本文選題：中國人 + 下頸椎��； 參考：《吉林大學》2015年博士論文

【摘要】：背景：椎弓根螺釘、側塊螺釘及椎板螺釘越來越多被應用于治療各種頸椎疾患。本研究的目的旨在明確中國人下頸椎后方骨性結構的形態(tài)學特征，為設計適合國人下頸椎后方骨性結構特點的內(nèi)固定器械研發(fā)及內(nèi)固定置入技術提供理論依據(jù)。各種各樣頸椎后路內(nèi)固定物的發(fā)明及應用，使脊柱外科醫(yī)生可以通過單一頸椎后路術式即可同時達到恢復頸椎正常解剖序列和穩(wěn)定固定的目的，尤其對于下頸椎（C3-7）而言更是如此。目前，在脊柱外科臨床工作中，應用最為廣泛的頸椎后路固定器械仍是椎弓根螺釘。頸椎椎弓根在滿足三柱堅強固定的同時，也表現(xiàn)出很多潛在的風險及并發(fā)癥，同時由于頸椎解剖結構的特殊性以及頸脊髓的極其重要性及易損性，頸椎椎弓根螺釘?shù)呐R床使用受到了一定程度地限制。因此，椎板螺釘、側塊螺釘?shù)阮i椎后路內(nèi)固定器械越來越多應用于治療各種頸椎疾病。然而，這些內(nèi)固定器械及其相關置入技術均伴隨著相應的神經(jīng)、血管損傷的風險。眾所周知，對于頸椎后路固定器械而言，內(nèi)植物的設計合理與否以及如何安全置入均與頸椎后方骨性結構的解剖形態(tài)學特點密切相關，那么獲得這些關鍵解剖結構的詳細形態(tài)學數(shù)據(jù)就是內(nèi)植物合理設計及安全置入的先決條件。有關頸椎形態(tài)學的研究已有很多，通過回顧這些研究，我們發(fā)現(xiàn)，在不同種族之間，這些形態(tài)學數(shù)據(jù)是存在差異的。而對于在狹小空間內(nèi)進行精細操作的脊柱外科醫(yī)生而言，這些差異已足以引起我們的重視。很遺憾，到目前為止，尚未見以指導頸椎后路內(nèi)固定器械研發(fā)而進行的針對國人頸椎后方骨性結構形態(tài)學研究。如對于椎板螺釘設計及置入均極其重要的椎板松質(zhì)骨腔徑線的測量，及對于國人而言不同頸椎節(jié)段是否應該采用不同的側塊螺釘技術，均未見相關研究報道。所以我的研究旨在對國人下頸椎后方骨性結構進行形態(tài)學研究，為相應內(nèi)固定器械的設計和研發(fā)及內(nèi)固定技術的選擇提供理論依據(jù)。 薄層CT掃描及3D影像技術的快速發(fā)展為下頸椎的精細化形態(tài)學研究提供了足夠的技術支持。本研究即以256層極速CT掃描所得的下頸椎薄掃影像為基礎，對國人下頸椎后方骨性結構進行形態(tài)學研究。其中對國人進行椎板峽部內(nèi)徑（椎板松質(zhì)骨腔內(nèi)徑）、椎管骨性面積測量均屬首次。 方法：本研究選取100名成年患者進行256排薄層頸椎CT掃描（層厚0.5mm），進行3D重建及數(shù)字化處理后可以任意選擇各角度平面進行測量。共測量、共計測量分析1000個軸位層面、500個冠狀面層面、2000個矢狀面層面，合計分析3500個CT重建層面。測量了以下21個下頸椎形態(tài)學數(shù)據(jù)：1、椎弓根數(shù)據(jù)：椎弓根外徑（POW）、椎弓根內(nèi)徑（PIW）、椎弓根外高度（POH），椎弓根內(nèi)高度（PIH）、椎弓根軸長（PAL）、椎弓根外側角（PTA）；2、側塊數(shù)據(jù)：側塊縱徑（LMLD），側塊橫徑（LMTD），側塊冠狀面高度（LMCH），上關節(jié)突矢狀面成角（SAPA）；3、椎板外徑（LOW），椎板內(nèi)徑（LIW），椎板外高（LOW），椎板內(nèi)高（LIW），椎板軸長（LAL），椎板橫向外傾角（LTA）；4、棘突數(shù)據(jù)：軸位棘突長度（ASPL），矢狀面棘突長度（SSPL）；5、椎管數(shù)據(jù)：椎管縱徑（SCLD），椎管橫徑（SCTD），骨性椎管面積（OSCA）；6、Pavlov比值。將這100名患者按性別及是否存在發(fā)育性頸椎管狹窄癥（以Pavlov比值小于等于0.75為存在發(fā)育性頸椎管狹窄癥）進行分組。 結果：1、各下頸椎節(jié)段間比較，除椎板橫向外傾角（LTA）及椎管骨性面積（OSCA）兩個參數(shù)外，其余所有參數(shù)的差異均有統(tǒng)計學意義（P0.05）；2、椎弓根內(nèi)徑（PIW）、椎弓根外徑（POW）、椎弓根內(nèi)高（POH）、椎弓根外高（PIH）最大值均出現(xiàn)在C7，最小值出現(xiàn)在C3、C4（P0.05）；3、椎板內(nèi)徑（LIW）、椎板外徑（LOW）、椎板內(nèi)高（LIH）、椎板外高（LOH）的最小值均出現(xiàn)在C5，最大值出現(xiàn)在C7（P0.05）。4、C5,C6的側塊矢狀徑（LMLD）最大，LMLD及LMCH最小值均出現(xiàn)于C7（P0.05）；5、左右側對稱性參數(shù)比較發(fā)現(xiàn)，除椎板橫向外傾角（LTA）外，其余所參數(shù)差異均有統(tǒng)計學意義（P0.05）；6、男性與女性組參數(shù)比較，椎弓根橫向外傾角（PTA）在各節(jié)段差異均無統(tǒng)計學意義（P0.05），上關節(jié)突矢狀面成角（SAPA）在除C4、5兩節(jié)段外，在余各節(jié)段上差異均無統(tǒng)計學意義（P0.05），椎板橫向外傾角（LTA）在除C3、6兩節(jié)段外，在余各節(jié)段上差異無統(tǒng)計學意義（P0.05），椎管縱徑（SCLD）在除C7節(jié)段外，在余各節(jié)段上差異均無統(tǒng)計學意義（P0.05），其余各參數(shù)差異均有統(tǒng)計學意義：男性在所有線性參數(shù)上均大于女性（P0.05），但男性椎板外傾角小于女性（P0.05）；7、發(fā)育性頸椎管狹窄癥患者（DCS）與非發(fā)育性頸椎管狹窄癥（NDCS）組相比，椎板外高（LOH）在節(jié)段差異均有統(tǒng)計學意義（P0.05），NDCS組大于DCS組；椎管縱徑（SCLD）在除C7外各節(jié)段上差異均有統(tǒng)計學意義（P0.05），，NDCS組大于DCS組；椎板橫向外傾角（LTA）在C4、C6、C7節(jié)段上差異有統(tǒng)計學意義，NDCS組大于DCS組；椎管骨性面積上（OSCA）僅在C3節(jié)段差異有統(tǒng)計學意義； 結論：1、多個下頸椎后方骨性結構形態(tài)學參數(shù)在左右側、男女性別間、及發(fā)育性椎管狹窄癥患者與無發(fā)育性椎管狹窄癥患者間存在顯著性差異；2、在下頸椎不同節(jié)段，由于側塊矢狀徑的差異，應采用不同的側塊螺釘置入技術，在C3，C4，C7節(jié)段，尤其C7，我們推薦選用Magerl技術而非Roy-Camille；3、C5不適宜應用椎板螺釘固定，僅C7椎板可以安全容納直徑為2.5mm椎板螺釘。4、推薦下頸椎椎板螺釘置入角度為55°，長度應小于30mm；5、推薦下頸椎椎弓根螺釘置入角度為40°，長度應小于32mm；本研究結果為針對國人進行下頸椎后路內(nèi)固定器械的研發(fā)及安全置入提供理論依據(jù)。
[Abstract]:Background: pedicle screws, lateral mass screws, and laminar screws are increasingly used in the treatment of various cervical disorders. The purpose of this study is to clarify the morphological features of the skeletal structure in the rear of the lower cervical spine of the Chinese people, and to provide a method for the design of internal fixation instruments and internal fixation techniques suitable for the bone structure characteristics of the lower cervical spine. The invention and application of all kinds of posterior cervical fixation can enable spine surgeons to restore the normal anatomical sequence and stable fixation of the cervical spine by a single cervical posterior approach, especially for the lower cervical spine (C3-7). Currently, the most widely used in the clinical work of the spine surgery is the most widely used. The cervical pedicle screw is still a pedicle screw. The cervical pedicle also shows a lot of potential risks and complications while the three columns are strong and fixed. At the same time, the clinical use of the cervical vertebral arch root screw is limited to a certain extent due to the particularity of the anatomical structure of the cervical spine and the importance and vulnerability of the cervical spinal cord. Therefore, more and more cervical posterior internal fixation instruments such as laminar screw and lateral mass screw are used to treat various cervical spondylosis. However, these internal fixation instruments and their related implantation techniques are associated with the risk of corresponding nerve and vascular damage. It is well known that the design of the internal plants is reasonable for the posterior cervical fixation apparatus. And how to safely implantation is closely related to the anatomic characteristics of the posterior cervical bone structure. Then the detailed morphological data of these key anatomical structures are the prerequisites for the rational design of the internal plants and the precondition for safe placement. There are many studies on the morphology of the cervical vertebrae. Among the ethnic groups, these morphological data are different, and these differences have been enough to cause our attention to the spinal surgeons operating in a narrow space. It is regrettable that the skeletal structure of the posterior cervical spine has not been seen to guide the research and development of the posterior cervical instrumentation. Study. Such as the measurement of vertebral lamina screw design and placement which are extremely important, and whether different lateral block screws should be used in different cervical segments for Chinese people, no related research is reported. Therefore, my study aims to study the morphology of the skeletal structure behind the lower cervical vertebrae in Chinese. It provides a theoretical basis for the design and development of internal fixator and the selection of internal fixation technology.
The rapid development of thin layer CT scan and 3D imaging technology provides sufficient technical support for the study of the fine morphology of the lower cervical spine. This study is based on the thin scan of the lower cervical spine of 256 layers of rapid CT scanning. The measurement of the osseous area of the vertebral canal is the first time.
Methods: 100 adult patients were selected for 256 rows of thin layer cervical CT scans (layer thickness 0.5mm). After 3D reconstruction and digital processing, we can choose the plane of each angle at random. A total of 1000 axial planes, 500 coronal planes, 2000 sagittal planes and 3500 CT reconstruction levels were measured. The following 21 lower cervical morphological data were measured: 1, Shiumi Ne data: Shiumi Ne's external diameter (POW), Shiumi Ne internal diameter (PIW), external height (POH), Shiumi Ne inner height (PIH), Shiumi Ne axis length (PAL), Shiumi Ne's lateral angle (PTA); 2, side block longitudinal diameter (LMLD), lateral block transverse diameter (LMTD), lateral block coronary height (LMCH), upper joint sagittal 3, 3, outer diameter of vertebral lamina (LOW), internal diameter of laminae (LIW), high (LOW), high intraspinal (LIW), long (LAL) vertebral plate axis (LAL), lateral obliquity of vertebral lamina (LTA); 4, spine process length (ASPL), length of sagittal spinous process (SSPL); 5, vertebral canal longitudinal diameter (SCLD), vertebral canal transverse diameter (SCTD), osseous spinal canal area (OSCA); 6, dialectical Avlov ratio. The 100 patients were grouped by sex and the existence of developmental cervical spinal stenosis (with a Pavlov ratio less than or equal to 0.75 in the presence of developmental cervical spinal stenosis).
Results: 1, in the comparison of the lower cervical vertebra segments, except the two parameters of the lateral obliquity (LTA) and the vertebral canal bone area (OSCA), the differences of all the other parameters were statistically significant (P0.05); 2, Shiumi Ne internal diameter (PIW), Shiumi Ne's outer diameter (POW), Shiumi Ne inner height (POH), and the maximum of Shiumi Ne height (PIH) all appeared in C7, and the minimum value appeared in C3, C4 (P0.05); 3, the inner diameter of the laminae (LIW), the outer diameter of the vertebral lamina (LOW), the height of the laminae (LIH), the minimum of the outer laminae (LOH) were all in C5, the maximum value appeared in C7 (P0.05).4, C5, the largest of the lateral mass of C6, and the minimum value of the lateral mass of C6. The lateral symmetry parameters of the left and right sides found, except the lateral obliquity of the laminae, it was found. The difference of the remaining parameters was statistically significant (P0.05). 6, there was no significant difference in the transverse obliquity of the pedicle (PTA) between the male and the female group (P0.05), and the sagittal angle (SAPA) of the upper joints (SAPA) had no statistical significance (P0.05) in the remaining segments except the C4,5 segment (P0.05), and the lateral obliquity of the vertebral lamina (LTA) was not significant. There was no statistical significance (P0.05) on the remaining segments outside the C3,6 section. There was no statistical significance (P0.05) on the spinal canal longitudinal diameter (SCLD) except for the C7 segment (P0.05). The differences in the rest of the parameters were statistically significant: men were larger than women in all linear parameters (P0.05), but the obliquity of the vertebral lamina was less than that of women (P0.05). 7, compared with the non developmental cervical canal stenosis (NDCS) group, the difference of the extra laminar height (LOH) in the segment was statistically significant (P0.05) and the NDCS group was larger than the DCS group, and the longitudinal diameter of the spinal canal (SCLD) was statistically significant (P0.05) in each segment except C7 (P0.05), and the NDCS group was larger than the DCS group; the lateral obliquity of the vertebral lamina (LTA) was larger than that of the C7. In C4, C6, C7, the difference was statistically significant, NDCS group was larger than DCS group, and the vertebral canal osseous area (OSCA) was only statistically significant in C3 segment.
Conclusions: 1, there are significant differences between the left and right morphological parameters of the bone structure in the left and right side of the lower cervical spine, sex between men and women, and the patients with developmental spinal stenosis and non developmental spinal stenosis. 2, different lateral mass screws should be used in the different segments of the lower cervical spine because of the difference in the lateral mass sagittal diameter, in C3, C4, and C7 sections. Segment, especially C7, we recommend Magerl technology instead of Roy-Camille; 3, C5 is not suitable for pedicle screw fixation. Only C7 vertebral plate can safely accommodate the diameter of 2.5mm laminectomy screw.4. It is recommended that the angle of the lower cervical laminectomy screw is 55 degrees, the length should be less than 30mm; 5, the angle of the lower cervical pedicle screw is 40 degrees, and the length should be less than 32mm. This study provides a theoretical basis for the development and safe placement of posterior cervical internal fixation devices for Chinese.

【學位授予單位】：吉林大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R687.3

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