CAJ | 학술논문

目的观察导航及传统手术方式在下腰椎术中不同节段螺钉置入精确性的差异及相关影响因素.方法本研究为前瞻性的随机对照研究,包括2011年3月至2012年5月间北京积水潭医院脊柱外科所有接受开放性腰椎手术共188例,并在L4、L5节段均置入椎弓根螺钉的病例.按照1∶3的比例随机分为导航组及对照组.采用术后CT三维重建图像判断L4及L5螺钉的位置,根据螺钉穿出椎弓根是否超过2 mm将螺钉位置分为侵害椎弓根和未侵害椎弓根两组.结果共有188例患者纳入研究,其中导航组47例,对照组141例.两组患者的出血量,住院时间及改善情况,差异均无统计学意义(均P＞0.05).导航组患者手术时间更长,差异有统计学意义(P＜0.05).在L4椎弓根,导航组94枚螺钉中93枚(98.9％)未侵害椎弓根,对照组282枚螺钉中273枚(96.8％)未侵害椎弓根,两者差异无统计学意义(P＞0.05).在L5椎弓根,导航组94枚螺钉中93枚(98.9％)未侵害椎弓根,对照组282枚螺钉中260枚(92.2％)未侵害椎弓根,在L5椎弓根导航组的置钉准确性更高(P＜0.05).结论在L5椎弓根,尤其是术前CT显示腰椎滑脱或小关节增生造成解剖标志缺失、或髂骨内聚、或低年资操作者的情况下建议应用术中即时三维导航辅助置入椎弓根螺钉以增加手术的准确性及安全性.
목적 관찰도항급전통수술방식재하요추술중불동절단라정치입정학성적차이급상관영향인소.방법 본연구위전첨성적수궤대조연구,포괄2011년3월지2012년5월간북경적수담의원척주외과소유접수개방성요추수술공188례,병재L4、L5절단균치입추궁근라정적병례.안조1∶3적비례수궤분위도항조급대조조.채용술후CT삼유중건도상판단L4급L5라정적위치,근거라정천출추궁근시부초과2 mm장라정위치분위침해추궁근화미침해추궁근량조.결과 공유188례환자납입연구,기중도항조47례,대조조141례.량조환자적출혈량,주원시간급개선정황,차이균무통계학의의(균P＞0.05).도항조환자수술시간경장,차이유통계학의의(P＜0.05).재L4추궁근,도항조94매라정중93매(98.9％)미침해추궁근,대조조282매라정중273매(96.8％)미침해추궁근,량자차이무통계학의의(P＞0.05).재L5추궁근,도항조94매라정중93매(98.9％)미침해추궁근,대조조282매라정중260매(92.2％)미침해추궁근,재L5추궁근도항조적치정준학성경고(P＜0.05).결론 재L5추궁근,우기시술전CT현시요추활탈혹소관절증생조성해부표지결실、혹가골내취、혹저년자조작자적정황하건의응용술중즉시삼유도항보조치입추궁근라정이증가수술적준학성급안전성.
Objective To compare the accuracy of lower lumbar pedicle screw placement at different levels with or without navigation system.Methods A prospective randomized controlled trial was conducted for patients undergoing open lumbar surgery with pedicle screws at both L4 and L5 levels from March 2011 to May 2012.The accuracy of pedicle screws at L4 and L5 level were evaluated by three-dimensional postoperative computed tomography (CT).There was no apparent violation of pedicle or ＜ 2 mm perforation of pedicle in non-violation group while ≥2 mm perforation of pedicle in violation group.Results A total of 188 patients were recruited and assigned randomly into navigation (n =47) and control (n =141) groups.Two groups did not differ in estimated blood loss volume,length of hospital stay,Japanese Orthopedics Association (JOA) score or JOA recovery rate (P ＞ 0.05).Navigation group had a longer operative duration (P ＜ 0.05).At L4 level,93/94 screws (98.9％) in navigation group and 273/282 screws (96.8％) in control group did not violate pedicle (P ＞0.05).At L5 level,93/94 screws (98.9％) in navigation group and 260/282 screws (92.2％) in control group did not violate pedicle.Thus navigation could achieve a higher accuracy at L5 level (P ＜ 0.05).Conclusion The profile of L5 pedicle at coronal plane is tilting oval.Screw may easily violate medioinferior part of pedicle and cause injures of nerve root.For improving the accuracy and safety of pedicle screw at L5 level,we recommend using intraoperative three-dimensional navigation for spondylolisthesis or facet hypertrophy,iliac cohesion or junior operator.