椎弓根皮质骨轨迹螺钉技术应用于国人腰椎退变性疾病的研究

发布时间：2018-01-20 10:04

本文关键词： 椎弓根螺钉皮质骨轨迹腰椎退变疾病骨质疏松腰椎融合术　出处：《第二军医大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究目的对椎弓根皮质骨轨迹螺钉技术(CBT)在国人应用中的安全性评估,进一步明确其应用的可行性,最后研究小切口CBT技术对腰背部肌肉损伤情况,明确该技术的微创价值。建立国人腰椎CBT螺钉固定技术标准,为下一步设计符合国人标准的腰椎CBT螺钉提供科学依据,为我国开展CBT螺钉技术治疗腰椎退变性疾病提供理论基础和技术支撑。研究背景在脊柱外科手术中,椎弓根螺钉固定技术(PS)是治疗各类脊柱疾病的常用固定方法。PS的生物力学强度主要依靠螺钉和松质骨的把持力;骨质疏松患者,螺钉-骨界面强度显著下降,螺钉松动、脱出是骨质疏松患者腰椎术后融合失败最常见的原因。通过延长脊柱固定节段,利用骨水泥增加椎弓根螺钉固定强度等,可以提高骨质疏松患者脊柱内固定稳定性。但是,这些方法存在一些缺点:比如:使用骨水泥时存在高温释放、单体毒性、骨水泥疲劳断裂等问题;延长固定节段则会增加手术费用、手术时间、出血量及增大并发症的发生率。生物力学实验发现垂直植入椎弓根螺钉可获得更坚强的固定效果。在此理论的启发下,Santoni等提出了一种全新的椎弓根螺钉固定技术,即椎弓根皮质骨轨迹螺钉(CBT,Cortical Bone Trajectory)固定技术。钉道方向在矢状面上是从尾部朝向头部,水平面上从内侧朝向外侧。CBT螺钉可与植入点背侧皮质骨、椎弓根后内侧壁、前外侧壁及椎体壁做到四点接触,从而得到更坚强的固定。本研究认为:CBT技术十分适应于罹患腰椎退行性疾病并伴有骨质疏松患者的腰椎内固定手术。研究方法本研究分为三个部分:CBT技术应用于腰椎退变性疾病的安全性研究、可行性研究以及小切口CBT技术的微创价值的研究。第一部分选择长征医院本治疗组2014年1月至2016年10月收治的行手术治疗的腰椎退变性疾病患者36例,采用CBT技术进行固定,观察所有患者在术中和术后是否出现的血管、神经及内脏损伤等并发症,术后通过CT薄层扫描来记录所有椎弓根内外侧壁及椎体前壁穿透皮质骨的螺钉数量,进一步利用计算机软件测量穿透皮质的距离;第二部分分为两组:选择长征医院本治疗组2014年1月至2015年7月经保守治疗无效的骨质疏松腰椎退变性疾病患者30例进行腰椎后路减压植骨融合内固定术手术治疗,18例采用PS技术,12例采用CBT技术,观察两组患者恢复情况、手术时间、术中出血量和手术前后VAS评分、JOA评分及改善率等。第三部分分为两组:A组患者47例,应用传统的椎弓根螺钉固定技术,B组患者36例,应用CBT技术,记录手术时间、术中出血量、术前、术后血清肌酸激酶(CK)水平以及术前、术后VAS评分、ODI评分等。研究结果第一部分研究结果:36例患者共置入168枚CBT螺钉,L1置钉最少,只有2枚,L5置钉数目最多,有78枚。在置钉过程中出现3例共6枚螺钉因CBT螺钉置钉困难后改为传统椎弓根螺钉置钉,出现5例共9枚螺钉因经C型臂X线机透视后发现CBT螺钉位置欠佳而改为传统椎弓根螺钉置钉,所有患者术后均未出现血管、神经、内脏损伤以及感染等并发症。所有36例患者术后均行腰椎CT断层薄层扫描,其中穿透椎弓根外侧壁数目最多,为21枚,最大穿透距离约为5mm;穿透椎弓根前壁13枚,最大穿透距离为约4.6mm;穿透椎弓根内侧壁数目最少,仅3枚,且穿透距离不到2mm。第二部分研究结果:所有30例患者症状均得到改善,术后JOA和VAS评分均有明显提高,两组之间在手术时间、出血量、JOA评分和VAS评分比较差异无统计学意义。第三部分研究结果:本研究中B组患者应用CBT技术,避免了广泛的肌肉剥离、牵拉及软组织切除,其术中出血量明显少于A组患者,可以做到小切口来完成手术各项操作,并且B组患者术后CK水平明显低于A组患者,较A组患者更快的恢复到正常水平,另外B组术后各个随访时间点VAS评分及ODI评分均低于A组。研究结论(1)本课题结合临床病例两两对照分析并评估CBT技术在国人上应用的价值,并且结合前人的研究明确了CBT技术在国人上应用较为安全可靠,针对适应证有良好的可行性,在一定程度上实现微创,有很大的微创价值。(2)本研究第一部分发现:应用CBT技术进行腰椎内固定治疗腰椎退变性疾病置入过程较为安全可靠;(3)本研究第二部分发现:应用CBT技术进行腰椎内固定使患者的损伤小、恢复快;增加了和皮质骨的接触面,牢固性更强等优势,早期疗效满意。(4)本研究第三部分发现:应用CBT螺钉技术进行腰椎内固定,其更靠内的进钉点避免了广泛的肌肉剥离与组织切除,术后患者腰背部肌肉炎症情况较传统椎弓根螺钉小,并且可以做到小切口,创伤小,有一定的微创价值。
[Abstract]:Objective to study the cortical bone screw trajectory Shiumi Ne Technology (CBT) security evaluation in the application, to further clarify the feasibility of its application, the study of small incision CBT on back muscle injury, the technique of minimally invasive value. Establish lumbar CBT screw fixation technique standard, provide scientific basis for lumbar CBT screw in line with the Chinese standards for the design, provide a theoretical basis and technical support for our country to carry out CBT screws in the treatment of lumbar degenerative disease. Background in spinal surgery, Shiumi Ne screw fixation technique (PS) is commonly used in all kinds of biomechanical strength of fixation methods for the treatment of spinal diseases mainly depends on.PS and cancellous screws bone holding force; osteoporosis, bone screw interface strength decreased significantly, screw loosening, prolapse of lumbar osteoporosis patients is the most common cause of failure of fusion Because. By extending the spinal fixation segments, using bone cement to increase the fixation strength of pedicle screws, can improve the patients with osteoporosis spinal stability. However, these methods have some drawbacks such as: the use of bone cement has high temperature release, monomer toxicity, such as fatigue fracture of bone cement fixation segments will extend; increase the operation cost, operation time, bleeding volume and increase the incidence of complications. Biomechanical experiments found vertical pedicle screw fixation effect can get stronger. Inspired by this theory, Santoni proposed a new technique of pedicle screw fixation, the pedicle cortical bone screw (CBT Cortical, Bone locus Trajectory) the direction of screw fixation. In the sagittal plane is from the tail toward the head, horizontal plane from inside toward the outer.CBT screw can be implanted with dorsal skin pedicle bone. After the medial wall, lateral wall and posterior vertebral wall do four point contact, in order to get a strong fixation. This study suggests that CBT technology is very suitable for suffering from lumbar degenerative disease of lumbar spine and osteoporosis bone internal fixation surgery. This study is divided into three parts: the research on the application of CBT technology in safety lumbar degenerative diseases, the research value of minimally invasive incision CBT feasibility study and technology. The first part of the selection of 36 patients with lumbar degenerative disease underwent surgical treatment in the treatment group Changzheng Hospital from January 2014 to October 2016 were selected and were fixed by CBT technology, were observed in all the patients is in the intraoperative and postoperative blood vessels, nerves and internal organs injury and other complications, postoperative CT by TLC scanning to record all pedicle screws and lateral wall and anterior wall penetrating cortical bone volume, the further use of computer Software measurement through the cortex distance; the second part is divided into two groups: the treatment group of Changzheng Hospital from January 2014 to 2015 7 menstrual conservative treatment of osteoporotic lumbar degenerative disease of invalid 30 cases of lumbar posterior decompression and bone graft fusion and internal fixation surgery, 18 cases of 12 cases by using PS technology, CBT technology, observation of two the recovery of patients, operation time, intraoperative bleeding volume and VAS score before and after surgery, JOA score and recovery rate. The third part is divided into two groups: 47 cases of A patients, the technique of pedicle screw fixation with traditional, 36 cases of B patients, the application of CBT technology, recording the operation time, bleeding volume, operation in the preoperative, postoperative serum creatine kinase (CK) and the level of preoperative, postoperative VAS score, ODI score. The results of the first part of the study results: 36 patients were implanted with 168 CBT screws, L1 screws at least, only 2 L5, the largest number of screws, 78. 3 cases of a total of 6 screws for CBT screw placement difficulties changed after traditional pedicle screw placement in the placement process, the appearance of 5 cases of a total of 9 screws for the C arm X-ray fluoroscopy and found CBT poor location instead of traditional screw placement of pedicle screws, all patients there was no nerve, vascular, visceral injury and complications such as infection. All 36 patients underwent lumbar CT fault scanning, which penetrate the outer wall of the pedicle number most, for 21 pieces, the maximum penetration distance is about 5mm; penetrating anterior pedicle in 13 cases, the maximum penetration distance is about 4.6mm; the number of penetration the medial wall of pedicle at least, only 3, and the penetration distance less than 2mm. second part of the research results: all 30 patients symptoms were improved, postoperative JOA and VAS scores were significantly improved, between the two groups in the operation time, bleeding volume, JOA score and VAS score were not The third part studies the statistical significance. Results: in this study, B group of patients with CBT technology, to avoid extensive muscle stripping, traction and soft tissue resection, the intraoperative blood loss was significantly less than that in A group can do small incision to complete the operation of the operation, and the patients of the B group CK level was significantly lower than that of A a group of patients, A patients quickly returned to normal levels, in addition to B group after each follow-up time point, VAS score and ODI score were lower than A group. Conclusions (1) the subject with clinical cases in 22 control analysis and evaluation of CBT technology should be used in people's value, and combined with previous research the CBT technology in the application of a more secure and reliable, the indications have good feasibility, implementation of minimally invasive to a certain extent, a minimally invasive value. (2) the first part of this study found that: the application of CBT in lumbar internal fixation In the process of lumbar degenerative disease is safe and reliable; (3) the second part of this study found that: the application of CBT in lumbar fixation so that patients with little injury, quick recovery; increase the contact surface and the cortical bone, more strong advantage, the early curative effect. (4) the third part of this study found that the application of CBT the lumbar internal fixation screw technique, the farther into the point of nail to avoid muscle dissection and organization wide resection, patients with small waist back muscle inflammation compared with conventional pedicle screw after operation, and it can make the small incision, less trauma, minimally invasive has certain value.

【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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