中国脊柱脊髓杂志
中國脊柱脊髓雜誌
중국척주척수잡지
CHINESE JOURNAL OF SPINE AND SPINAL CORD
2014年
4期
359-365
,共7页
上胸椎%前路%逆向椎弓根螺钉%内固定
上胸椎%前路%逆嚮椎弓根螺釘%內固定
상흉추%전로%역향추궁근라정%내고정
Upper Thoracic vertebrae%Anterior%Reverse transpedicular screw%Internal fixation
目的：通过放射解剖学研究及标本上的模拟手术操作来验证上胸椎（T1~T4）前路逆向椎弓根螺钉内固定技术的可行性及安全性。方法：在放射科CT数据库中选取40例层厚为0.625mm的正常上胸椎薄层CT扫描数据（男20例，女20例，年龄18～68岁，平均39.7岁），对数据进行MPR重建，在每侧椎弓根轴心上选取其横切面和矢状面进行观察和测量，测得每侧椎弓根的横径、高度、横切面进钉点距离、进钉角度、矢状面进钉点距离、进钉角度、钉道长度，对所得数据进行统计学处理。选取10具（男5例、女5例，年龄不详）完整的成人上胸椎防腐标本（包括C7～T6），外观无畸形和破损，完整保留T1～T4两旁肋椎关节及椎旁软组织，于椎体前方逆向置入椎弓根螺钉，通过X线透视、CT扫描、剖面观察、测量，参照Rao等的椎弓根螺钉穿破分级标准对置钉优良率进行评测。结果：T1～T4椎弓根横径逐渐减小8.14～3.47mm；椎弓根高度逐渐增大6.89～10.29mm；横切面进钉角度逐渐减小32.96°～11.64°；横切面进钉点距离逐渐增大1.80～5.50mm；矢状面进钉角度逐渐增大104.95°～115.74°；矢状面进钉点距离逐渐增大5.95～8.76mm；钉道长度32.95～35.96mm。 T3、T4椎弓根横径过于细小，不适合逆向椎弓根螺钉的置入，但在T3、T4逆向置入椎弓根-肋骨复合体螺钉是可行的。 T1、T2前路逆向椎弓根螺钉的规格为：直径4.0mm、长度35mm左右，T3、T4前路逆向椎弓根-肋骨复合体螺钉的规格为：直径5.0mm、长度35mm左右。在10具上胸椎标本上共置钉80枚，根据Rao等的椎弓根螺钉穿破分级标准，总体优良率达90%，其中椎弓根侧壁穿破小于2mm未造成脊髓压迫的共7枚；椎弓根内侧壁穿破距离在2～4mm的共有5枚，分别为T1椎体1枚，T3椎体1枚，T4椎体3枚，有不同程度脊髓压迫；椎弓根内侧壁穿破距离大于4mm的2枚，其中T2椎体1枚，T4椎体1枚，脊髓受压严重；T2椎体有1枚椎弓根外侧壁穿破。结论：T1、T2椎体前路逆向椎弓根螺钉内固定技术和T3、T4椎体前路逆向椎弓根-肋骨复合体螺钉内固定技术可达到双皮质固定的目的，但其安全性及临床实用性尚需进一步探讨。
目的：通過放射解剖學研究及標本上的模擬手術操作來驗證上胸椎（T1~T4）前路逆嚮椎弓根螺釘內固定技術的可行性及安全性。方法：在放射科CT數據庫中選取40例層厚為0.625mm的正常上胸椎薄層CT掃描數據（男20例，女20例，年齡18～68歲，平均39.7歲），對數據進行MPR重建，在每側椎弓根軸心上選取其橫切麵和矢狀麵進行觀察和測量，測得每側椎弓根的橫徑、高度、橫切麵進釘點距離、進釘角度、矢狀麵進釘點距離、進釘角度、釘道長度，對所得數據進行統計學處理。選取10具（男5例、女5例，年齡不詳）完整的成人上胸椎防腐標本（包括C7～T6），外觀無畸形和破損，完整保留T1～T4兩徬肋椎關節及椎徬軟組織，于椎體前方逆嚮置入椎弓根螺釘，通過X線透視、CT掃描、剖麵觀察、測量，參照Rao等的椎弓根螺釘穿破分級標準對置釘優良率進行評測。結果：T1～T4椎弓根橫徑逐漸減小8.14～3.47mm；椎弓根高度逐漸增大6.89～10.29mm；橫切麵進釘角度逐漸減小32.96°～11.64°；橫切麵進釘點距離逐漸增大1.80～5.50mm；矢狀麵進釘角度逐漸增大104.95°～115.74°；矢狀麵進釘點距離逐漸增大5.95～8.76mm；釘道長度32.95～35.96mm。 T3、T4椎弓根橫徑過于細小，不適閤逆嚮椎弓根螺釘的置入，但在T3、T4逆嚮置入椎弓根-肋骨複閤體螺釘是可行的。 T1、T2前路逆嚮椎弓根螺釘的規格為：直徑4.0mm、長度35mm左右，T3、T4前路逆嚮椎弓根-肋骨複閤體螺釘的規格為：直徑5.0mm、長度35mm左右。在10具上胸椎標本上共置釘80枚，根據Rao等的椎弓根螺釘穿破分級標準，總體優良率達90%，其中椎弓根側壁穿破小于2mm未造成脊髓壓迫的共7枚；椎弓根內側壁穿破距離在2～4mm的共有5枚，分彆為T1椎體1枚，T3椎體1枚，T4椎體3枚，有不同程度脊髓壓迫；椎弓根內側壁穿破距離大于4mm的2枚，其中T2椎體1枚，T4椎體1枚，脊髓受壓嚴重；T2椎體有1枚椎弓根外側壁穿破。結論：T1、T2椎體前路逆嚮椎弓根螺釘內固定技術和T3、T4椎體前路逆嚮椎弓根-肋骨複閤體螺釘內固定技術可達到雙皮質固定的目的，但其安全性及臨床實用性尚需進一步探討。
목적：통과방사해부학연구급표본상적모의수술조작래험증상흉추（T1~T4）전로역향추궁근라정내고정기술적가행성급안전성。방법：재방사과CT수거고중선취40례층후위0.625mm적정상상흉추박층CT소묘수거（남20례，녀20례，년령18～68세，평균39.7세），대수거진행MPR중건，재매측추궁근축심상선취기횡절면화시상면진행관찰화측량，측득매측추궁근적횡경、고도、횡절면진정점거리、진정각도、시상면진정점거리、진정각도、정도장도，대소득수거진행통계학처리。선취10구（남5례、녀5례，년령불상）완정적성인상흉추방부표본（포괄C7～T6），외관무기형화파손，완정보류T1～T4량방륵추관절급추방연조직，우추체전방역향치입추궁근라정，통과X선투시、CT소묘、부면관찰、측량，삼조Rao등적추궁근라정천파분급표준대치정우량솔진행평측。결과：T1～T4추궁근횡경축점감소8.14～3.47mm；추궁근고도축점증대6.89～10.29mm；횡절면진정각도축점감소32.96°～11.64°；횡절면진정점거리축점증대1.80～5.50mm；시상면진정각도축점증대104.95°～115.74°；시상면진정점거리축점증대5.95～8.76mm；정도장도32.95～35.96mm。 T3、T4추궁근횡경과우세소，불괄합역향추궁근라정적치입，단재T3、T4역향치입추궁근-륵골복합체라정시가행적。 T1、T2전로역향추궁근라정적규격위：직경4.0mm、장도35mm좌우，T3、T4전로역향추궁근-륵골복합체라정적규격위：직경5.0mm、장도35mm좌우。재10구상흉추표본상공치정80매，근거Rao등적추궁근라정천파분급표준，총체우량솔체90%，기중추궁근측벽천파소우2mm미조성척수압박적공7매；추궁근내측벽천파거리재2～4mm적공유5매，분별위T1추체1매，T3추체1매，T4추체3매，유불동정도척수압박；추궁근내측벽천파거리대우4mm적2매，기중T2추체1매，T4추체1매，척수수압엄중；T2추체유1매추궁근외측벽천파。결론：T1、T2추체전로역향추궁근라정내고정기술화T3、T4추체전로역향추궁근-륵골복합체라정내고정기술가체도쌍피질고정적목적，단기안전성급림상실용성상수진일보탐토。
Objectives: To verify the feasibility and safety of the anterior transpedicular screw(ATPS) fixation of the upper thoracic spine (T1-T4) through the radiological anatomy study on the cadaveric specimens. Methods: The upper thoracic spine thin-section CT data of 40 cases were collected from the radiology de-partment′s database(20 males and 20 females, aged from 18 to 68 years, the mean age was 39.7 years). The data of OPW(outer pedicle width), OPH(outer pedicle height), PAL(pedicle axis length), TPA(transverse section angle), SPA(sagittal section angle), DTIP(distance of transverse intersection point) and DSIP(distance of sagittal intersection point) of each pedicle were measured on the transverse and sagittal sections through the axis of each pedicle. The data were recorded and statistically analyzed. 10 upper thoracic spine(C7-T6) specimens of adults(5 males and 5 females, with unknown ages), with no damage to their appearance, the costovertebral joints and paravertebral soft tissue were completely retained. Then simulate surgical operations were done on the cadaveric specimens based on the obtained data. Screws were implanted anteriorly by free hand. After that, the specimens accepted X-ray fluoroscopy and CT scan. At last, the screws were removed, the speci-mens were sawed along the transaction and sagittal section of the screw channel. Then the success rate of the screw placement was evaluated according to Rao′s worn out classification standard of pedicle screws. Results: From T1 to T4, the OPW decreased from 8.14mm to 3.47mm; the OPH increased from 6.89mm to 10.29mm; the TPA decreased from 32.96° to 11.64°; the DTIP increased from 1.80mm to 5.50mm; the SPA increased from 104.95° to 115.74°; the DSIP increased from 5.95 to 8.76mm; the PAL changed irregularly, from 32.95 to 35.96mm. The pedicle diameters of T3 and T4 were too small to implant ATPS, but the ARTPS can be implanted successfully. The diameter of ATPS was about 4.0mm; the length of ATPS was about 35mm. The diameter of ARTPS was about 5.0mm; the length of ARTPS was about 35mm. 80 pedicle screws were implanted anteriorly, according to Rao′s worn out classification standard of pedicle screws, the fine rate was 90%. The internal walls of 7 pedicles were broken by screws of less than 2mm and no compression to the spinal cord. The internal walls of 5 pedicles were broken of 2 to 4mm, 1 at T1, 1 at T3 and 3 at T4, with varying degrees of spinal cord compression. The internal walls of 2 pedicles were broken of greater than 4mm, 1 at T2 and 1 at T4, with serious spinal cord compression. The external wall of 1 pedicle was broken at T2. Conclusions: The ATPS techniques at T1, T2 and the ARTPS techniques at T3, T4 are feasible, but the safety and clinical practice and further research is needed.
