计算机辅助设计应用于复杂脊柱矫形手术的初步研究

发布时间：2018-01-14 21:22

本文关键词：计算机辅助设计应用于复杂脊柱矫形手术的初步研究　出处：《南方医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：研究背景伴随计算机技术的兴起与发展,计算机辅助技术在医学领域的发展非常迅猛,并且得到医学界的广泛认可与应用,从各个方面丰富了当前的医学诊疗手段,改变了医学诊疗模式。特别是在骨科领域,基于骨骼系统及骨科手术的特殊性,计算机辅助手术技术尤与骨科临床结合紧密,显示出良好的实用性,能够直接用于科学研究和指导临床应用。而在骨科领域内,脊柱畸形的手术治疗相对难度较大,涉及三维方向上的精细解剖和复杂变异,需要手术医师高超的手术技巧与丰富的临床诊疗经验。随着三维矫形理论与技术的发展、内固定系统的改良以及脊柱矫形技术和麻醉技术的卓著进步,脊柱矫形的手术效果已经获得了大幅度的提升,但同时亦存在术式多样,适应症不够明确,诊疗过程不够标准和规范,并发症的发生率仍较高等不足之处。目前,计算机辅助技术已经在脊柱外科获得一定应用,但检索国内外文献,未见将计算机辅助设计应用于脊柱矫形的相关报道,其应用效果亦不得而知。研究目的对计算机辅助技术在骨科领域的发展和应用现状进行综述。对脊柱畸形的手术治疗,特别是重度脊柱畸形的截骨矫形手术的临床应用进展进行综述。基于计算机辅助技术在脊柱外科的前期应用,本研究通过运用计算机辅助设计辅助探索山羊胸椎椎弓根螺钉的置钉参数并试图模拟截骨矫形手术,以弥补对于实验动物缺乏手术操作经验的不足。进行山羊后路胸椎单节段全椎骨切除手术的实验研究,利用椎弓根钉棒内固定系统的轴向加压,在脊髓监护下探索脊柱和脊髓短缩的安全范围,以期为临床脊柱短缩手术提供数据参考及实验依据。同时基于交互式医学影像控制系统这一平台进行重度脊柱畸形矫形手术相关的计算机辅助设计,进而通过临床分组研究比较组别之间的手术安全性与手术效果,探索该技术对于重度脊柱畸形矫形手术的重要指导意义。方法 (1)查阅近年来国内外关于计算机辅助技术的文献,了解其发展史及其在医学,尤其是骨科领域内的应用,检索相关新兴技术及其相关原理、关键技术、应用范围及进展,学习并掌握基于交互式医学影像控制系统的计算机辅助设计,并应用于指导骨科手术。(2)查阅文献了解脊柱畸形手术治疗发展史及当期诊疗手段,重点检索重度脊柱畸形后路截骨矫形手术的相关文献,熟悉各种手术方式的发展,包括不同术式的手术原理、手术系统以及适应症、手术效果以及并发症,掌握各种截骨手术的操作过程,综述后路截骨矫形手术的最新进展。(3)选择6只健康山羊进行动物实验,所有动物术前行X线及MR检查,排除脊柱及神经系统疾病,多层薄层扫描获取脊柱断层CT数据,利用交互式医学影像控制系统重建山羊脊柱模型,分离手术节段的椎体,模拟椎弓根螺钉置钉,选择最佳进钉点、置钉方向与深度,模拟脊柱截骨短缩手术。然后依据模拟手术获取的相关参数实施动物实验,在全程体感诱发电位监护下完成脊柱后路T6-10的后路椎弓根螺钉固定,从两侧进行T8节段的全椎骨切除,设定全椎骨切除后的皮层体感诱发电位(CSEP)为基准线,设定CSEP P1波幅下降50%和／或潜伏期延长10%为提示脊髓损伤的阳性结果。测量此时截骨间隙的高度,再利用后路胸椎椎弓根钉棒系统的椎间加压,以1mm/5min的速度模拟脊柱轴向短缩,直至脊髓监护刚好不出现阳性结果,此时再次记录截骨间隙高度,如截骨间隙存在,即于截骨间隙植入合适高度的椎间支撑体,完全固定椎弓根钉棒系统并逐层缝合术口,记录截骨前后及内固定后的CSEP,术后严密观测山羊肢体活动情况,继续饲养1周,复查X线及MR检查,并记录行为学检测指标恢复正常的时间,最终获得脊柱短缩的安全范围。(4)临床研究中选取2010年6月～2012年6月中国人民解放军广州军区广州总医院骨科医院收治的脊柱畸形病例共62例,分为模拟手术组31例及非模拟手术组31例。所有病例签署知情同意书,排除手术禁忌及其他入组禁忌后,术前进行T1-S1脊柱的多层薄层螺旋CT扫描,模拟手术组病例获取CT光盘数据导入Mimics10.01软件平台进行手术区域的脊柱以及周围重要脏器,如心肺、肝脏、肾脏等,以及截骨矫形区血管的数字化三维重建,仔细观察三维模型了解脊柱及其周围重要脏器、血管的空间关系,明确有无结构变异,并确定手术节段,是否需要截骨以及截骨区域,模拟置钉、截骨和内固定等手术操作,优化手术方案,必要时利用快速原型技术制作三维实物模型辅助术中参考。非模拟手术组术前不进行上述操作,单纯按照传统常规方式结合术者经验制定手术方案。术后通过X线检查及CT钉道扫描比较两组椎弓根螺钉的置钉成功率(定义椎弓根螺钉完全不穿破皮质为置钉成功)评估手术安全性,比较Cobb角纠正率以评估手术效果。术后两组患者进行了10～28月的随访。结果 (1)数字骨科技术全面覆盖了骨科术前图像重建及处理、手术模拟、术中导航与术后评估等各个方面,技术成熟。(2)伴随脊柱矫形手术技术的进步,脊柱畸形的手术效果大幅提升。临床中,截骨手术在重度脊柱畸形的矫形中正在逐步得到推广应用,矫形效果良好,但其方式较多,缺乏标准,手术并发症多。(3)在缺乏山羊胸椎椎弓根螺钉置钉经验的情况下,基于山羊脊柱CT扫描数据的三维重建,通过计算机辅助设计获得了山羊胸椎后路椎弓根螺钉可靠的进钉点、置钉方向与深度、螺钉直径等置钉参数,并成功完成置钉,同时可以模拟截骨短缩手术,最大限度地优化实验方案,保证了动物实验的实施。在体感诱发电位监护下截除T8全椎骨,加压椎弓根钉棒系统进行脊柱短缩,测量山羊T8节段水平脊柱短缩的安全范围,发现随着脊柱短缩负荷增大,CSEP波幅下降、潜伏期延长,波幅降低多先于潜伏期延长出现,但均又逐步恢复正常,均尚未达到脊髓监护阳性标准,直至截骨间隙完全闭合仍不能导致脊髓监护指标阳性改变的出现,此时固定内固定系统,并持续维持内固定1周,发现所有山羊术后当日肢体活动即完全正常,行为学检测指标亦均正常,均未出现不可逆性脊髓损伤表现。(4)临床研究中应用Mimics软件平台可以清晰地重建脊柱及周围重要脏器、血管等,术前可以直观、客观地观察并测量手术区域的精细解剖与变异,能够反复多次进行模拟置钉、截骨以及内固定等手术操作,甚至能够预测手术效果,从而优化手术方案。两组临床病例术后所有患者均未发现神经、血管损伤及感染等并发症,模拟手术组置钉共418枚,成功率为97.1%,非模拟手术组置钉共451枚,成功率90.5%,两组有显著性差异(p0.001):Cobb角纠正率(模拟手术组63.3%±14.3%,非模拟手术组58.3%±13.0%),两组无显著性差异(P0.05)。结论 (1)数字技术大大提高了骨科手术的精准度和安全性,有效提升了手术技术及手术效果,凸显了其临床实用性。(2)随着三维矫形理论和内固定器械的发展,截骨术成为治疗重度脊柱畸形的革命性技术,从早期的经椎弓根截骨发展到全椎体切除术,大大提高了重度脊柱畸形的矫形率。但目前重度脊柱畸形的诊疗策略尚难以达到标准化和规范化,相关的实验研究及循证医学证据仍然不足,个体化的截骨矫形手术方式的选择及如何规避手术并发症仍然有待探索研究。(3)在动物实验中,计算机辅助设计可用于缺乏手术经验时的术前探索及操作模拟,体感诱发电位监护下模拟T8水平的脊柱短缩,发现单位椎体高度的脊柱短缩并不导致脊髓监护的阳性改变及脊髓功能损害,这一结果稳定可靠,可以用于临床脊柱截骨短缩矫形手术的参考依据。(4)在临床中,重度脊柱畸形往往合并脊柱及周围软组织三维方向不同程度的畸形,个体之间矫形参数相差悬殊,手术难度极大,我们成功将计算机辅助设计技术运用于重度脊柱畸形的矫形手术,该系统使用方便,操作简单,不仅可以简便地重建患者CT数据获得清晰的骨性及软组织三维结构,而且可以直接根据自己的临床经验进行手术相关参数的测量、制定个体化的矫形方案并反复多次模拟手术,同时还可以连接快速成型设备制作实体模型术中实时参考,为脊柱矫形特别是对复杂畸形的矫形带来诸多益处,可以明确地提高手术准确性和安全性,甚至通过术后的重建分析患者的手术效果及预后。应用计算机辅助设计指导脊柱矫形手术,尤其是重度脊柱畸形的矫形手术,均获得满意的临床疗效,故推荐在临床脊柱矫形中进一步推广应用。
[Abstract]:Research background
With the rise and development of computer technology, the development of computer aided technology in the field of medicine is very rapid, and has been widely recognized and applied in medical field, from the aspects of enriching the current medical diagnosis method, change the medical treatment model. Especially in the field of Department of orthopedics, particularity of the skeletal system and Department of orthopedics surgery based on surgery computer aided technology especially closely combined with clinical department of orthopedics, shows good practicability, can be directly used in scientific research and clinical applications. While in the Department of orthopedics in the field of surgical treatment of spinal deformity is relatively difficult, involving the direction of three-dimensional fine and complex anatomical variation, surgical techniques are necessary for physicians skilled operation and rich clinical the experience of diagnosis and treatment. With the development of three-dimensional correction theory and technology, internal fixation system improvement and orthopedic surgery and anaesthesia technology Zhuo progress, ridge The operation effect has already obtained the orthopedic column greatly improved, but at the same time also has the operation diversity, indications are not clear enough, the treatment process is not standard and the complication rate is still higher shortcomings. At present, the computer aided technology has got certain application in spinal surgery, but the retrieval of literatures at home and abroad, no the relevant reports of computer aided design application in orthopedic surgery and its application effect also can make nothing of it.
research objective
To summarize the development and application of computer aided technology in the field of Department of orthopedics. Surgical treatment for spinal deformity, especially the progress of clinical application of osteotomy for severe spinal deformity surgery were reviewed. The application of computer aided technology in spinal surgery on the basis of this study through the use of computer aided design exploration goat thoracic pedicle screws screw parameters and try to simulate osteotomy, to make up for lack of experimental animal lack of operation experience. Experimental study of goat posterior total vertebral resection single segmental thoracic surgery, using axial pedicle screw rod fixation system pressure, explore the safety range of spine and spinal cord shortening in spinal cord monitoring, to for a period of clinical spinal shortening surgery to provide reference data and experimental basis. At the same time, based on the platform of interactive medical image control system Computer aided design for corrective surgery of severe spinal deformity is carried out, and then the clinical safety and operative effect between different groups are compared through clinical grouping to explore the important guiding significance of the technology for severe spinal deformity correction surgery.
Method
(1) the published literatures about computer aided technology, understand its development history and its application in medicine, especially in the Department of orthopedics in the field of information retrieval related emerging technology and its related principle, application scope and progress, to learn and master the computer aided design of interactive medical image control system based on the application and to guide the Department of orthopedics surgery. (2) the literature about the history of the development of spinal deformity surgery treatment and the treatment means, the related literature focus on the retrieval of severe spinal deformity posterior osteotomy surgery, familiar with the development of various operation modes, including the operation principle of different operation, operation system and indications, operative effect and complications of operation. The process of mastering all kinds of osteotomy, the latest progress of posterior osteotomy surgery. (3) 6 healthy goats were used in animal experiments, all animal underwent X-ray and M Check out R, spine and nervous system disease, multi fault CT data acquisition spine TLC scanning control system, reconstruction of goat spine model using the interactive medical image, the separation operation segment of vertebral pedicle screw placement, simulation, select the best point of screw insertion angle and depth, simulation of spine shortening operation. Then the parameters according to the simulation surgery to obtain the implementation of animal experiment, the whole body in the sense of posterior pedicle screw complete posterior spinal T6-10 evoked potential monitoring under the fixed T8 segment total vertebral resection from both sides, set the total vertebral resection of somatosensory evoked potential (CSEP) as the base line, set the CSEP P1 amplitude decreased 50% and / or latency of 10% positive results suggest that spinal cord injury. When measuring the osteotomy gap height using posterior thoracic pedicle screw rod system with 1mm/5min intervertebral compression, speed Simulation of axial spine shortening, until spinal cord monitoring just positive results, then again to record the osteotomy gap height, such as the existence of the osteotomy gap, namely in the osteotomy gap implanted suitable height of intervertebral supporting body, completely fixed with pedicle screw system and sutured incision, recorded after fixation of osteotomy before and after CSEP and, close observation of goat limbs after operation, continue for 1 weeks, X-ray and MR examination, and record the behavioral detection indicators to restore the normal time, finally get the safety range of spinal shortening. (4) from June 2010 to June 2012 China people's Liberation Army Genenral Hospital of PLA Guangzhou Military Area Department of orthopedics hospital admitted 62 cases of spinal deformity patients in the clinical study, divided into group of 31 cases of surgical simulation and Simulation of non operation group 31 cases. All patients signed informed consent, exclude contraindication and other groups contraindicated after preoperative T1-S Scanning 1 spine multilayer spiral CT, simulate the surgical group to obtain CT disk data into Mimics10.01 software platform for the operation area of spinal and peripheral organs such as heart, lung, liver, kidney, blood vessels and osteotomy area digital three-dimensional reconstruction, carefully observe the 3D models to understand the important organs and around the spinal space. The relationship between blood vessels, clear the structure variation, and to determine the surgical segment, need osteotomy and osteotomy area, simulation of screw, osteotomy and internal fixation operation, optimize the operation plan, if necessary using rapid prototyping technology refer to the production of three dimensional physical model of auxiliary operation. Without the operation simulation before surgery, simply follow the conventional combination of experience and surgical planning. After operation by X-ray examination and CT scan screw compared with two groups of pedicle screw placement success rate (fixed The operative safety was evaluated by pedicle screw completely without perforation. The corrected rate of Cobb angle was used to evaluate the operative effect. Two groups of patients were followed up for 10~28 months after operation.
Result
(1) digital technology comprehensive coverage of the Department of orthopedics department of orthopedics preoperative image reconstruction and processing, operation simulation, intraoperative navigation and postoperative evaluation and other aspects, mature technology. (2) with spinal surgery technology, the surgical effect of spinal deformity increased dramatically. Clinically, osteotomy in the correction of severe deformity the spine is gradually popularized, orthopedic effect is good, but it means more, the lack of standards, more complications. (3) in the absence of goat thoracic pedicle screw placement experience, three-dimensional reconstruction of goat spinal CT scan based on the data obtained through computer aided design of goat thoracic posterior pedicle screw into reliable nail, screw direction and depth, the diameter of screw screw parameters, and the successful completion of the screw, and can simulate the osteotomy surgery, to optimize the experimental scheme, to ensure the real animal experiment In the application of somatosensory evoked potential monitoring cutting T8 total vertebral compression, pedicle screw system for spinal shortening, safety range measurement goat T8 segment level spinal shortening, with spinal shortening load increases, the amplitude of CSEP decreased and latency was prolonged and the amplitude decreased earlier than latency, but also gradually return to normal, has not reached a positive standard of spinal cord monitoring, until the osteotomy gap closed completely still can not lead to spinal cord monitoring index positive change, the internal fixation system, and maintain internal fixation for 1 weeks, found the goat postoperative day physical activity is completely normal, behavioral detection indicators were normal, were no irreversible spinal cord injury. (4) can clearly reconstruct the spine and important organs surrounding the application of Mimics software in clinical research vessels, can be directly observed and objectively before operation. Fine anatomical measurement of the operation area and variation, which can repeatedly simulate the screw osteotomy and internal fixation operation, and can even predict the operation effect, in order to optimize the surgical plan. Clinical cases in two groups after operation all patients were found no nerve, vascular injury and complications such as infection, a total of 418 screw simulation operation group one, the success rate was 97.1%, the non simulation operation group nailing a total of 451, the success rate was 90.5%, there was significant difference between two groups (p0.001): Cobb angle correction rate (analog operation group 63.3% + 14.3%, 58.3% + 13% non simulated surgery group), no significant differences between the two groups (P0.05).
conclusion
(1) digital technology can greatly improve the accuracy and safety of operation in the Department of orthopedics, improve the surgical technique and operative effect, highlighting its clinical utility. (2) with the development of three-dimensional correction theory and instrumentation, become the osteotomy for the treatment of severe spinal deformity of the revolution of technology, from the early pedicle cut-off the bone to the entire vertebral resection, greatly improving the severe orthopedic spinal deformity rate. But the current strategy for diagnosis and treatment of severe spinal deformity is difficult to achieve standardization and related experimental research and evidence-based medicine is still insufficient, individual osteotomy methods and the choice of how to avoid the complications of surgery remains to be to explore and study. (3) in animal experiments, computer aided design for the lack of surgical experience when preoperative exploration and operation simulation, simulation of shortening T8 somatosensory evoked potential monitoring in spinal level under It is found that the unit of vertebral height, spinal shortening does not lead to positive changes and the function of spinal cord spinal cord monitoring, this result is stable and reliable, can be used for clinical spine shortening surgery reference. (4) in the clinic, severe spinal deformity is often associated with 3D spine and surrounding soft tissue deformities between the individual parameters, correction disparity, operation difficulty is great, our success will be the technology of computer aided design applied to severe spinal deformity correction surgery, the system is easy to use, simple operation, can not only simple reconstruction with CT data obtained clear three-dimensional structure of bone and soft tissue, and can be directly related to the operation of measuring parameters according to the our clinical experience, orthopedic individualized and repeated surgical simulation, but also can be connected with rapid prototyping equipment production model The type of operation in real-time reference, especially for scoliosis bring many benefits to complex deformity correction, can clearly improve the operation accuracy and safety, even through the postoperative reconstruction analysis of patients with the effect of surgery and prognosis. The application of computer aided design guidance for spinal surgery, especially in severe spinal deformity correction surgery clinical curative effect were satisfactory, so it is recommended to be widely used in clinical orthopedic surgery.

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

【参考文献】