&skey=tomography%2C%20X-ray%20computed&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank tomography, X-ray computed; HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=kw&skey=

31、cone%20beam%20computed%20tomography&code=&uid=WEEvREcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank cone beam computed tomography; HYPERLINK /kcms/detail/knetsearch.aspx?dbcode=CJFD&sfield=kw&skey=pedicle%20screw&code=&uid=WEEvR

32、EcwSlJHSldRa1FhdXNXYXFuU2lIUGRrWkMyYmE4ekdzNC91alozWT0=$9A4hF_YAuvQ5obgVAqNKPCYcEjKensW4ggI8Fm4gTkoUKaID8j8gFw! t _blank pedicle screw; Received： 2017-07-18脊柱椎弓根螺钉作为一种具有优秀生物力学性能的内固定系统, 被广泛应用于脊柱内固定手术中。手术要求将螺钉完全置入椎弓根内, 同时不破坏椎弓根内外侧皮质, 否则患者可能因神经根或脊髓损伤出现疼痛、麻木甚至瘫痪等与置钉失误有关的神经症状, 部分误置的螺钉甚至会导致血管或内脏损伤 HYPERLI

33、NK javascript:void(0); 1-2。然而由于不同个体以及同一个体不同椎体的形态均存在一定的差异, 这给准确置钉带来了一定的困难。术中尽早发现并调整螺钉能有效降低并发症的发生率。术中置钉后利用C形臂X线机透视可粗略地判断螺钉的位置, 但准确性仍不理想。CT扫描可获得更为直观、精确的影像学信息, 帮助术者评估置钉位置和椎弓根破坏情况, 但目前很少用于术中。为此, 我们将锥束CT扫描应用于椎弓根螺钉内固定手术中, 用于评估螺钉位置和椎弓根破坏情况, 并将检查结果与术后CT扫描结果进行了对比, 以探讨其准确性, 现总结报告如下。1 临床资料纳入研究的患者共43例, 均为2015年10

34、月至2017年6月在沈阳军区总医院住院治疗的患者。男19例, 女24例;年龄 (56.612.9) 岁;所有患者均因脊柱病变需接受椎弓根螺钉内固定手术, 腰椎退行性疾病21例、胸腰椎骨折9例、胸腰椎肿瘤11例、脊柱畸形2例。2 方法在全身麻醉下, 43例患者分别经后路进行椎间融合、骨折复位内固定、肿瘤切除内固定和脊柱矫形手术。术中置入椎弓根螺钉后用西门子公司Artis Zeego系统 (图1) 行锥束CT扫描 (图2) , 扫描结束后通过工作站将扫描数据以0.5 mm的厚度进行多平面重建和容积重建。根据重建的二维或三维图像, 术者从轴位、矢状位、冠状位了解螺钉位置和椎弓根破坏情况, 必要时及时

35、进行调整。术后1周内所有患者均采用Lightspeed VCT 64排CT (GE公司) 进行病变部位扫描。术中锥束CT扫描图像和术后CT扫描图像分别由2位骨科副主任医师采用Gertzbein分级系统 HYPERLINK javascript:void(0); 3评估螺钉位置和椎弓根破坏情况:螺钉完全在椎弓根内为0级;螺钉穿破椎弓根内壁4 mm为3级;椎弓根外侧及其他破损为4级。若2名医师对同一枚螺钉的分级存在分歧, 则沟通后统一分级意见。3 结果43例患者均顺利完成手术, 手术时间 (224.247.1) min, 术中出血 (482.6471.6) m L。43例患者共置入262枚椎弓根螺

36、钉, 胸椎置钉104枚、腰椎置钉142枚、骶骨 (S1节段) 置钉16枚。无1例患者因椎弓根螺钉误置行二次手术调整钉位, 未发生椎弓根螺钉置入导致的神经损伤。图1 Artis Zeego系统 下载原图图2 椎弓根螺钉内固定术中置钉后锥束CT扫描图像 下载原图置入的262枚螺钉中, 仅10枚螺钉根据术中锥束CT图像评估的分级结果与根据术后CT图像评估的分级结果不一致 (表1) 。根据术中锥束CT图像评估的分级结果与根据术后CT图像评估的分级结果具有非常好的一致性 (Kappa=0.804, P=0.000) 。表1 椎弓根螺钉置钉Gertzbein分级结果枚 下载原表 4 讨论椎弓根螺钉作为脊柱

37、外科最常用的内固定工具, 术中一旦出现椎弓根螺钉误置, 将发生严重的并发症。Gertzbein等 HYPERLINK javascript:void(0); 4分析了100例行椎弓根螺钉内固定的患者, 认为椎弓根螺钉的误置率为15%, 且7%的患者因术后严重并发症行二次手术。Amiot等 HYPERLINK javascript:void(0); 5的观察了964例脊柱病变患者, 共置入6816枚椎弓根螺钉, 经统计胸腰椎徒手置钉中螺钉误置率为1.7%, 发生于9%的患者。Parker等 HYPERLINK javascript:void(0); 6的研究也认为徒手置钉并不可靠, 术者需要更加

38、可靠的工具进行辅助。对此, 许多研究者尝试通过三维重建、数字打印、术中直视和球形探针探查钉道等方法提高术中置钉的精确性 HYPERLINK javascript:void(0); 7-11, 但这些方法均不能在置入椎弓根螺钉后及时探查螺钉位置和椎弓根的破坏情况 HYPERLINK javascript:void(0); 6。目前常用的在术中判断螺钉位置和椎弓根破坏情况的方法为术中C形臂X线机透视, 但该方法的敏感性较差。目前临床用于评估椎弓根螺钉置钉位置、椎弓根破坏和椎间融合的检查方法为术后CT扫描 HYPERLINK javascript:void(0); 12, 但术后发现螺钉位置不佳时已

39、经失去在术中调整螺钉位置的机会, 严重者需要急诊行二次手术。Belmont等 HYPERLINK javascript:void(0); 13-15的研究表明, 与术中C形臂X线机透视和术后CT扫描相比, 术中使用Artis Zeego系统进行锥束CT扫描的放射线剂量更低, 而且扫描期间医护人员可在手术间外等待, 也可降低对医护人员的损害。Artis Zeego系统初期主要应用于神经介入、心脏血管介入领域, 近年来逐渐被运用于非神经血管介入手术或开放手术。Cordemans等 HYPERLINK javascript:void(0); 16于2015年首先将Artis Zeego系统用于骨科手

40、术中。在椎弓根螺钉内固定手术中应用Artis Zeego系统进行锥束CT扫描, 能够在术中置钉后及时评估螺钉位置及椎弓根破坏情况, 对于误置螺钉可以在术中及时调整, 提高了椎弓根螺钉内固定手术的成功率。本研究的结果提示, 椎弓根螺钉内固定手术中, 应用锥束CT扫描评估螺钉位置和椎弓根破坏情况, 准确性较高。但已有许多研究证实, 根据术后CT扫描判断螺钉位置和椎弓根破坏情况的敏感性为67%94% HYPERLINK javascript:void(0); 17-19, 因此根据术中锥束CT图像评估螺钉位置和椎弓根破坏情况也有一定的误诊和漏诊率, 临床中需要注意。此外, Artis Zeego系统

41、价格昂贵, 国内引进较少, 而且会增加治疗费用, 因此该技术短期内难以在基层医院普及。参考文献1JUTTE PC, CASTELEIN RM.Complications of pedicle screws in lumbar and lumbosacral fusions in 105 consecutive primary operationsJ.Eur Spine J, 2002, 11 (6) :594-598. 2LI G, LV G, PASSIAS P, et al.Complications associated with thoracic pedicle screws in s

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45、178. HYPERLINK /result.aspx?q=Is%20in%20vivo%20manual%20palpation%20for%20thoracic%20pedicle%20screw%20instrumentation%20reliable? t _blank 7DONOHUE ML, MOQUIN RR, SINGLA A, et al.Is in vivo manual palpation for thoracic pedicle screw instrumentation reliable?J.J Neurosurg Spine, 2014, 20 (5) :492-4

46、96. 8杨波, 方世兵, 尹飚, 等.三维重建腰椎椎弓根螺钉置入的精确性J.中国组织工程研究, 2013, 17 (13) :2333-2338. 9闫煌, 刘臻, 伍伟飞, 等.腰椎脊柱侧凸矫正中电钻驱动与克氏针加叩击法技术置钉精确性与安全性的比较研究J.中国骨与关节杂志, 2016, 5 (6) :454-458. 10周文钰, 陈扬, 李振宇.三维CT导航在腰椎再次手术及翻修术中椎弓根螺钉置入的应用研究 (附13例报告) J.中国骨与关节损伤杂志, 2010, 25 (3) :199-201. HYPERLINK /result.aspx?q=Freehand%20thoracic%2

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