椎间后方加压单节段固定治疗胸腰椎骨折脱位的生物力学研究与临床评价

发布时间：2018-05-15 04:23

本文选题：胸腰椎 + 骨折脱位　；参考：《山东大学》2016年博士论文

【摘要】：第一部分经伤椎单节段椎弓根螺钉固定治疗胸腰椎骨折脱位的生物力学研究研究目的比较经伤椎单节段4钉固定与传统的跨伤椎4钉固定、含伤椎在内的三椎体6钉固定治疗胸腰椎骨折脱位的生物力学效果。研究经伤椎单节段4钉固定治疗胸腰椎骨折脱位的生物力学稳定性。研究方法选取12具6-7月龄小猪胸腰段(T11-L2)脊柱标本。经X线透视排除脊柱肿瘤、畸形、感染以及骨质疏松等病理状态。剔除椎旁肌肉、脂肪等软组织,保留椎骨、椎间盘、小关节囊以及周围韧带结构。首先将12具脊柱标本两端(T11和L2椎骨)用义齿基托树脂包埋,然后进行脊柱完整状态下的生物力学测试。测试完成后在每具标本的T13椎体中上1/3处行楔形截骨,锯断T12/13椎间盘并切断T12/13之间的棘上韧带、棘间韧带,凿断T12双侧下关节突,造成三柱损伤(保留双侧椎弓根完整)。咬除T12一侧下关节突及椎板中、下2/3,咬除同侧T13椎板上1/2,行椎板间开窗,显露脊髓,制造开窗减压模型,制成试验用的脊柱胸腰段骨折脱位模型。将12具胸腰段骨折脱位脊柱模型随机分为3组,每组采用不同的固定方式进行固定：A组采用经伤椎置钉单节段固定(伤椎及上方脱位椎各置入两枚椎弓根螺钉,行单节段4钉固定)；B组采用传统的跨伤椎4钉固定(伤椎不置钉,伤椎相邻的上、下椎体各置入两枚椎弓根螺钉,双节段4钉固定)；C组采用包括伤椎在内的三椎体6钉固定(伤椎及伤椎的上、下相邻的椎体各置入两枚椎弓根螺钉,双节段6钉固定)。应用生物力学试验机(MTA)进行力学测试,三维动态检测系统测定脊柱标本T12/13完整状态及三种固定组间载荷-位移及前屈、后伸、左侧屈、右侧屈、左旋、右旋6个方向的运动范围(ROM)。采用SPSS 13.0统计软件分析,所有数据采用x±s表示,所得完整状态及三种固定组结果进行对比,采用t检验。为均衡数目的固定节段(A组T12-13；B组、C组T13-L1)对ROM的影响,采用用稳定指数(stability potential index, SPI)反映两种固定方法的即刻稳定性,SPI=(完整状态ROM-固定状态ROM)/完整状态ROM。统计检验的显著性均设定在a=0.05。结果：三组标本固定后损伤节段轴向刚度比较：在最大载荷500N下,T12/13节段完整状态下脊柱轴向压缩平均位移为1.732±0.018mm；经伤椎置钉单节段固定组(A组)平均位移为1.102±0.016mm；传统的跨伤椎4钉固定组(B组)平均位移为1.372±0.032mm。含伤椎在内的三椎体6钉固定组(C组)平均位移为1.098±0.010mm。轴向压缩状态下各固定组较完整状态椎间位移均有明显减少,有显著差异性(P0.01)。提示三种固定方式固定后稳定性较完整状态明显提高。固定后三组模型组间比较：经伤椎置钉单节段固定组与含伤椎在内的三椎体6钉固定组稳定性无显著性差异(P0.05),两组稳定性均高于传统的跨伤椎4钉固定组(P0.05)。在屈、伸,左、右侧屈及扭转实验中：完整脊柱标本的活动范围分别为1.72±0.92°,2.81±0.97°,1.71±0.75°,1.72±0.80°,3.55±0.77。,3.53±0.75°；单节段固定组(A组)的活动范围分别为：0.40±0.05°,0.48±0.08°,0.77±0.11°,0.76±0.09°,0.52±0.11°,0.53±0.09°；传统的跨伤椎固定组(B组)的活动范围分别为：1.08±0.14°,0.97±0.11,1.05±0.19°,1.05±0.16°,0.69±0.14°,0.69±0.14°；含伤椎在内的三椎体6钉固定组(C组)的活动范围分别为：0.30±0.07。,0.37±0.09°,0.75±0.12°,0.74±0.08°,0.49±0.16°,0.50±0.12°。三种不同方式固定后的脊柱模型稳定性均高于完整状态的脊柱(P0.01)。三种不同方式固定后的脊柱模型的稳定性组间比较：在屈、伸实验中含伤椎在内的三椎体6钉固定组的稳定性强于经伤椎置钉单节段固定组及传统的跨伤椎4钉固定组(P0.05)；经伤椎置钉单节段固定组稳定性强于传统的跨伤椎4钉固定组(P0.05)。在左、右侧弯实验及扭转实验中,经伤椎置钉单节段固定组与含伤椎在内的三椎体6钉固定组稳定性无显著性差异(P0.05),稳定性均强于传统的跨伤椎4钉固定组,具有显著性差异(P0.05)。三组不同固定状态下的脊柱模型在屈、伸,左、右侧屈和扭转实验中的稳定指数(SPI, stable potential index)分别为：单节段固定组(A组)：0.89±0.05,0.89±0.08,0.96±0.11,0.96±0.09,0.97±0.11,0.97±0.09；传统的跨伤椎固定组(B组)：0.79±0.11,0.90±0.19,0.91±0.16,0.89±0.14,0.88±0.16；含伤椎在内的三椎体6钉固定组(C组)：0.92±0.07,0.91±0.09,0.97±0.12,0.97±0.08,0.98±0.16,0.98±0.12。显示含伤椎在内的三椎体6钉固定组(C组)稳定性与单节段固定组(A组)无显著性差异(P0.05)；二者稳定性均强于传统的跨伤椎4钉固定组(B组),具有显著性差异(P0.05)。结论：1.经伤椎置钉的单节段固定、传统的跨伤椎双节段固定及含伤椎在内的三椎体6钉固定均能为骨折脱位的脊柱的建立即刻稳定性。2.经伤椎置钉的单节段固定及含伤椎在内的三椎体6钉固定的即刻稳定性优于传统的跨伤椎固定组。3.经伤椎置钉的单节段固定治疗胸腰椎脱位能提供足够的即刻稳定性。第二部分椎间后方加压单节段固定治疗胸腰椎骨折脱位的临床研究研究背景胸腰椎骨折脱位为典型的脊柱三柱损伤,极度不稳定。除存在椎体、椎板、椎弓根、棘突等骨性结构破坏外,多数合并前、后纵韧带、棘上韧带及椎间盘等软组织断裂,大多合并脊髓及神经根损伤,手术指证明确。目前对其手术方式尚未形成共识,前路手术可重建良好的前方支撑,但其复位困难,很难达到牢固的固定；同时后方结构破坏无法修复,遗留后方不稳定；且椎管内减压困难,目前己较少采用。传统的后路四钉跨伤椎复位固定技术由于力学悬挂效应,常常使骨折椎、脱位椎复位困难,且容易导致脱位的椎间隙过度撑开。近来多数学者采用包括伤椎在内的三椎体六钉复位固定技术,获得满意的效果。魏富鑫等采用小牛标本模拟经伤椎单节段固定和跨伤椎短节段固定治疗胸腰椎骨折,证实两种手术在重建脊柱稳定性方面无显著差异,为单节段固定提供了生物力学理论支持。既然伤椎可以置钉,有没有必要同时固定其下方一个无辜的椎体?多固定融合一个正常的椎间隙?前期已有较多伤椎置钉的生物力学及解剖学研究,证实伤椎置钉的可行性、可靠性。本研究第一部分已经进行动物离体脊柱模型的生物力学研究,证实其稳定性满足固定要求,本节对其在临床应用中的疗效进行评价。研究目的比较后路切开复位椎间加压单节段内固定,传统的后路复位跨伤椎4钉内固定,包括伤椎在内的三椎体六钉复位内固定三种手术方式在治疗胸腰椎骨折脱位患者的临床疗效,为胸腰椎骨折脱位患者提供最佳治疗策略。研究方法26例胸腰椎骨折患者随机分为3组。A组：采用经伤椎置钉的椎间后方加压单节段内固定技术；B组：采用传统跨伤椎短节段内固定技术；C组：采用包括伤椎在内的三椎体六钉内固定技术治疗。26例胸腰椎骨折患者中A组10例；B组9例；C组7例。所有患者于伤后12天内在全麻俯卧位下进行手术,根据分组采用不同的固定方式实施后路切开复位、椎管开窗减压椎弓根钉内固定术。术中尽量保留棘突及棘间韧带、棘上韧带结构,手术过程包括减压、复位、置钉固定、后方融合,并缝合修复断裂的棘突及棘上、棘间韧带。本组病例均未行椎体间植骨融合。患者术后均常规抗生素预防感染、消除神经水肿及神经营养药物治疗及对症处理。术后1周在支具保护下逐渐下地行走。26例患者均经12个月以上随访,平均随访时间22.3个月比较三组间围手术期指标：手术时间、失血量、切口长度、并发症发生率；及术前／术后ASIA功能评分、骨折椎前缘高度比、脱位率、Cobb角椎管侵占率脊髓损伤率等指标。采用SPSS 13.0统计软件进行统计分析,数据以x±s表示,计量资料采用t检验,计数资料(Frankel分级)采用秩和检验。结果末次随访时三组患者神经功能(ASIA评分)较术前均有明显提高(P0.05),三组患者组间比较神经功能改善无显著性差异(P0.05)。三组患者在手术时间、术中出血量、切口长度及术后并发症发生率方面：A组优于B组及C组,有显著性差异(P0.05)；B组手术时间短于C组,有显著性差异(P0.05)；术中出血量、切口长度及术后并发症发生率方面B组及C组组间比较无显著性差异(P0.05)。三组患者术前伤椎前缘高度比、Cobb角、脱位率及伤椎椎管侵占率的差异无统计学意义(P0.05)。各影像学指标：三组组内比较术后比术前均有明显改善,差异具有统计学意义(P0.05)。末次随访时三组伤椎前缘高度差异无统计学意义(P0.05)；而在Cobb角、脱位率及伤椎椎管侵占率的改善方面：A组、C组明显优于B组,差异具有统计学意义(P0.05)。A组、C组组间比较无显著性差异(P0.05)。结论1.对于胸腰椎骨折脱位,椎间后方加压单节段内固定、传统的四钉跨伤椎复位内固定及包括伤椎在内的三椎体六钉复位内固定术都能获得较好的临床功能恢复。2.椎间后方加压单节段内固定的总体疗效优于传统的跨伤椎四钉内固定及包括伤椎在内的三椎体六钉复位内固定。
[Abstract]:Part 1 biomechanical study on the treatment of thoracolumbar fracture and dislocation through single segmental pedicle screw fixation for thoracolumbar fracture and dislocations. Objective to compare the biodynamic effects of the 4 nailed 4 nailed vertebrae and three vertebrae, including the injured vertebrae, and the three vertebral body with the injured vertebra for the treatment of thoracolumbar fracture dislocation. The biomechanical stability of the treatment of thoracolumbar fracture and dislocation. 12 6-7 months old piglet (T11-L2) spine specimens were selected to remove the pathological state of the spinal tumor, deformity, infection and osteoporosis by X-ray fluoroscopy. The paravertebral muscles, fat and other soft tissues were removed, and the vertebral, intervertebral disc, small joint capsule and the surrounding ligament structure were retained. First, a denture base resin was embedded at both ends of the 12 spine specimens (T11 and L2 vertebrae) with a denture base resin. Then the biomechanical test of the spinal integrity was performed. After completion of the test, the wedge osteotomy was performed at the upper 1/3 of the T13 vertebral body of each specimen. The T12/13 intervertebral disc was cut and the supraspinal ligaments, the interspinous ligaments, and the T12 bilateral lower joint processes were cut off from the T12/13. Three columns were damaged (preserving bilateral pedicle integrity). A model of thoracolumbar fracture and dislocation of the spine was made into 3 groups, each of the 12 thoracolumbar fractures and depressor models were divided into 3 groups randomly, by biting the lower 2/3 on the T12 side of the articular process and vertebral lamina, the lower 1/2 on the ipsilateral vertebral lamina, the interlaminar window, the spinal cord, and the decompression model of the open window, and the model of the thoracolumbar fracture dislocation. Group A was fixed in different fixed ways: group A was fixed with single segment of the injured vertebra (injured vertebra and upper dislocation vertebra each of two pedicle screws and single segment 4 nails); in group B, the traditional 4 nailed spanning vertebrae were fixed (injured vertebra without nail, adjacent to the injured vertebra, two pedicle screws in the lower vertebral body, and 4 segment fixed in the double segment). In group C, the three vertebrae, including 6 vertebrae including the injured vertebra, were fixed (the upper vertebrae and the injured vertebrae, the lower adjacent vertebral bodies were inserted into two pedicle screws and the double segment 6 nails). The biomechanical test machine (MTA) was applied to the mechanical test. The three-dimensional dynamic detection system was used to determine the complete state of the T12/13 in the spine specimens and the load displacement and the front of the three fixed groups. Flexion, extension, left flexion, right flexion, left rotation, dextral 6 direction movement range (ROM). Using SPSS 13 statistical software analysis, all data were expressed by X + s, the whole state and the three fixed groups were compared and t test was used. The effect of the equilibrium number of fixed segments (A group T12-13; B group, C group T13-L1) on ROM was used to use stability. The stability potential index (SPI) reflects the immediate stability of the two fixed methods. The significance of SPI= (complete state ROM- fixed state ROM) / complete state ROM. statistical test is set in the a=0.05. result: the axial stiffness comparison of the damaged segments after the three groups of specimens are fixed: under the maximum load 500N, the T12/13 section of the spinal column The average displacement of axial compression was 1.732 0.018mm, and the average displacement of the single segment fixation group (group A) was 1.102 + 0.016mm, the average displacement of the traditional 4 nail fixation group (group B) was 1.372 + 0.032mm. and the three vertebral 6 nail fixation group (C group) with the average displacement of 1.098 + 0.010mm. axial compression. The whole state of the intervertebral displacement was significantly reduced (P0.01). It was suggested that the stability of the three fixed methods was significantly improved after fixation. After fixation, there was no significant difference between the three groups of model groups: the stability of the three vertebrae, including the single segment fixation group and the three vertebrae, and the stability of the two groups. It was higher than the traditional 4 screw fixation group (P0.05). In the flexion, extension, left, right flexion and torsion test, the activity range of the complete spine specimen was 1.72 + 0.92, 2.81 + 0.97, 1.71 + 0.75, 1.72 + 0.80, 3.55 + and 3.53 + 0.75. The activity range of single segment fixation group (group A) was respectively 0.40 + and + 11 degrees, 0.76 + 0.09 degrees, 0.52 + 0.11 degrees, 0.53 + 0.09 degrees. The range of activities of the traditional intervertebral fixation group (group B) were 1.08 + 0.14, 0.97 + 0.11,1.05 +, 1.05 +, 0.16 [0.09]. The stability of the spinal model was higher than that of the intact spinal column (P0.01). The stability of the spinal model after the three different ways of fixation was compared with the stability of the spinal model after the three different ways of fixation. The stability of the three vertebral 6 nail fixation group in the flexion and extension experiment was stronger than that of the single segment fixation of the injured vertebral column in the flexion and extension experiment. The fixed group and the traditional 4 nail fixation group (P0.05), the stability of the single segment fixation group was stronger than the traditional 4 nail fixation group (P0.05). In the left, right bending experiment and torsion test, there was no significant difference in the stability between the single segment fixation group and the three vertebra 6 nail fixation group (P0.05). It is stronger than the traditional 4 nail fixation group of cross wound vertebra (P0.05). The stability index (SPI, stable potential index) in the three groups of different fixed states of the spinal model in the flexion, extension, left, right flexion and torsion (stable potential index) are:0.89 + 0.05,0.89 + 0.08,0.96 + 0.11,0.96 + 0.09,0.97 + 0.11,0.97 + 0 in the single segment group, respectively. .09; the traditional group (group B) was:0.79 + 0.11,0.90 + 0.19,0.91 + 0.16,0.89 + 0.16; the three vertebral 6 nail fixation group (group C) containing the injured vertebra (group C) showed the stability of the 6 nail fixation group in the three vertebral body and the single segment fixation group. There was no significant difference (P0.05). The stability of the two was stronger than that of the traditional 4 nail fixation group (group B) with a significant difference (P0.05). Conclusion: 1. the single segment fixation of the injured vertebral nail, the traditional trans vertebral double segmental fixation and the three vertebra 6 nail fixation, including the injured vertebra, can be the immediate stability of the fracture dislocation of the spine,.2. The immediate stability of the three vertebrae, including the single segment fixation of the injured vertebral nail and the three vertebra containing the injured vertebra, is superior to the traditional intervertebral fixation group. The treatment of thoracolumbar dislocation can provide sufficient immediate stability. Second partial posterior compression single segment fixation for the treatment of thoracolumbar fracture dislocation Research background, thoracolumbar fracture dislocation is a typical spinal three column injury, extremely unstable. Apart from the destruction of vertebral body, vertebral plate, pedicle, spinous process and other skeletal structures, most of the anterior longitudinal ligaments, supraspinal ligaments and intervertebral discs are broken, most of which are combined with spinal cord and nerve root injury, and the surgical indications are clear. At present, the operation method is clear. At present, the operation method is clear. At present, the operation method is clear. There is no consensus that anterior surgery can reconstruct a good front support, but its reduction is difficult and it is difficult to achieve a strong fixation. At the same time, the posterior structure failure can not be repaired, and the remnants of the posterior spinal canal are not stable, and the decompression of the spinal canal is difficult. The traditional posterior four nail cross wound fixation technique is often due to the mechanical suspension effect. It is difficult to reposition the fracture vertebra and dislocation vertebrae and easily lead to the excessive distraction of the dislocation of the vertebra. Most scholars recently adopted the technique of six nail reduction and fixation of three vertebrae including the vertebral body, and obtained satisfactory results. Wei Fuxin and other calf specimens were used to simulate the treatment of thoracolumbar fractures with single segmental fixation of the injured vertebra and short segmental fixation of the vertebra. There is no significant difference in the reconstruction of spinal stability between the two operations, which provides a biomechanical support for single segment fixation. Since the injured vertebra can be inserted, it is necessary to fix an innocent vertebral body at the same time at the same time? The first part of this study has carried out the biomechanical study of the animal model of the spinal column, which confirms that the stability meets the fixed requirements. The results of this section are evaluated in the clinical application. The purpose of this section is to compare the posterior reduction and reduction of the intervertebral compression single segment internal fixation and the traditional posterior reduction. The treatment of thoracolumbar fracture and dislocation in patients with thoracolumbar fracture and dislocation, including three vertebrae 4 nail internal fixation, including three vertebral body and six nail reduction and internal fixation, provides the best treatment strategy for patients with thoracolumbar fracture and dislocation. Methods 26 patients with thoracolumbar fracture were randomly divided into groups of 3.A groups: the posterior lumbar vertebra posterior to the posterior intervertebral body The technique of compression single segment internal fixation; group B: using the traditional intervertebral short segment internal fixation technique; group C: 10 cases of group A in.26 cases of thoracolumbar fractures, including 10 cases in.26 cases of thoracolumbar fractures, including six vertebrae including injured vertebrae, B group 9 cases and C group 7 cases. Posterior decompression, interspinous ligament and supraspinous ligament were retained in the operation. The procedure included decompression, reduction, fixation, posterior fusion, and suture repair of spinous process and spinous interspinous ligament. No intervertebral interbody bone was performed in this group. .26 patients were followed up for more than 12 months after 1 weeks of support. The average follow-up time was 22.3 months compared to the three groups: operation time, blood loss, incision length, and the average follow-up time of the three groups. The incidence of hair disease, ASIA function score before and after operation, the height ratio of anterior edge of fracture vertebra, dislocation rate, Cobb angle spinal canal embezzlement rate spinal cord injury rate and so on. The statistical analysis was carried out by SPSS 13 statistical software, the data were represented by X + s, the measurement data were tested by t test, and the count data (Frankel classification) were tested by rank sum test. The results were three at the last follow-up. The neurological function (ASIA score) of the group was significantly higher than that before the operation (P0.05). There was no significant difference in the improvement of nerve function between the three groups. In the three groups, the operation time, the amount of bleeding, the length of the incision and the incidence of postoperative complications: the group A was better than the B group and the C group (P0.05); the operation time of the B group was short. There was significant difference in group C (P0.05). There was no significant difference between group B and group C (P0.05) in the amount of intraoperative bleeding, incision length and postoperative complication rate (P0.05). There was no significant difference between the three groups in the anterior margin of the vertebral height, Cobb angle, dislocation and vertebral canal intraspinal embezzlement rate (P0.05). All imaging indexes: the internal ratio of the three groups The difference was statistically significant compared with that before operation (P0.05). There was no significant difference in the height difference between the three groups at the last follow-up (P0.05), but in the Cobb angle, the dislocation rate and the improvement of the vertebral canal embezzlement rate in the group A, the C group was obviously superior to the B group, and the difference was statistically significant (P0.05).A group, and there was no significant difference between the C group. Conclusion 1.. Conclusion 1. for thoracolumbar fracture dislocation, posterior intervertebral compression single segment internal fixation, traditional four nailed intervertebral reduction internal fixation and three vertebral six nail reduction internal fixation, including the injured vertebra, the overall effect of.2. posterior compression single segment internal fixation is better than that of the traditional one. Four pedicle screws and three pedicle screws were used to replace the three vertebrae.

【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R687;R318.01

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