俯卧0度位和30度位下腰椎后柱结构的CT测量研究—对脊柱内镜手术的提示

发布时间：2018-03-13 18:17

  本文选题：腰椎退变　切入点：三维CT　出处：《吉林大学》2016年博士论文　论文类型：学位论文

【摘要】：背景:腰椎退行性疾病往往需要手术治疗,手术方法:开放性手术或者微创内镜治疗,内镜治疗已被广泛应用于腰椎退变疾病,出现的并发症有:硬膜囊损伤和神经根损伤,原因就是由于腰椎后方骨性结构复杂不规则,自然孔道小,空间小而且周围是硬膜囊和脊神经,器械孔道安放过程中伤害硬膜囊和脊神经可能性较大,一旦损伤带来的伤害是巨大不可逆的,故此项技术的操作是存在难度的,造成微创技术发展上的瓶颈,需要医生在牢固掌握解剖结构的同时探讨手术的经验,包括体位的变化都是我们在实践中所需要考虑和摸索的。目的:模拟腰椎退变疾病手术俯卧位,分别在俯卧0度位和30度位时对于腰椎后柱结构进行CT三维测量,分别测量和微创内镜下手术相关的数据:冠状位椎板间最大距离,矢状位椎间孔长径(纵径),矢状位下位椎体的上关节突尖部和上位椎体后下缘距离,横轴位下位椎体上关节突和上位椎体后下缘中点距离,观察和研究腰椎退变患者俯卧位0度和30度位腰椎后路结构的变化,尤其和微创内镜下手术相关的数据,寻找不同体位下腰椎侧路和后路置管适合入路的客观依据,对于不同俯卧位的腰椎后柱结构位置的变化,可以为临床腰椎退变疾病微创内镜手术选择合理的术式、合适的置管入路,为新型内镜配套器械设计、研制及应用提供解剖学基础,从而提高微创脊柱内镜手术的安全性和便捷性。方法:采用50名腰椎退变患者(自愿者),根据腰痛为主和下肢痛为主的症状主诉分成两组,采用西门子64层螺旋CT行L3-S1平扫,先对所有参加CT检查的患者进行螺旋CT扫描,所有患者先进行俯卧0度位CT扫描,然后俯卧30度位进行CT扫描,将采集的DICOM数据导入宝葫芦数字医学影像工作站进行三维重建,分别测量:冠状位椎板间最大距离、矢状位椎间孔长径、矢状位上关节突尖部到上位椎体后下缘最下缘距离、横轴位下位椎体上关节突和上位椎体后下缘中点距离。将所得数据分别填入相关表格,统计数据,分别列入腰痛组和下肢痛组、男女组、俯卧0度位和俯卧30度位置组再分别统计相关数据,应用SPSS13软件包进行统计学分析,两组数据采用方差分析。结果:1.冠状位椎板间最大距离,L34、L45、L5S1各部位俯卧位0度和30度有显著性差异;2.矢状位椎间孔长径(纵径),L34、L45、L5S1各部位俯卧位0度和30度亦有显著性差异;3.矢状位下位椎体的上关节突尖部和上位椎体后下缘距离,L34、L45、L5S1各部位俯卧位0度和30度存在显著性差异;4.横轴位下位椎体上关节突和上位椎体后下缘中点距离,L34、L45、L5S1各部位俯卧位0度和30度也有明显的统计学差异;5.上述四个参数经过分析,在性别(男女)组和症状组(腰痛和下肢痛组)无显著性差异;6.椎板间隙的宽度,矢状位椎间孔长径(纵径)测量表明:俯卧0度小于俯卧30度,差异显著,所以无论是后路全内镜手术还是是MED手术,都可以在俯卧30度位加大椎板间隙,快速有效进入椎管开展手术,所以俯卧30度体位的摆放对于脊柱后路镜的进入作业十分有效和帮助减少手术操作的困难。7.矢状位下位椎体上关节突尖部和上位椎体后下缘距离,横轴位下位椎体上关节突和上位椎体后下缘中点距离距离,测量表明:俯卧0度小于俯卧30度,差异显著,这为我们在穿刺和置入工作套管时要十分注意进入深度,防止过深进入会导致穿刺针和套管进入到椎体前方损伤椎体前方的血管,导致危险和意外的发生。说明脊柱微创手术椎间孔入路时,利用术前三维CT测量规划,有利于指导椎间孔镜入路操作(去除部分关节突和控制置管深度),防止出口神经根和走行神经根的损伤。根据测得的数据,我们应用椎间盘镜手术不同体位下治疗腰椎间盘突出症患者并观察手术疗效,共观察22例,结论:椎间盘镜下治疗腰间盘突出症采用俯卧30度位对比采用俯卧0度位更有利于操作,安全,缩短置管进入椎管内时间,降低并发症,手术切口小,出血量和术后第三天JOA评分没有明显差异。结论:测量结果表明:1.冠状位椎板间最大距离,L34、L45、L5S1各部位俯卧位0度和30度有显著性差异;2.矢状位椎间孔长径(纵径),L34、L45、L5S1各部位俯卧位0度和30度亦有显著性差异;3.矢状位下位椎体的上关节突尖部和上位椎体后下缘距离,L34、L45、L5S1各部位俯卧位0度和30度存在显著性差异;4.横轴位下位椎体上关节突和上位椎体后下缘中点距离,L34、L45、L5S1各部位俯卧位0度和30度也有明显的统计学差异;5.上述四个参数经过分析,在性别(男女)组和症状组(腰痛和下肢痛组)无显著性差异;6.应用测得的数据进一步行临床观察和验证,对22例采用椎间盘镜手术治疗腰椎间盘突出症的患者,采用俯卧30度的患者在置管进入椎管时间,手术切口大小,并发症的发生率显著低于俯卧0度位的患者。7.对于脊柱微创手术,无论椎板间路还是椎间孔入路俯卧30度均有利于内镜套管的置入,减少神经根和硬膜囊的损伤机会。8.脊柱微创手术椎间孔入路时,利用术前三维CT测量规划,有利于指导椎间孔镜入路操作(去除部分关节突和控制置管深度),防止出口神经根和走行神经根的损伤。
[Abstract]:Background: lumbar degenerative diseases often require surgery, surgical methods: open surgery or minimally invasive endoscopic treatment, endoscopic therapy has been widely used in lumbar degenerative diseases, complications: dural injury and nerve root injury, the reason is due to the complex irregular bony structures of lumbar vertebrae, natural orifice small, small space it is around the dural sac and spinal nerve injury in the process of placing channel equipment, dural sac and spinal nerve injury caused by the possibility of a larger, once the damage is huge and irreversible, so the technology is the difficulty of the operation, causing bottlenecks in the development of minimally invasive techniques, to firmly grasp the doctor in the anatomy and discuss the surgical experience, including the change of position is in practice we need to consider and explore. Objective: to simulate the surgery of lumbar degenerative disease prone, prone position and 0 degrees respectively in 3 CT 3D measurement for lumbar column structure after 0 degrees, were measured and the minimally invasive endoscopic surgery related data: the maximum distance between posterior coronal, sagittal intervertebral foramen diameter (longitudinal diameter), sagittal lower vertebral facet on the tip of the upper and lower edge after centrum distance under the distance from the middle and upper margin of articular posterior vertebral axial inferior vertebra, observation and study of lumbar spondylosis prone position 0 degrees and 30 degrees of lumbar posterior structure, especially the minimally invasive endoscopic surgery and related data, for different positions of lumbar lateral and posterior catheter approach for the objective basis for. Changes of different lumbar prone position after column structure position, can reasonable surgical options for clinical degenerative disorders of the lumbar minimally invasive endoscopic surgery, catheter into the right way, design new endoscopic equipment, provide anatomic basis of development and application, from To improve the safety and convenience of minimally invasive spine endoscopic surgery. Methods: 50 patients with degenerative lumbar spine (volunteer), according to the symptoms of lumbago and leg pain were divided into two groups, using SIEMENS 64 slice CT underwent L3-S1 scan, the first spiral CT scanning was performed in all CT patients, all the first 0 patients prone CT scan, then prone CT scans were performed in 30 degrees, the DICOM data into baohulu digital medical image acquisition workstation for 3D reconstruction, were measured: the maximum distance between posterior coronal, sagittal intervertebral foramen diameter, sagittal facet to the tip of the upper vertebral body after the lower edge of the lower edge of the distance from the midpoint of the lower edge of the facet and the posterior axial lower vertebra. The data are in table, statistics, lumbago and leg pain group were included in the group, the group of men and women, prone to 0 degrees 浣嶅拰淇�鍗�30搴︿綅缃�缁勫啀鍒嗗埆缁熻�＄浉鍏虫暟鎹，

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