超声容积导航技术引导腰椎经皮后外侧入路完全内镜下微创手术椎间孔穿刺的应用研究

发布时间：2018-11-06 09:13

【摘要】：目的：在尸体上应用图像融合与电磁导航相结合的超声容积导航技术引导经皮后外侧入路椎间孔穿刺并评估其准确性。在临床上将这一穿刺引导方法与常规C臂机引导穿刺作对比,评估超声容积导航技术应用于引导经皮后外侧入路椎间孔穿刺的可行性。方法：解剖学研究：15具尸体应用容积导航引导双侧L4/5椎间孔穿刺,记录配准误差、超声所能观察到针尖的最后位置距靶点距离(distance between needle tip and target, DNT)及总穿刺时间(包括配准及放置穿刺针时间),CT测量穿刺误差(导航到位后经CT验证针尖到目标靶点的距离)。临床研究：选择2012年6月至2013年10月间行经皮内镜下腰椎间盘切除术(percutaneous endoscopic lumbar discectomy,PELD)的腰椎间盘突出症患者63例,随机分配至两组。C臂机引导组30例,利用C臂机引导椎间孔穿刺,记录穿刺时间及透视次数；容积导航组33例,利用容积导航技术引导椎间孔穿刺,记录配准误差、DNT、总穿刺时间和透视次数。两组患者采用Oswestry功能障碍指数(Oswestry disability index, ODI)以及腰腿痛视觉模拟评分(Visual analogue scale, VAS)评定临床疗效。结果：解剖学研究中,15具尸体共行30次L4/5椎间孔穿刺,配准误差为2.66mm (0.9-4.7mm), DNT为20.08mm (17.8-22.9mm),穿刺误差为2.91mm (1.1-6. lmm);其中有两次穿刺误差为5.3mm及6.1mm,可能有损伤出行神经根或置入工作通道困难的风险。总穿刺时间为22. lmin(16-33min),其中图像配准时间19. lmin(14-29min),放置穿刺针时间3min (2-4min)。临床研究中：C臂机引导组30例患者穿刺时间为27.9min (25-32min),到达目标区域所需C臂机透视次数为14.3次(13-17次)。容积导航组中30例患者首次配准即穿刺成功；3例患者穿刺过程中出现了下肢放射痛,重新配准后穿刺成功。总穿刺时间20.4min (16-28min),图像配准时间为15.5min (13-22min),放置穿刺针时间4.9min (3-7min),C臂机透视次数4.9次(4-7次),配准误差为3.25mm (1.9-4.8mm), DNT为20.35mm (16.9-24.9mm)。通过对比两组患者穿刺过程总用时及透视次数可以发现,容积导航组穿刺总时间及透视次数均少于C臂机引导组(P0.001)。C臂机引导组随访时间为18.8月(12-28月),容积导航组为18.4月(12-28月)；两组患者术前及术后各个时间点ODI及VAS评分无统计学差异(P0.05)。两组患者均无神经损伤、伤口感染等并发症,随访终末两组患者腰椎间盘突出均无复发。结论：与传统C臂机导航相比,利用图像融合与电磁导航相结合的超声容积导航技术可准确引导经皮后外侧入路椎间孔穿刺,且减少穿刺时间及X线辐射量,可应用于经皮内窥镜下腰椎间盘切除术。
[Abstract]:Objective: to evaluate the accuracy of percutaneous posterolateral approach of intervertebral foramen puncture by ultrasound volume navigation combined with image fusion and electromagnetic navigation on cadavers. Compared with the conventional C-arm guided puncture in clinic, the feasibility of the application of the ultrasonic volumetric navigation technique to the percutaneous posterolateral approach of intervertebral foramen puncture was evaluated. Methods: anatomical study: bilateral L4 / 5 intervertebral foramen puncture was guided by volumetric navigation in 15 cadavers. Registration errors were recorded. The final position of the needle was observed by ultrasound. The distance from the target to the target was observed by ultrasound. DNT) and total puncture time (including registration and placement of puncture needle time), CT measurement of puncture error (after navigation is in place CT verifies the distance between the needle and the target). Clinical study: Sixty-three patients with lumbar disc herniation underwent percutaneous endoscopic discectomy (percutaneous endoscopic lumbar discectomy,PELD) from June 2012 to October 2013 were randomly assigned to two groups. C-arm machine was used to guide intervertebral foramen puncture to record puncture time and times of fluoroscopy. The volume navigation technique was used to guide intervertebral foramen puncture in 33 cases of volume navigation group. The registration error, the total puncture time of DNT, and the times of fluoroscopy were recorded. The clinical efficacy was evaluated by Oswestry dysfunction index (Oswestry disability index, ODI) and visual analogue score (Visual analogue scale, VAS) of lumbago and leg pain. Results: in the anatomical study, 15 cadavers underwent 30 L 4 / 5 intervertebral foramen puncture, the registration error was 2.66mm (0.9-4.7mm), DNT was 20.08mm (17.8-22.9mm), and the puncture error was 2.91mm (1.1-6). Lmm); has two puncture errors of 5.3mm and 6.1 mm, which may have the risk of damaging nerve roots or difficult placement of working channels. The total puncture time was 22. Lmin (16-33min), where the image registration time is 19. Lmin (14-29min), place needle time 3min (2-4min). In the clinical study, the puncture time was 27.9min (25-32min) in the C-arm guidance group, and the number of fluoroscopy needed to reach the target area was 14.3 times (13-17 times). In the volume navigation group, 30 patients were successfully punctured for the first time, 3 patients had lower extremity radiation pain during the puncture, and the puncture was successful after the alignment. The total puncture time was 20.4min (16-28min), the time of image registration was 15.5min (13-22min), the time of placement of puncture needle was 4.9min (4. 9 times of 3-7min), C arm machine). The registration error is 3.25mm (1.9-4.8mm), DNT is 20.35mm (16.9-24.9mm). By comparing the total time of puncture and the times of fluoroscopy in the two groups, it was found that the total puncture time and the times of fluoroscopy in the volumetric navigation group were less than those in the C-arm guidance group (P 0.001). C arm guide group was 18.8 months (12-28 months). The volume navigation group was 18.4 months (12-28 months); There was no significant difference in ODI and VAS scores between the two groups before and after operation (P0.05). No nerve injury, wound infection and other complications were found in both groups, and no recurrence of lumbar disc herniation was found in the two groups at the end of follow-up. Conclusion: compared with the traditional C-arm navigation, the ultrasonic volume navigation combined with image fusion and electromagnetic navigation can accurately guide the percutaneous posterolateral approach intervertebral foramen puncture, and reduce the puncture time and X-ray radiation. It can be used in percutaneous endoscope lumbar discectomy.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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