多中心CT评估腰骶段后路椎弓根置钉的准确性研究

发布时间：2018-06-21 23:58

  本文选题：下腰椎 + 骶骨　； 参考：《浙江大学》2017年硕士论文

【摘要】：目的:多中心研究统计分析第3腰椎(L3),第4腰椎(L4),第5腰椎(L5)及第1骶椎(S1)的后路椎弓根置钉准确性,并分析造成椎弓根穿透的原因。方法:回顾性分析2014年1月至2014年12月符合纳入及排除标准、接受腰骶椎后路椎弓根钉-棒系统固定手术的患者共401例,其中包括152节L3椎体,219节L4椎体,270节L5椎体及95节S1椎体。术后24-48小时内对所有患者均进行腰骶椎CT平扫及重建,2名专业人员评估L3,L4,L5及S1椎弓根螺钉在椎弓根区域的位置。对于穿透椎弓根的螺钉,记录其穿透位置与程度,详细统计螺钉在腰骶椎各节段的穿透情况,分析椎弓根穿透的相关因素。对三所医院间以及不同脊柱疾病间椎弓根螺钉穿透率差异进行统计分析。对所有病人均进行术后临床症状的随访观察,记录所有可能因椎弓根螺钉穿透而导致的并发症。结果:401例患者共置入椎弓根螺钉1467枚,其中穿透椎弓根侧壁的螺钉371枚。L3 节段穿透率为 30.2%(91/301),L4节段为 28.9%(126/436),L5 节段为 24.5%(132/539),S1节段为11.5%(22/191)。椎弓根螺钉在L3,L4和L5节段穿透率的差异无统计学意义,但均高于S1节段,差异均有统计学意义。椎弓根穿透位置统计结果显示,L3节段内下缘穿透率为47.3%(43/91),L4节段为58.7%(74/126),L5 节段为 75%(99/132),S1节段为 86.4%(19/22)。与 L3,L4节段相比,L5和S1椎弓根螺钉穿透更集中于椎弓根内下缘。穿透严重程度统计结果显示,L3节段高危穿透率(Ⅲ级Ⅳ级)为8.8%(8/91),L4节段为6.3%(8/126),L5节段为14.4%(19/132),S1节段为36.4%(8/22);L5 S 节段达到严重破损的比例均明显高于L3,L4节段。三所医院间穿透率的差异有统计学意义,而各医院椎弓根螺钉穿透节段、穿透程度以及穿透位置的特点与总体结果趋于一致。椎间盘突出症,椎体滑移和椎管狭窄组的椎弓根穿透率均高于椎体骨折组,而不同组别间穿透程度以及穿透位置的特点与总体结果一致,且相互间无显著差异。在椎弓根穿透的病例中9例发生脑脊液漏,3例神经损伤表现。所有发生并发症的患者均未进行翻修手术,采取保守治疗后临床症状有效缓解。结论:L5椎弓根与L3,L4具有同样的高穿透率。在穿透事件中,L5,S1椎弓根达到高危穿透的比例更高,且更多地集中于椎弓根内下缘,这与椎弓根的解剖形态密切相关。此外,低级别医院以及退变性疾病中发生椎弓根钉穿透的比例及相关并发症更高。椎弓根穿透引起相关并发症并不多见,但仍应引起重视。
[Abstract]:Objective: to analyze the accuracy of posterior pedicle screw insertion in the third lumbar vertebra (L3), the 4th lumbar vertebrae (L4), the 5th lumbar vertebra (L5) and the first sacral vertebra (S1), and to analyze the causes of pedicle penetration. Methods: from January 2014 to December 2014, 401 cases of lumbar and sacral posterior pedicle screw fixation were retrospectively analyzed. These include 152 L3, 219 L4, 270 L5 and 95 S1 vertebrae. All patients underwent lumbar and sacral CT plain scan and reconstruction within 24 to 48 hours after operation. Two professionals evaluated the position of L3L4, L5 and S1 pedicle screws in the pedicle area. For the screws penetrating the pedicle, the penetrating position and degree were recorded, the penetration of screws in each segment of lumbosacral vertebrae was analyzed in detail, and the related factors of pedicle penetration were analyzed. The differences of pedicle screw penetration rate among three hospitals and different spinal diseases were analyzed statistically. All patients were followed up to record all possible complications caused by pedicle screw penetration. Results 1467 pedicle screws were inserted into the lateral wall of pedicle of 1467 cases. The penetration rate of L3 segment was 30.2% (91 / 301) and 28.9% (126 / 436) in L4 segment, 24.5% (132 / 539) in S1 segment and 11.5% (22 / 191) in S1 segment. There was no significant difference in the penetration rate of pedicle screw between L3, L4 and L5, but they were higher than those in S1, and the differences were statistically significant. The results of pedicle penetration location showed that the penetration rate of L3 segment was 47.3% (43 / 91) and that of L4 segment was 58.7% (74 / 126), and that of L5 segment was 75% (99 / 132), and that of S1 segment was 86.4% (19 / 22). The transpedicle screw penetration of L5 and S1 was more concentrated in the lower margin of the pedicle than in the L3 or L4 segment. The statistical results of penetration severity showed that the high risk penetration rate of L3 segment (grade 鈪，

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