本文關(guān)鍵詞： 椎弓根螺釘 皮質(zhì)骨軌跡 腰椎退變疾病 骨質(zhì)疏松 腰椎融合術(shù)　出處：《第二軍醫(yī)大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究目的對(duì)椎弓根皮質(zhì)骨軌跡螺釘技術(shù)(CBT)在國(guó)人應(yīng)用中的安全性評(píng)估,進(jìn)一步明確其應(yīng)用的可行性,最后研究小切口CBT技術(shù)對(duì)腰背部肌肉損傷情況,明確該技術(shù)的微創(chuàng)價(jià)值。建立國(guó)人腰椎CBT螺釘固定技術(shù)標(biāo)準(zhǔn),為下一步設(shè)計(jì)符合國(guó)人標(biāo)準(zhǔn)的腰椎CBT螺釘提供科學(xué)依據(jù),為我國(guó)開展CBT螺釘技術(shù)治療腰椎退變性疾病提供理論基礎(chǔ)和技術(shù)支撐。研究背景在脊柱外科手術(shù)中,椎弓根螺釘固定技術(shù)(PS)是治療各類脊柱疾病的常用固定方法。PS的生物力學(xué)強(qiáng)度主要依靠螺釘和松質(zhì)骨的把持力;骨質(zhì)疏松患者,螺釘-骨界面強(qiáng)度顯著下降,螺釘松動(dòng)、脫出是骨質(zhì)疏松患者腰椎術(shù)后融合失敗最常見(jiàn)的原因。通過(guò)延長(zhǎng)脊柱固定節(jié)段,利用骨水泥增加椎弓根螺釘固定強(qiáng)度等,可以提高骨質(zhì)疏松患者脊柱內(nèi)固定穩(wěn)定性。但是,這些方法存在一些缺點(diǎn):比如:使用骨水泥時(shí)存在高溫釋放、單體毒性、骨水泥疲勞斷裂等問(wèn)題;延長(zhǎng)固定節(jié)段則會(huì)增加手術(shù)費(fèi)用、手術(shù)時(shí)間、出血量及增大并發(fā)癥的發(fā)生率。生物力學(xué)實(shí)驗(yàn)發(fā)現(xiàn)垂直植入椎弓根螺釘可獲得更堅(jiān)強(qiáng)的固定效果。在此理論的啟發(fā)下,Santoni等提出了一種全新的椎弓根螺釘固定技術(shù),即椎弓根皮質(zhì)骨軌跡螺釘(CBT,Cortical Bone Trajectory)固定技術(shù)。釘?shù)婪较蛟谑笭蠲嫔鲜菑奈膊砍蝾^部,水平面上從內(nèi)側(cè)朝向外側(cè)。CBT螺釘可與植入點(diǎn)背側(cè)皮質(zhì)骨、椎弓根后內(nèi)側(cè)壁、前外側(cè)壁及椎體壁做到四點(diǎn)接觸,從而得到更堅(jiān)強(qiáng)的固定。本研究認(rèn)為:CBT技術(shù)十分適應(yīng)于罹患腰椎退行性疾病并伴有骨質(zhì)疏松患者的腰椎內(nèi)固定手術(shù)。研究方法本研究分為三個(gè)部分:CBT技術(shù)應(yīng)用于腰椎退變性疾病的安全性研究、可行性研究以及小切口CBT技術(shù)的微創(chuàng)價(jià)值的研究。第一部分選擇長(zhǎng)征醫(yī)院本治療組2014年1月至2016年10月收治的行手術(shù)治療的腰椎退變性疾病患者36例,采用CBT技術(shù)進(jìn)行固定,觀察所有患者在術(shù)中和術(shù)后是否出現(xiàn)的血管、神經(jīng)及內(nèi)臟損傷等并發(fā)癥,術(shù)后通過(guò)CT薄層掃描來(lái)記錄所有椎弓根內(nèi)外側(cè)壁及椎體前壁穿透皮質(zhì)骨的螺釘數(shù)量,進(jìn)一步利用計(jì)算機(jī)軟件測(cè)量穿透皮質(zhì)的距離;第二部分分為兩組:選擇長(zhǎng)征醫(yī)院本治療組2014年1月至2015年7月經(jīng)保守治療無(wú)效的骨質(zhì)疏松腰椎退變性疾病患者30例進(jìn)行腰椎后路減壓植骨融合內(nèi)固定術(shù)手術(shù)治療,18例采用PS技術(shù),12例采用CBT技術(shù),觀察兩組患者恢復(fù)情況、手術(shù)時(shí)間、術(shù)中出血量和手術(shù)前后VAS評(píng)分、JOA評(píng)分及改善率等。第三部分分為兩組:A組患者47例,應(yīng)用傳統(tǒng)的椎弓根螺釘固定技術(shù),B組患者36例,應(yīng)用CBT技術(shù),記錄手術(shù)時(shí)間、術(shù)中出血量、術(shù)前、術(shù)后血清肌酸激酶(CK)水平以及術(shù)前、術(shù)后VAS評(píng)分、ODI評(píng)分等。研究結(jié)果第一部分研究結(jié)果:36例患者共置入168枚CBT螺釘,L1置釘最少,只有2枚,L5置釘數(shù)目最多,有78枚。在置釘過(guò)程中出現(xiàn)3例共6枚螺釘因CBT螺釘置釘困難后改為傳統(tǒng)椎弓根螺釘置釘,出現(xiàn)5例共9枚螺釘因經(jīng)C型臂X線機(jī)透視后發(fā)現(xiàn)CBT螺釘位置欠佳而改為傳統(tǒng)椎弓根螺釘置釘,所有患者術(shù)后均未出現(xiàn)血管、神經(jīng)、內(nèi)臟損傷以及感染等并發(fā)癥。所有36例患者術(shù)后均行腰椎CT斷層薄層掃描,其中穿透椎弓根外側(cè)壁數(shù)目最多,為21枚,最大穿透距離約為5mm;穿透椎弓根前壁13枚,最大穿透距離為約4.6mm;穿透椎弓根內(nèi)側(cè)壁數(shù)目最少,僅3枚,且穿透距離不到2mm。第二部分研究結(jié)果:所有30例患者癥狀均得到改善,術(shù)后JOA和VAS評(píng)分均有明顯提高,兩組之間在手術(shù)時(shí)間、出血量、JOA評(píng)分和VAS評(píng)分比較差異無(wú)統(tǒng)計(jì)學(xué)意義。第三部分研究結(jié)果:本研究中B組患者應(yīng)用CBT技術(shù),避免了廣泛的肌肉剝離、牽拉及軟組織切除,其術(shù)中出血量明顯少于A組患者,可以做到小切口來(lái)完成手術(shù)各項(xiàng)操作,并且B組患者術(shù)后CK水平明顯低于A組患者,較A組患者更快的恢復(fù)到正常水平,另外B組術(shù)后各個(gè)隨訪時(shí)間點(diǎn)VAS評(píng)分及ODI評(píng)分均低于A組。研究結(jié)論(1)本課題結(jié)合臨床病例兩兩對(duì)照分析并評(píng)估CBT技術(shù)在國(guó)人上應(yīng)用的價(jià)值,并且結(jié)合前人的研究明確了CBT技術(shù)在國(guó)人上應(yīng)用較為安全可靠,針對(duì)適應(yīng)證有良好的可行性,在一定程度上實(shí)現(xiàn)微創(chuàng),有很大的微創(chuàng)價(jià)值。(2)本研究第一部分發(fā)現(xiàn):應(yīng)用CBT技術(shù)進(jìn)行腰椎內(nèi)固定治療腰椎退變性疾病置入過(guò)程較為安全可靠;(3)本研究第二部分發(fā)現(xiàn):應(yīng)用CBT技術(shù)進(jìn)行腰椎內(nèi)固定使患者的損傷小、恢復(fù)快;增加了和皮質(zhì)骨的接觸面,牢固性更強(qiáng)等優(yōu)勢(shì),早期療效滿意。(4)本研究第三部分發(fā)現(xiàn):應(yīng)用CBT螺釘技術(shù)進(jìn)行腰椎內(nèi)固定,其更靠?jī)?nèi)的進(jìn)釘點(diǎn)避免了廣泛的肌肉剝離與組織切除,術(shù)后患者腰背部肌肉炎癥情況較傳統(tǒng)椎弓根螺釘小,并且可以做到小切口,創(chuàng)傷小,有一定的微創(chuàng)價(jià)值。
[Abstract]:Objective to study the cortical bone screw trajectory Shiumi Ne Technology (CBT) security evaluation in the application, to further clarify the feasibility of its application, the study of small incision CBT on back muscle injury, the technique of minimally invasive value. Establish lumbar CBT screw fixation technique standard, provide scientific basis for lumbar CBT screw in line with the Chinese standards for the design, provide a theoretical basis and technical support for our country to carry out CBT screws in the treatment of lumbar degenerative disease. Background in spinal surgery, Shiumi Ne screw fixation technique (PS) is commonly used in all kinds of biomechanical strength of fixation methods for the treatment of spinal diseases mainly depends on.PS and cancellous screws bone holding force; osteoporosis, bone screw interface strength decreased significantly, screw loosening, prolapse of lumbar osteoporosis patients is the most common cause of failure of fusion Because. By extending the spinal fixation segments, using bone cement to increase the fixation strength of pedicle screws, can improve the patients with osteoporosis spinal stability. However, these methods have some drawbacks such as: the use of bone cement has high temperature release, monomer toxicity, such as fatigue fracture of bone cement fixation segments will extend; increase the operation cost, operation time, bleeding volume and increase the incidence of complications. Biomechanical experiments found vertical pedicle screw fixation effect can get stronger. Inspired by this theory, Santoni proposed a new technique of pedicle screw fixation, the pedicle cortical bone screw (CBT Cortical, Bone locus Trajectory) the direction of screw fixation. In the sagittal plane is from the tail toward the head, horizontal plane from inside toward the outer.CBT screw can be implanted with dorsal skin pedicle bone. After the medial wall, lateral wall and posterior vertebral wall do four point contact, in order to get a strong fixation. This study suggests that CBT technology is very suitable for suffering from lumbar degenerative disease of lumbar spine and osteoporosis bone internal fixation surgery. This study is divided into three parts: the research on the application of CBT technology in safety lumbar degenerative diseases, the research value of minimally invasive incision CBT feasibility study and technology. The first part of the selection of 36 patients with lumbar degenerative disease underwent surgical treatment in the treatment group Changzheng Hospital from January 2014 to October 2016 were selected and were fixed by CBT technology, were observed in all the patients is in the intraoperative and postoperative blood vessels, nerves and internal organs injury and other complications, postoperative CT by TLC scanning to record all pedicle screws and lateral wall and anterior wall penetrating cortical bone volume, the further use of computer Software measurement through the cortex distance; the second part is divided into two groups: the treatment group of Changzheng Hospital from January 2014 to 2015 7 menstrual conservative treatment of osteoporotic lumbar degenerative disease of invalid 30 cases of lumbar posterior decompression and bone graft fusion and internal fixation surgery, 18 cases of 12 cases by using PS technology, CBT technology, observation of two the recovery of patients, operation time, intraoperative bleeding volume and VAS score before and after surgery, JOA score and recovery rate. The third part is divided into two groups: 47 cases of A patients, the technique of pedicle screw fixation with traditional, 36 cases of B patients, the application of CBT technology, recording the operation time, bleeding volume, operation in the preoperative, postoperative serum creatine kinase (CK) and the level of preoperative, postoperative VAS score, ODI score. The results of the first part of the study results: 36 patients were implanted with 168 CBT screws, L1 screws at least, only 2 L5, the largest number of screws, 78. 3 cases of a total of 6 screws for CBT screw placement difficulties changed after traditional pedicle screw placement in the placement process, the appearance of 5 cases of a total of 9 screws for the C arm X-ray fluoroscopy and found CBT poor location instead of traditional screw placement of pedicle screws, all patients there was no nerve, vascular, visceral injury and complications such as infection. All 36 patients underwent lumbar CT fault scanning, which penetrate the outer wall of the pedicle number most, for 21 pieces, the maximum penetration distance is about 5mm; penetrating anterior pedicle in 13 cases, the maximum penetration distance is about 4.6mm; the number of penetration the medial wall of pedicle at least, only 3, and the penetration distance less than 2mm. second part of the research results: all 30 patients symptoms were improved, postoperative JOA and VAS scores were significantly improved, between the two groups in the operation time, bleeding volume, JOA score and VAS score were not The third part studies the statistical significance. Results: in this study, B group of patients with CBT technology, to avoid extensive muscle stripping, traction and soft tissue resection, the intraoperative blood loss was significantly less than that in A group can do small incision to complete the operation of the operation, and the patients of the B group CK level was significantly lower than that of A a group of patients, A patients quickly returned to normal levels, in addition to B group after each follow-up time point, VAS score and ODI score were lower than A group. Conclusions (1) the subject with clinical cases in 22 control analysis and evaluation of CBT technology should be used in people's value, and combined with previous research the CBT technology in the application of a more secure and reliable, the indications have good feasibility, implementation of minimally invasive to a certain extent, a minimally invasive value. (2) the first part of this study found that: the application of CBT in lumbar internal fixation In the process of lumbar degenerative disease is safe and reliable; (3) the second part of this study found that: the application of CBT in lumbar fixation so that patients with little injury, quick recovery; increase the contact surface and the cortical bone, more strong advantage, the early curative effect. (4) the third part of this study found that the application of CBT the lumbar internal fixation screw technique, the farther into the point of nail to avoid muscle dissection and organization wide resection, patients with small waist back muscle inflammation compared with conventional pedicle screw after operation, and it can make the small incision, less trauma, minimally invasive has certain value.

【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

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本文編號(hào)：1447784