本文關(guān)鍵詞： 后方韌帶復(fù)合體 有限元 椎弓根螺釘 生物力學(xué) 后方韌帶復(fù)合體 腰椎融合術(shù) 椎板切除 鄰近節(jié)段退變 導(dǎo)航　出處：《廣西醫(yī)科大學(xué)》2016年碩士論文　論文類型：學(xué)位論文

【摘要】：腰椎退行性疾病行后路融合術(shù)已成為目前常用手術(shù)治療方式。充分的椎管減壓及椎間融合內(nèi)固定是解除疼痛并重建脊柱穩(wěn)定性的有效方法。常規(guī)腰椎后路椎間融合術(shù)采用全椎板切除椎管擴(kuò)大,取得了良好的早期治療效果。但是長(zhǎng)期隨訪資料表明：后路全椎板切除對(duì)脊柱遠(yuǎn)期穩(wěn)定性會(huì)產(chǎn)生影響,造成失穩(wěn)；鄰近節(jié)段退變已成為后路腰椎融合術(shù)后主要并發(fā)癥之一。椎管減壓方式的選擇是其重要原因。傳統(tǒng)的全椎板切除方式將后方韌帶復(fù)合體(Posterior Ligament Complex,PLC)結(jié)構(gòu)一并切除,直接影響脊柱后方的穩(wěn)定,而鄰近節(jié)段退變加速亦可產(chǎn)生相應(yīng)臨床癥狀,部分患者必須選擇再次手術(shù)。PLC結(jié)構(gòu)以其張力帶力學(xué)特性成為維持脊柱后柱穩(wěn)定的重要結(jié)構(gòu)。保留PLC的腰椎融合術(shù)中不僅需要實(shí)施有效的椎管減壓,而且需通過(guò)融合器及椎弓根釘維持脊柱運(yùn)動(dòng)中多軸向的穩(wěn)定,最終提高手術(shù)療效并減少術(shù)后并發(fā)癥。后路腰椎融合術(shù)中隨著椎間融合器及椎弓根釘?shù)膹V泛使用,相關(guān)并發(fā)癥報(bào)道也逐漸增多。研究表明內(nèi)植物的初始穩(wěn)定性至關(guān)重要,而這將直接影響植骨融合的進(jìn)程。導(dǎo)航引導(dǎo)下椎弓根釘植入在置釘?shù)臏?zhǔn)確性方面已得到充分的證實(shí)。借助導(dǎo)航可實(shí)現(xiàn)融合器的精準(zhǔn)置入以提高其初始穩(wěn)定,進(jìn)而維持脊柱的整體穩(wěn)定�？傊挥型ㄟ^(guò)生物力學(xué)持續(xù)研究才能對(duì)PLC結(jié)構(gòu)力學(xué)特性做到準(zhǔn)確認(rèn)識(shí)。國(guó)內(nèi)外生物力學(xué)研究過(guò)程中,有限元分析法以其傳統(tǒng)方法無(wú)法比擬的優(yōu)勢(shì)并成為人體生物力學(xué)研究系統(tǒng)中重要組成部分。本文正是對(duì)PLC結(jié)構(gòu)的生物力學(xué)特性展開研究并結(jié)合相關(guān)手術(shù)方式臨床療效觀察,進(jìn)一步分析驗(yàn)證實(shí)驗(yàn)結(jié)果。最終為臨床治療提供生物力學(xué)依據(jù)。基于此目的分以下兩部分進(jìn)行研究。第一部分保留后方韌帶復(fù)合體對(duì)腰椎后路手術(shù)影響的有限元分析目的：構(gòu)建脊柱腰椎L1-L3三維有限元模型,運(yùn)用三維有限元方法分析后方韌帶復(fù)合體缺失的全椎板切除術(shù)及雙側(cè)椎弓根螺釘置入后脊柱穩(wěn)定性變化和應(yīng)力分布情況。方法：采集1例成年健康男性志愿者L1-L3 CT數(shù)據(jù),應(yīng)用Mimics14.11、 3-matic(V6.0)、Ansys 15.0等軟件構(gòu)建L1-L3有限元模型。后方韌帶復(fù)合體完整有限元模型(A組)、后方韌帶復(fù)合體缺失的全椎板切除模型(B組)、后方韌帶復(fù)合體缺失的全椎板切除后雙側(cè)單節(jié)段椎弓根螺釘內(nèi)固定系統(tǒng)模型(C組)。模擬腰椎行前屈、后伸、側(cè)彎及旋轉(zhuǎn),分別對(duì)3個(gè)模型進(jìn)行有限元力學(xué)分析。結(jié)果：①根據(jù)不同運(yùn)動(dòng)狀態(tài)下的ROM均值比較,B組ROM均值大于A組、C組(P0.05),C組ROM均值小于B組(P0.05)。②根據(jù)不同運(yùn)動(dòng)狀態(tài)下的VonMises最大應(yīng)力比較可知,B組最大應(yīng)力大于A組(P0.05),C組最大應(yīng)力大于B組(P0.05)。最大應(yīng)力提示椎板切除后椎體局部受力增加,尤以相鄰椎板、椎弓根及關(guān)節(jié)處增加明顯。結(jié)論：①后方韌帶復(fù)合體結(jié)構(gòu)對(duì)維持脊柱穩(wěn)定性起到重要作用,切除后方韌帶復(fù)合體結(jié)構(gòu)可使椎體間活動(dòng)范圍加大,影響椎體穩(wěn)定性。②后方韌帶復(fù)合體缺失下使用內(nèi)固定物,活動(dòng)范圍減小,節(jié)段內(nèi)椎體穩(wěn)定性增加,但脊柱后方應(yīng)力重新分布。固定相鄰節(jié)段應(yīng)力增加,可加速退變。③過(guò)大的應(yīng)力集中會(huì)增加內(nèi)固定失敗風(fēng)險(xiǎn)。第二部分保留后方韌帶復(fù)合體在手術(shù)治療腰椎退行性疾病中的回顧性對(duì)照研究目的：比較保留后方韌帶復(fù)合體的改良椎板切除減壓術(shù)、保留后方韌帶復(fù)合體的改良椎板切除減壓術(shù)導(dǎo)航輔助內(nèi)固定與傳統(tǒng)全椎板切除減壓治療腰椎退行性疾病的近期、遠(yuǎn)期療效。方法：回顧性對(duì)照分析2013年1月至2015年1月通過(guò)腰椎后路減壓融合內(nèi)固定術(shù)治療腰椎退行性疾病98例,按手術(shù)方式分為后方韌帶復(fù)合體缺失的全椎板減壓組(A組)、保留后方韌帶復(fù)合體改良椎板減壓組(B組)、保留后方韌帶復(fù)合體改良椎板減壓導(dǎo)航輔助內(nèi)固定組(C組)。分別記錄三組手術(shù)時(shí)間、術(shù)中出血量和住院時(shí)間；術(shù)后隨訪采用ODI及VAS評(píng)分系統(tǒng)評(píng)價(jià)術(shù)后療效；通過(guò)術(shù)前術(shù)后影像學(xué)資料測(cè)量椎間隙角度變化、融合器深度偏差、融合器軸線偏差,同時(shí)評(píng)價(jià)植骨融合程度及椎弓根螺釘準(zhǔn)確率。結(jié)果：三組的手術(shù)時(shí)間和住院天數(shù)均無(wú)明顯差異,但A組的手術(shù)出血量明顯大于B組、C組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后三組ODI及VAS評(píng)分均較術(shù)前明顯下降,差異有統(tǒng)計(jì)學(xué)意義(P0.05),三組間ODI及VAS評(píng)分無(wú)明顯差異。A組末次隨訪鄰近椎間隙角度丟失較B組、C組明顯(P0.05),C組在融合器植入深度及位置方面優(yōu)于A組、B組(P0.05),三組在融合率及椎弓根釘準(zhǔn)確率方面三組差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論：①后方韌帶復(fù)合體是脊柱后柱重要結(jié)構(gòu),破壞其結(jié)構(gòu)完整可造成融合鄰近節(jié)段加速退變②有效的椎管減壓均能獲得滿意的早期療效③導(dǎo)航下可實(shí)現(xiàn)內(nèi)植物的精準(zhǔn)置入,為一種理想引導(dǎo)模式。
[Abstract]:Degenerative disease of lumbar posterior arthrodesis has become the most commonly used surgical treatment. The spinal canal decompression and intervertebral fusion sufficient internal fixation is an effective method to relieve the pain and the reconstruction of spinal stability. Conventional posterior lumbar interbody fusion with laminectomy and spinal canal, early achieved good therapeutic effect. But the long-term follow-up data show that the posterior laminectomy resection will affect the long-term stability of the spine, resulting in instability; adjacent segment degeneration has become one of the major complications of posterior lumbar interbody fusion after decompression. The choice is an important reason. The traditional laminectomy to the posterior ligamentous complex (Posterior Ligament, Complex, PLC) structure resection directly affects the posterior stability however, accelerated degeneration of the adjacent segments can generate the corresponding clinical symptoms, some patients must choose surgery again.PLC The mechanical properties of tension band structure to become an important structure to maintain the stability of the spinal column. Keep PLC lumbar fusion not only need to implement effective decompression of the spinal canal, and through the fusion and pedicle screw to maintain spinal movement in multi axial stability, and ultimately improve the surgical effect and reduce postoperative complications. Posterior lumbar interbody fusion with the widespread use of interbody fusion and pedicle screw, complications reported is gradually increasing. The initial stability study showed that vital plant, which will directly affect the fusion process. Guided implantation of pedicle screw has been fully confirmed in the accuracy of screw placement. With the help of navigation can realize the precise placement of the cages in order to improve the initial stability, and maintain the overall stability of the spine. In conclusion only through continuous research on biomechanical structure mechanical properties of PLC to do To accurately understand the biomechanical research at home and abroad. In the process, the finite element analysis method with the traditional method of incomparable advantages and become an important part of the human body biomechanics research system. This paper is the biomechanical characteristics of PLC structure research and observe the clinical curative effect of combined operation mode, further analysis of experimental results. The final provide biomechanics the basis for clinical treatment. This is divided into two parts. The first part is studied based on the retention of the posterior ligamentous complex of posterior lumbar surgery effect of finite element analysis objective: to construct a three-dimensional finite element model of the lumbar spine L1-L3, using three-dimensional finite element method in stability analysis of spinal posterior ligament complex missing laminectomy and bilateral pedicle screw implantation and the distribution of stress. Methods: collected 1 cases of healthy adult male volunteers L1-L3 CT Data, application of Mimics14.11, 3-matic (V6.0), L1-L3 finite element model was established with Ansys 15 software. The finite element model of complete posterior ligament complex (A group), laminectomy model posterior ligament complex deletion (B group), model of fixed system posterior ligament loss after total laminectomy and bilateral single segmental pedicle screw in (group C). The simulation for lumbar flexion, extension, lateral bending and rotation of the finite element mechanics analysis of the 3 models. Results: 1. According to the different state of motion ROM mean comparison, B group mean ROM than in the A group, C group, C group (P0.05) ROM means less than B group (P0.05). According to the different state of motion of VonMises maximum stress compared with B group, the maximum stress is higher than that of group A (P0.05) C group, the maximum stress is higher than that of group B (P0.05). The maximum stress that after laminectomy vertebral local stress increase, especially in the adjacent lamina, pedicle and joint at Conclusion: the increased significantly. The posterior ligamentous complex structure plays an important role in maintaining the stability of the spine, resection of the posterior ligamentous complex structure can make the intervertebral activities to increase the scope of influence the stability of the vertebral body. Use in the fixation of posterior ligamentous complex loss, reduced its range, increase in segment posterior vertebral stability, but the redistribution of stress fixed. Adjacent segment stress increases, can accelerate the degeneration. The excessive stress concentration will increase the risk of failure of internal fixation. The second part to retain the posterior ligamentous complex in the surgical treatment of the control objective to study lumbar degenerative disease: a comparison of the modified posterior ligamentous complex lamina resection decompression, laminectomy and posterior ligament sparing modified complex navigation assisted resection decompression fixation with traditional laminectomy decompression in the treatment of lumbar degenerative disease recently, long-term Efficacy. Methods: a retrospective analysis from January 2013 to January 2015 through the control of lumbar posterior decompression and fusion with internal fixation in the treatment of lumbar degenerative disease in 98 cases, according to the operation mode is divided into the posterior ligamentous complex deletion laminectomy group (A group), retention of the posterior ligamentous complex modified laminectomy group (B group), retention of the posterior ligamentous complex improvement laminectomy navigation assisted internal fixation group (C group). Three groups were recorded the operation time, bleeding volume and hospitalization time; the postoperative curative effect of ODI and VAS scoring system to evaluate the postoperative follow-up by; through changes in preoperative imaging data after measuring the intervertebral angle, fusion depth deviation, fusion axis deviation at the same time, bone fusion and pedicle screw accuracy. Results: the operation time of the three groups and hospitalization days were not significantly different, but A group blood loss was significantly higher than that of B group, C group, difference There was statistical significance (P0.05). After the operation of three groups of ODI and VAS were decreased significantly, there were statistically significant differences between the three groups (P0.05), ODI and VAS were no significant differences in the.A group at the end of the follow-up of adjacent intervertebral angle loss compared with B group, C group, C group significantly (P0.05) in cage insertion depth and position is better than that of A group, B group (P0.05), the three groups in the rate of fusion and pedicle screw accuracy rate had no significant difference between the three groups (P0.05). Conclusion: the posterior ligament complex is the posterior column structure, destroying the structure of integrity can be caused by fusion of adjacent segment degeneration. Effective decompression can obtain satisfactory curative effect of the early navigation system can realize the precise placement within the plant, as an ideal guide mode.

【學(xué)位授予單位】：廣西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R687.3

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