保留后方韧带复合体对腰椎后路手术影响的生物力学分析及临床疗效观察

发布时间：2018-01-24 17:26

本文关键词： 后方韧带复合体有限元椎弓根螺钉生物力学后方韧带复合体腰椎融合术椎板切除邻近节段退变导航　出处：《广西医科大学》2016年硕士论文　论文类型：学位论文

【摘要】：腰椎退行性疾病行后路融合术已成为目前常用手术治疗方式。充分的椎管减压及椎间融合内固定是解除疼痛并重建脊柱稳定性的有效方法。常规腰椎后路椎间融合术采用全椎板切除椎管扩大,取得了良好的早期治疗效果。但是长期随访资料表明：后路全椎板切除对脊柱远期稳定性会产生影响,造成失稳；邻近节段退变已成为后路腰椎融合术后主要并发症之一。椎管减压方式的选择是其重要原因。传统的全椎板切除方式将后方韧带复合体(Posterior Ligament Complex,PLC)结构一并切除,直接影响脊柱后方的稳定,而邻近节段退变加速亦可产生相应临床症状,部分患者必须选择再次手术。PLC结构以其张力带力学特性成为维持脊柱后柱稳定的重要结构。保留PLC的腰椎融合术中不仅需要实施有效的椎管减压,而且需通过融合器及椎弓根钉维持脊柱运动中多轴向的稳定,最终提高手术疗效并减少术后并发症。后路腰椎融合术中随着椎间融合器及椎弓根钉的广泛使用,相关并发症报道也逐渐增多。研究表明内植物的初始稳定性至关重要,而这将直接影响植骨融合的进程。导航引导下椎弓根钉植入在置钉的准确性方面已得到充分的证实。借助导航可实现融合器的精准置入以提高其初始稳定,进而维持脊柱的整体稳定。总之只有通过生物力学持续研究才能对PLC结构力学特性做到准确认识。国内外生物力学研究过程中,有限元分析法以其传统方法无法比拟的优势并成为人体生物力学研究系统中重要组成部分。本文正是对PLC结构的生物力学特性展开研究并结合相关手术方式临床疗效观察,进一步分析验证实验结果。最终为临床治疗提供生物力学依据。基于此目的分以下两部分进行研究。第一部分保留后方韧带复合体对腰椎后路手术影响的有限元分析目的：构建脊柱腰椎L1-L3三维有限元模型,运用三维有限元方法分析后方韧带复合体缺失的全椎板切除术及双侧椎弓根螺钉置入后脊柱稳定性变化和应力分布情况。方法：采集1例成年健康男性志愿者L1-L3 CT数据,应用Mimics14.11、 3-matic(V6.0)、Ansys 15.0等软件构建L1-L3有限元模型。后方韧带复合体完整有限元模型(A组)、后方韧带复合体缺失的全椎板切除模型(B组)、后方韧带复合体缺失的全椎板切除后双侧单节段椎弓根螺钉内固定系统模型(C组)。模拟腰椎行前屈、后伸、侧弯及旋转,分别对3个模型进行有限元力学分析。结果：①根据不同运动状态下的ROM均值比较,B组ROM均值大于A组、C组(P0.05),C组ROM均值小于B组(P0.05)。②根据不同运动状态下的VonMises最大应力比较可知,B组最大应力大于A组(P0.05),C组最大应力大于B组(P0.05)。最大应力提示椎板切除后椎体局部受力增加,尤以相邻椎板、椎弓根及关节处增加明显。结论：①后方韧带复合体结构对维持脊柱稳定性起到重要作用,切除后方韧带复合体结构可使椎体间活动范围加大,影响椎体稳定性。②后方韧带复合体缺失下使用内固定物,活动范围减小,节段内椎体稳定性增加,但脊柱后方应力重新分布。固定相邻节段应力增加,可加速退变。③过大的应力集中会增加内固定失败风险。第二部分保留后方韧带复合体在手术治疗腰椎退行性疾病中的回顾性对照研究目的：比较保留后方韧带复合体的改良椎板切除减压术、保留后方韧带复合体的改良椎板切除减压术导航辅助内固定与传统全椎板切除减压治疗腰椎退行性疾病的近期、远期疗效。方法：回顾性对照分析2013年1月至2015年1月通过腰椎后路减压融合内固定术治疗腰椎退行性疾病98例,按手术方式分为后方韧带复合体缺失的全椎板减压组(A组)、保留后方韧带复合体改良椎板减压组(B组)、保留后方韧带复合体改良椎板减压导航辅助内固定组(C组)。分别记录三组手术时间、术中出血量和住院时间；术后随访采用ODI及VAS评分系统评价术后疗效；通过术前术后影像学资料测量椎间隙角度变化、融合器深度偏差、融合器轴线偏差,同时评价植骨融合程度及椎弓根螺钉准确率。结果：三组的手术时间和住院天数均无明显差异,但A组的手术出血量明显大于B组、C组,差异有统计学意义(P0.05)。术后三组ODI及VAS评分均较术前明显下降,差异有统计学意义(P0.05),三组间ODI及VAS评分无明显差异。A组末次随访邻近椎间隙角度丢失较B组、C组明显(P0.05),C组在融合器植入深度及位置方面优于A组、B组(P0.05),三组在融合率及椎弓根钉准确率方面三组差异无统计学意义(P0.05)。结论：①后方韧带复合体是脊柱后柱重要结构,破坏其结构完整可造成融合邻近节段加速退变②有效的椎管减压均能获得满意的早期疗效③导航下可实现内植物的精准置入,为一种理想引导模式。
[Abstract]:Degenerative disease of lumbar posterior arthrodesis has become the most commonly used surgical treatment. The spinal canal decompression and intervertebral fusion sufficient internal fixation is an effective method to relieve the pain and the reconstruction of spinal stability. Conventional posterior lumbar interbody fusion with laminectomy and spinal canal, early achieved good therapeutic effect. But the long-term follow-up data show that the posterior laminectomy resection will affect the long-term stability of the spine, resulting in instability; adjacent segment degeneration has become one of the major complications of posterior lumbar interbody fusion after decompression. The choice is an important reason. The traditional laminectomy to the posterior ligamentous complex (Posterior Ligament, Complex, PLC) structure resection directly affects the posterior stability however, accelerated degeneration of the adjacent segments can generate the corresponding clinical symptoms, some patients must choose surgery again.PLC The mechanical properties of tension band structure to become an important structure to maintain the stability of the spinal column. Keep PLC lumbar fusion not only need to implement effective decompression of the spinal canal, and through the fusion and pedicle screw to maintain spinal movement in multi axial stability, and ultimately improve the surgical effect and reduce postoperative complications. Posterior lumbar interbody fusion with the widespread use of interbody fusion and pedicle screw, complications reported is gradually increasing. The initial stability study showed that vital plant, which will directly affect the fusion process. Guided implantation of pedicle screw has been fully confirmed in the accuracy of screw placement. With the help of navigation can realize the precise placement of the cages in order to improve the initial stability, and maintain the overall stability of the spine. In conclusion only through continuous research on biomechanical structure mechanical properties of PLC to do To accurately understand the biomechanical research at home and abroad. In the process, the finite element analysis method with the traditional method of incomparable advantages and become an important part of the human body biomechanics research system. This paper is the biomechanical characteristics of PLC structure research and observe the clinical curative effect of combined operation mode, further analysis of experimental results. The final provide biomechanics the basis for clinical treatment. This is divided into two parts. The first part is studied based on the retention of the posterior ligamentous complex of posterior lumbar surgery effect of finite element analysis objective: to construct a three-dimensional finite element model of the lumbar spine L1-L3, using three-dimensional finite element method in stability analysis of spinal posterior ligament complex missing laminectomy and bilateral pedicle screw implantation and the distribution of stress. Methods: collected 1 cases of healthy adult male volunteers L1-L3 CT Data, application of Mimics14.11, 3-matic (V6.0), L1-L3 finite element model was established with Ansys 15 software. The finite element model of complete posterior ligament complex (A group), laminectomy model posterior ligament complex deletion (B group), model of fixed system posterior ligament loss after total laminectomy and bilateral single segmental pedicle screw in (group C). The simulation for lumbar flexion, extension, lateral bending and rotation of the finite element mechanics analysis of the 3 models. Results: 1. According to the different state of motion ROM mean comparison, B group mean ROM than in the A group, C group, C group (P0.05) ROM means less than B group (P0.05). According to the different state of motion of VonMises maximum stress compared with B group, the maximum stress is higher than that of group A (P0.05) C group, the maximum stress is higher than that of group B (P0.05). The maximum stress that after laminectomy vertebral local stress increase, especially in the adjacent lamina, pedicle and joint at Conclusion: the increased significantly. The posterior ligamentous complex structure plays an important role in maintaining the stability of the spine, resection of the posterior ligamentous complex structure can make the intervertebral activities to increase the scope of influence the stability of the vertebral body. Use in the fixation of posterior ligamentous complex loss, reduced its range, increase in segment posterior vertebral stability, but the redistribution of stress fixed. Adjacent segment stress increases, can accelerate the degeneration. The excessive stress concentration will increase the risk of failure of internal fixation. The second part to retain the posterior ligamentous complex in the surgical treatment of the control objective to study lumbar degenerative disease: a comparison of the modified posterior ligamentous complex lamina resection decompression, laminectomy and posterior ligament sparing modified complex navigation assisted resection decompression fixation with traditional laminectomy decompression in the treatment of lumbar degenerative disease recently, long-term Efficacy. Methods: a retrospective analysis from January 2013 to January 2015 through the control of lumbar posterior decompression and fusion with internal fixation in the treatment of lumbar degenerative disease in 98 cases, according to the operation mode is divided into the posterior ligamentous complex deletion laminectomy group (A group), retention of the posterior ligamentous complex modified laminectomy group (B group), retention of the posterior ligamentous complex improvement laminectomy navigation assisted internal fixation group (C group). Three groups were recorded the operation time, bleeding volume and hospitalization time; the postoperative curative effect of ODI and VAS scoring system to evaluate the postoperative follow-up by; through changes in preoperative imaging data after measuring the intervertebral angle, fusion depth deviation, fusion axis deviation at the same time, bone fusion and pedicle screw accuracy. Results: the operation time of the three groups and hospitalization days were not significantly different, but A group blood loss was significantly higher than that of B group, C group, difference There was statistical significance (P0.05). After the operation of three groups of ODI and VAS were decreased significantly, there were statistically significant differences between the three groups (P0.05), ODI and VAS were no significant differences in the.A group at the end of the follow-up of adjacent intervertebral angle loss compared with B group, C group, C group significantly (P0.05) in cage insertion depth and position is better than that of A group, B group (P0.05), the three groups in the rate of fusion and pedicle screw accuracy rate had no significant difference between the three groups (P0.05). Conclusion: the posterior ligament complex is the posterior column structure, destroying the structure of integrity can be caused by fusion of adjacent segment degeneration. Effective decompression can obtain satisfactory curative effect of the early navigation system can realize the precise placement within the plant, as an ideal guide mode.

【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R687.3

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