基于3D-CT数字化中国人下颈椎后方骨性结构形态学研究

发布时间：2018-05-15 21:21

本文选题：中国人 + 下颈椎　；参考：《吉林大学》2015年博士论文

【摘要】：背景：椎弓根螺钉、侧块螺钉及椎板螺钉越来越多被应用于治疗各种颈椎疾患。本研究的目的旨在明确中国人下颈椎后方骨性结构的形态学特征，为设计适合国人下颈椎后方骨性结构特点的内固定器械研发及内固定置入技术提供理论依据。各种各样颈椎后路内固定物的发明及应用，使脊柱外科医生可以通过单一颈椎后路术式即可同时达到恢复颈椎正常解剖序列和稳定固定的目的，尤其对于下颈椎（C3-7）而言更是如此。目前，在脊柱外科临床工作中，应用最为广泛的颈椎后路固定器械仍是椎弓根螺钉。颈椎椎弓根在满足三柱坚强固定的同时，也表现出很多潜在的风险及并发症，同时由于颈椎解剖结构的特殊性以及颈脊髓的极其重要性及易损性，颈椎椎弓根螺钉的临床使用受到了一定程度地限制。因此，椎板螺钉、侧块螺钉等颈椎后路内固定器械越来越多应用于治疗各种颈椎疾病。然而，这些内固定器械及其相关置入技术均伴随着相应的神经、血管损伤的风险。众所周知，对于颈椎后路固定器械而言，内植物的设计合理与否以及如何安全置入均与颈椎后方骨性结构的解剖形态学特点密切相关，那么获得这些关键解剖结构的详细形态学数据就是内植物合理设计及安全置入的先决条件。有关颈椎形态学的研究已有很多，通过回顾这些研究，我们发现，在不同种族之间，这些形态学数据是存在差异的。而对于在狭小空间内进行精细操作的脊柱外科医生而言，这些差异已足以引起我们的重视。很遗憾，到目前为止，尚未见以指导颈椎后路内固定器械研发而进行的针对国人颈椎后方骨性结构形态学研究。如对于椎板螺钉设计及置入均极其重要的椎板松质骨腔径线的测量，及对于国人而言不同颈椎节段是否应该采用不同的侧块螺钉技术，均未见相关研究报道。所以我的研究旨在对国人下颈椎后方骨性结构进行形态学研究，为相应内固定器械的设计和研发及内固定技术的选择提供理论依据。薄层CT扫描及3D影像技术的快速发展为下颈椎的精细化形态学研究提供了足够的技术支持。本研究即以256层极速CT扫描所得的下颈椎薄扫影像为基础，对国人下颈椎后方骨性结构进行形态学研究。其中对国人进行椎板峡部内径（椎板松质骨腔内径）、椎管骨性面积测量均属首次。方法：本研究选取100名成年患者进行256排薄层颈椎CT扫描（层厚0.5mm），进行3D重建及数字化处理后可以任意选择各角度平面进行测量。共测量、共计测量分析1000个轴位层面、500个冠状面层面、2000个矢状面层面，合计分析3500个CT重建层面。测量了以下21个下颈椎形态学数据：1、椎弓根数据：椎弓根外径（POW）、椎弓根内径（PIW）、椎弓根外高度（POH），椎弓根内高度（PIH）、椎弓根轴长（PAL）、椎弓根外侧角（PTA）；2、侧块数据：侧块纵径（LMLD），侧块横径（LMTD），侧块冠状面高度（LMCH），上关节突矢状面成角（SAPA）；3、椎板外径（LOW），椎板内径（LIW），椎板外高（LOW），椎板内高（LIW），椎板轴长（LAL），椎板横向外倾角（LTA）；4、棘突数据：轴位棘突长度（ASPL），矢状面棘突长度（SSPL）；5、椎管数据：椎管纵径（SCLD），椎管横径（SCTD），骨性椎管面积（OSCA）；6、Pavlov比值。将这100名患者按性别及是否存在发育性颈椎管狭窄症（以Pavlov比值小于等于0.75为存在发育性颈椎管狭窄症）进行分组。结果：1、各下颈椎节段间比较，除椎板横向外倾角（LTA）及椎管骨性面积（OSCA）两个参数外，其余所有参数的差异均有统计学意义（P0.05）；2、椎弓根内径（PIW）、椎弓根外径（POW）、椎弓根内高（POH）、椎弓根外高（PIH）最大值均出现在C7，最小值出现在C3、C4（P0.05）；3、椎板内径（LIW）、椎板外径（LOW）、椎板内高（LIH）、椎板外高（LOH）的最小值均出现在C5，最大值出现在C7（P0.05）。4、C5,C6的侧块矢状径（LMLD）最大，LMLD及LMCH最小值均出现于C7（P0.05）；5、左右侧对称性参数比较发现，除椎板横向外倾角（LTA）外，其余所参数差异均有统计学意义（P0.05）；6、男性与女性组参数比较，椎弓根横向外倾角（PTA）在各节段差异均无统计学意义（P0.05），上关节突矢状面成角（SAPA）在除C4、5两节段外，在余各节段上差异均无统计学意义（P0.05），椎板横向外倾角（LTA）在除C3、6两节段外，在余各节段上差异无统计学意义（P0.05），椎管纵径（SCLD）在除C7节段外，在余各节段上差异均无统计学意义（P0.05），其余各参数差异均有统计学意义：男性在所有线性参数上均大于女性（P0.05），但男性椎板外倾角小于女性（P0.05）；7、发育性颈椎管狭窄症患者（DCS）与非发育性颈椎管狭窄症（NDCS）组相比，椎板外高（LOH）在节段差异均有统计学意义（P0.05），NDCS组大于DCS组；椎管纵径（SCLD）在除C7外各节段上差异均有统计学意义（P0.05），，NDCS组大于DCS组；椎板横向外倾角（LTA）在C4、C6、C7节段上差异有统计学意义，NDCS组大于DCS组；椎管骨性面积上（OSCA）仅在C3节段差异有统计学意义；结论：1、多个下颈椎后方骨性结构形态学参数在左右侧、男女性别间、及发育性椎管狭窄症患者与无发育性椎管狭窄症患者间存在显著性差异；2、在下颈椎不同节段，由于侧块矢状径的差异，应采用不同的侧块螺钉置入技术，在C3，C4，C7节段，尤其C7，我们推荐选用Magerl技术而非Roy-Camille；3、C5不适宜应用椎板螺钉固定，仅C7椎板可以安全容纳直径为2.5mm椎板螺钉。4、推荐下颈椎椎板螺钉置入角度为55°，长度应小于30mm；5、推荐下颈椎椎弓根螺钉置入角度为40°，长度应小于32mm；本研究结果为针对国人进行下颈椎后路内固定器械的研发及安全置入提供理论依据。
[Abstract]:Background: pedicle screws, lateral mass screws, and laminar screws are increasingly used in the treatment of various cervical disorders. The purpose of this study is to clarify the morphological features of the skeletal structure in the rear of the lower cervical spine of the Chinese people, and to provide a method for the design of internal fixation instruments and internal fixation techniques suitable for the bone structure characteristics of the lower cervical spine. The invention and application of all kinds of posterior cervical fixation can enable spine surgeons to restore the normal anatomical sequence and stable fixation of the cervical spine by a single cervical posterior approach, especially for the lower cervical spine (C3-7). Currently, the most widely used in the clinical work of the spine surgery is the most widely used. The cervical pedicle screw is still a pedicle screw. The cervical pedicle also shows a lot of potential risks and complications while the three columns are strong and fixed. At the same time, the clinical use of the cervical vertebral arch root screw is limited to a certain extent due to the particularity of the anatomical structure of the cervical spine and the importance and vulnerability of the cervical spinal cord. Therefore, more and more cervical posterior internal fixation instruments such as laminar screw and lateral mass screw are used to treat various cervical spondylosis. However, these internal fixation instruments and their related implantation techniques are associated with the risk of corresponding nerve and vascular damage. It is well known that the design of the internal plants is reasonable for the posterior cervical fixation apparatus. And how to safely implantation is closely related to the anatomic characteristics of the posterior cervical bone structure. Then the detailed morphological data of these key anatomical structures are the prerequisites for the rational design of the internal plants and the precondition for safe placement. There are many studies on the morphology of the cervical vertebrae. Among the ethnic groups, these morphological data are different, and these differences have been enough to cause our attention to the spinal surgeons operating in a narrow space. It is regrettable that the skeletal structure of the posterior cervical spine has not been seen to guide the research and development of the posterior cervical instrumentation. Study. Such as the measurement of vertebral lamina screw design and placement which are extremely important, and whether different lateral block screws should be used in different cervical segments for Chinese people, no related research is reported. Therefore, my study aims to study the morphology of the skeletal structure behind the lower cervical vertebrae in Chinese. It provides a theoretical basis for the design and development of internal fixator and the selection of internal fixation technology.
The rapid development of thin layer CT scan and 3D imaging technology provides sufficient technical support for the study of the fine morphology of the lower cervical spine. This study is based on the thin scan of the lower cervical spine of 256 layers of rapid CT scanning. The measurement of the osseous area of the vertebral canal is the first time.
Methods: 100 adult patients were selected for 256 rows of thin layer cervical CT scans (layer thickness 0.5mm). After 3D reconstruction and digital processing, we can choose the plane of each angle at random. A total of 1000 axial planes, 500 coronal planes, 2000 sagittal planes and 3500 CT reconstruction levels were measured. The following 21 lower cervical morphological data were measured: 1, Shiumi Ne data: Shiumi Ne's external diameter (POW), Shiumi Ne internal diameter (PIW), external height (POH), Shiumi Ne inner height (PIH), Shiumi Ne axis length (PAL), Shiumi Ne's lateral angle (PTA); 2, side block longitudinal diameter (LMLD), lateral block transverse diameter (LMTD), lateral block coronary height (LMCH), upper joint sagittal 3, 3, outer diameter of vertebral lamina (LOW), internal diameter of laminae (LIW), high (LOW), high intraspinal (LIW), long (LAL) vertebral plate axis (LAL), lateral obliquity of vertebral lamina (LTA); 4, spine process length (ASPL), length of sagittal spinous process (SSPL); 5, vertebral canal longitudinal diameter (SCLD), vertebral canal transverse diameter (SCTD), osseous spinal canal area (OSCA); 6, dialectical Avlov ratio. The 100 patients were grouped by sex and the existence of developmental cervical spinal stenosis (with a Pavlov ratio less than or equal to 0.75 in the presence of developmental cervical spinal stenosis).
Results: 1, in the comparison of the lower cervical vertebra segments, except the two parameters of the lateral obliquity (LTA) and the vertebral canal bone area (OSCA), the differences of all the other parameters were statistically significant (P0.05); 2, Shiumi Ne internal diameter (PIW), Shiumi Ne's outer diameter (POW), Shiumi Ne inner height (POH), and the maximum of Shiumi Ne height (PIH) all appeared in C7, and the minimum value appeared in C3, C4 (P0.05); 3, the inner diameter of the laminae (LIW), the outer diameter of the vertebral lamina (LOW), the height of the laminae (LIH), the minimum of the outer laminae (LOH) were all in C5, the maximum value appeared in C7 (P0.05).4, C5, the largest of the lateral mass of C6, and the minimum value of the lateral mass of C6. The lateral symmetry parameters of the left and right sides found, except the lateral obliquity of the laminae, it was found. The difference of the remaining parameters was statistically significant (P0.05). 6, there was no significant difference in the transverse obliquity of the pedicle (PTA) between the male and the female group (P0.05), and the sagittal angle (SAPA) of the upper joints (SAPA) had no statistical significance (P0.05) in the remaining segments except the C4,5 segment (P0.05), and the lateral obliquity of the vertebral lamina (LTA) was not significant. There was no statistical significance (P0.05) on the remaining segments outside the C3,6 section. There was no statistical significance (P0.05) on the spinal canal longitudinal diameter (SCLD) except for the C7 segment (P0.05). The differences in the rest of the parameters were statistically significant: men were larger than women in all linear parameters (P0.05), but the obliquity of the vertebral lamina was less than that of women (P0.05). 7, compared with the non developmental cervical canal stenosis (NDCS) group, the difference of the extra laminar height (LOH) in the segment was statistically significant (P0.05) and the NDCS group was larger than the DCS group, and the longitudinal diameter of the spinal canal (SCLD) was statistically significant (P0.05) in each segment except C7 (P0.05), and the NDCS group was larger than the DCS group; the lateral obliquity of the vertebral lamina (LTA) was larger than that of the C7. In C4, C6, C7, the difference was statistically significant, NDCS group was larger than DCS group, and the vertebral canal osseous area (OSCA) was only statistically significant in C3 segment.
Conclusions: 1, there are significant differences between the left and right morphological parameters of the bone structure in the left and right side of the lower cervical spine, sex between men and women, and the patients with developmental spinal stenosis and non developmental spinal stenosis. 2, different lateral mass screws should be used in the different segments of the lower cervical spine because of the difference in the lateral mass sagittal diameter, in C3, C4, and C7 sections. Segment, especially C7, we recommend Magerl technology instead of Roy-Camille; 3, C5 is not suitable for pedicle screw fixation. Only C7 vertebral plate can safely accommodate the diameter of 2.5mm laminectomy screw.4. It is recommended that the angle of the lower cervical laminectomy screw is 55 degrees, the length should be less than 30mm; 5, the angle of the lower cervical pedicle screw is 40 degrees, and the length should be less than 32mm. This study provides a theoretical basis for the development and safe placement of posterior cervical internal fixation devices for Chinese.

【学位授予单位】：吉林大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R687.3

【共引文献】