颅颈交界畸形后路钉棒固定徒手置钉及术中CT导航下置钉的优缺点（附26病例）

发布时间：2018-05-27 13:33

本文选题：术中CT导航 + 徒手置钉　；参考：《大连医科大学》2015年硕士论文

【摘要】：目的:通过对比分析颅颈交界畸形(Craniovertebral Junction Malformation)患者术后影像学改变及有螺钉穿出皮质数量及并发症,探讨分析枢椎徒手椎弓根螺钉固定技术与术中CT导航下颅颈交界区畸形后路钉棒固定手术中的优缺点。资料与方法:本研究患者为沈阳军区总医院神经外科2011年10月-2015年2月收治颅颈交界畸形患者26例,其中男性8例,女性18例。年龄24~68岁,平均46.5岁,病程4个月~60年,平均5.6年。单纯颅底凹陷9例,伴小脑扁桃体下疝者13例,寰枢椎侧块脱位者4例,伴脊髓空洞症7例,临床表现:颈短伴偏斜、发迹偏低2例;颈枕肩部持续性疼痛18例,喉返神经受损症状3例。其14例出现感觉分离和骨骼肌萎缩等症状;23例表现为共济失调,眼球震颤、Romberg征阳性。将患者随机分为A、B两组,均采用术背侧减压手术,A组男3例,女10例,年龄24~59岁(36.3±7.1岁),B组男5例,女8例,年龄24~68岁(31.5±10.6),其中A组行徒手经验螺钉固定,B组采用术中CT联合神经导航下确定螺钉进钉点及固定入路。A组徒手根据术前普通CT检查确定进钉位置及角度后手锥钻取进钉入路,探针植入,B组在CT导航下直接固定钉棒。应用术中CT扫描进一步验证椎弓根螺钉位置,无螺钉穿出皮质结束螺钉植入。A组根据术中CT结果,将所检测到钉棒穿透骨皮质、压迫脊髓、神经、椎动脉的钉棒重新调整,再次行CT导航满意后固定结束。结果:术后22例(84.6%)患者Nurick分级症状至少改善l级以上,2例(7.7%)患者症状无明显改善,2例(7.7%)患者失访。所有病例术中均未发生椎动脉及神经功能损上,A组平均手术时间为146min,出血量平均为194ml,B组平均手术时间为187min,出血量平均为214ml。所有患者术程顺利,术中均未输血。术后A组有5例出现并发症:硬脊膜破损致脑脊液切口漏1例,切口感染1例,切口脂肪液化1例,肺部感染2例,给予对症处理后均恢复良好,B组有1例出现肺部感染并发症,给予对症治疗后症状好转。术后三月门诊复查19例,电话随访5例,失访2例。术后3月门诊复查均未见螺钉松动,所有随访患者症状明显缓解。结论:1.术中CT可准确评价寰枢关节复位情况和植入螺钉的轨迹、植入深度及是否穿出皮质情况,避免了患者二次手术的风险;对于提高手术定位准确性、手术路径及提高手术成功率和有效率等具有重要意义。但术中患者辐射暴露时间相对较长,且手术费用相对较高。2.徒手植钉对技术要求高,需扎实的专业知识及影像学定位技能。虽患者手术时间、放射线暴露时间短,但穿透皮质的风险较术中CT导航明显偏高。
[Abstract]:Objective: to compare and analyze the postoperative imaging changes, the number of cortical perforations with screws and complications in patients with craniocervical junction malformation (Crani overtebral Junction malformation). Objective: to analyze the advantages and disadvantages of pedicle screw fixation technique and posterior screw fixation of craniocervical junction malformation under CT guidance. Materials and methods: a total of 26 patients with craniocervical junction malformation were admitted to the Department of Neurosurgery, Shenyang military region General Hospital from October 2011 to February 2015, including 8 males and 18 females. The average age was 46.5 years. The course of disease ranged from 4 months to 60 years with an average of 5.6 years. There were 9 cases of simple skull base depression, 13 cases of subtonsillar hernia, 4 cases of atlantoaxial lateral mass dislocation and 7 cases of syringomyelia. There were 3 cases of recurrent laryngeal nerve injury. The symptoms of sensory separation and skeletal muscle atrophy in 14 cases were ataxia and nystagmus Romberg sign positive. The patients were randomly divided into two groups: group A (n = 3) and group A (n = 10), group A (n = 5) and group B (n = 8), aged 24 to 59 years (n = 36.3 卤7.1), group B (n = 8). The age of group A was 31.5 卤10.6 years old. Group A was treated with manual experience screw fixation and group B was treated with intraoperative CT combined with neuronavigation to determine the point of screw entry and fixation approach. Group A was performed to determine the position and angle of the screw entry and the posterior hand cone drilling approach according to the conventional CT examination before operation. The probe was implanted into group B and fixed directly under CT guidance. The position of pedicle screw was further verified by intraoperative CT scan. According to the results of CT during operation, the screw rod was detected to penetrate the cortex of bone, compress the spinal cord, nerve and vertebral artery, and adjust the screw rod in group A according to the results of CT during the operation. Ct navigation was performed again after satisfactory fixation. Results: 22 cases (84.6%) with Nurick grade symptoms improved at least 2 cases (7. 7%) there were no significant improvement in 2 cases (7. 7%). The mean operative time was 146min in group A, 18.7 min in group B, and 214ml in group B. All patients had a smooth procedure and no blood transfusion was performed during the operation. In group A, complications were found in 5 cases: cerebrospinal fluid incision leakage (1 case), incision infection (1 case), incision fat liquefaction (1 case), pulmonary infection (2 cases). One patient in group B had pulmonary infection complications after symptomatic treatment, and the symptoms were improved after treatment. Three months after operation, 19 cases were checked out by telephone, 5 cases were followed up by telephone, 2 cases were lost. No screw loosening was found in the outpatient examination 3 months after operation, and the symptoms of all the patients were obviously relieved. Conclusion 1. Ct can accurately evaluate the reduction of atlantoaxial joint and the track of screw implantation, the depth of implantation and whether the cortex is perforated, thus avoiding the risk of secondary operation. It is of great significance to improve the successful rate and effective rate of operation. However, the duration of radiation exposure was relatively long and the operation cost was relatively high. 2. 2. High technical requirements, solid professional knowledge and imaging positioning skills are required. Although the operative time and radiation exposure time were shorter, the risk of penetrating cortex was significantly higher than that of CT navigation.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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