腰椎椎弓根小斜位在术中透视的临床应用

发布时间：2018-01-14 13:20

本文关键词：腰椎椎弓根小斜位在术中透视的临床应用　出处：《河北医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：研究设计：将出现椎弓根偏置的患者以及部分正常的患者的术后影像资料进行汇总，分组存档，请相关骨科医师进行判断，从而进行一项回顾性研究。目的：椎弓根螺钉内固定是基于Roy-camile理论基础上产生,它能够在避免破坏脊柱结构的前提下，实现对脊柱的三柱固定，有效的治疗了脊柱的各种疾病，诸如骨折、先天性脊柱侧弯，腰椎滑脱等。手术中准确无误置入螺钉是本术式成功的关键所在,准确的椎弓根螺钉置入，必须严格界定在椎弓根的骨性标志之内，才能有效防止潜在的对血管神经的损伤。1-4故医学界探索各种途径，来试图减少椎弓根钉的误置率，椎弓根轴位技术、机器人辅助技术、X线导航以及CT导航、导航模板应运而生，随着这些技术的日臻成熟，使得其发生椎弓根穿出的概率明显减少。但新技术的出现必定带来新的问题，手术时间、放射剂量以及设备维护，使用费用，严格的解剖学配对，软组织的分离等都是这些新技术在临床广泛应用的阻碍。本项实验研究目的为探寻一种新的透视方式来提高术中椎弓根置钉的准确性。找一种基于最简单的X成像原理，通过改变椎弓根透视角度，提高椎弓根钉置入的准确性，以供广大医院进行推广和普及，从而使术者能够在术中及时发现问题，并有效地纠正误置的椎弓根钉，减少其神经血管并发症的发生率。材料与方法：选取25位合格需行椎弓根内固定的腰椎骨折患者，应用术前正侧位来排除目标椎体存在的异常、肿瘤、腰椎滑脱等疾病，排除其中五位不符合条件者，其中三位因为术前神经症状严重，术后神经症状无明显改善，，其中一位是X线片未达到供术者诊断的标准，一例是术后缺乏双斜位X线片。纳入的20名患者中男性患者16名，女性患者4名。其平均年龄为41岁。手术方法在患者全身麻醉之后,病人取俯卧位，卧于可透视床上，定位准确后，以伤椎为中心，去后正中合适长度切口，常规后正中手术入路。术后嘱患者绝对卧床休息，24-48小时之间拔出引流管，定期伤区换药。平均手术时间为93分钟，平均出血量为800ml。术后透视正侧位、双斜位以及术后CT,将20名实验者正侧位与斜侧位分别建立两个文件集，请三位不同资历医师通过两个不同的文件集，对术中126枚螺钉的位置进行判断。对比应用两种透视方法中，三位观察者总计以及各自对误置钉判断的准确性、敏感度、特异度、阳性预测值、阴性预测值，将术后CT检查作为诊断的金标准。采用四格表卡方检验的Fisher确切概率，以及行乘列表卡方检验比较分析两种置钉方法之间的置钉准确率，并对结果做出统计学计算。结果：三位观察者正位显示，准确率、敏感度、特异度、阳性预测值、阴性预测值分别为88%、27%、98%、63%、90%；斜位显示92%、50%、98%、86%、93%。三位观察者正斜位对比通过统计学计算得出P值分别为（P1=0;P2=0;P3=0.025）,差异有统计学意义。第一位观察者通过正侧位正确判断出4枚偏内的螺钉，1枚偏外的螺钉；斜侧位判断出6枚偏内的螺钉，3枚偏外螺钉。第二位观察者正侧位中2枚偏内，1枚偏外；斜侧位中4枚偏内，3枚偏外。第三位观察者中，正侧位中5枚偏内，1枚偏外；斜侧位中6枚偏内，3枚偏外。正位片中一共有106枚螺钉得到了相同的判断。但其中一病的正常的L2左侧钉，被一致地误认为是偏内。只有另外一病例的L2左侧钉，均通过正位片成功的检验出偏内，故实际上判断正确的螺钉只有105个。小斜位组的病人中，共有112枚得到了一致性的判断，而且其中没有三位观察者统一误诊的个体出现。结论：正位与斜位比较，后者能够对椎弓根钉置钉的位置进行预判，有助于术中椎弓根钉置钉准确性的提高，能够便于及时在术中调整椎弓根钉的位置，避免了误置钉所造成的不必要的医源性损伤
[Abstract]:Study Design : Patients with pedicle bias and post - operative image data of some normal patients are summarized , grouped and archived , and relevant orthopedic surgeons are requested to conduct a retrospective study . Objective : The internal fixation of pedicle screw is based on Roy - camile theory . It can effectively prevent the damage of vertebral arch root . Materials and Methods : Twenty - five patients with lumbar spine fracture treated with pedicle internal fixation were selected to exclude the abnormality , tumor , lumbar spondylolisthesis and other diseases in the target vertebral body . Among them , one was the standard for the diagnosis of the preoperative neurological symptoms . One was the lack of double oblique X - rays . Among the 20 patients , 16 were male patients and 4 female patients . The mean age was 41 years . After general anesthesia of the patient , the patient took the prone position , lying on the fluoroscopy bed , positioned accurately , the incision in proper length was taken in the middle of the posterior median , and the posterior median operation was taken into the way . The patient was instructed to take off the drainage tube between 24 and 48 hours . The average operation time was 93 minutes , and the average bleeding amount was 800ml . In contrast , the accuracy , sensitivity , specificity , positive predictive value , negative predictive value and negative predictive value of the two methods were compared and analyzed by using the Fisher ' s exact probability of the four - gauge chi - square test and the Chi - square test . Results : The positive position display , accuracy , sensitivity , specificity , positive predictive value and negative predictive value of three observer were 88 % , 27 % , 98 % , 63 % and 90 % , respectively . In the third observer , there were 106 screws in the positive lateral position , one in the lateral position , one in the lateral position , one in the lateral position , one in the lateral position and one in the lateral position . Only one hundred and six of the two lateral positions of the second observer were considered to be in the same position . Only the other cases showed that there were only 105 screws in the lateral position . Conclusion : Compared with the oblique position , the latter can pretreat the position of the pedicle screw nail , which can help to improve the accuracy of the pedicle screw during the operation , and can adjust the position of the pedicle nail in time and avoid unnecessary medical injury caused by the misplacement of the nail .

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.3

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