本文選題：術中CT導航 + 徒手置釘　； 參考：《大連醫(yī)科大學》2015年碩士論文

【摘要】：目的:通過對比分析顱頸交界畸形(Craniovertebral Junction Malformation)患者術后影像學改變及有螺釘穿出皮質數量及并發(fā)癥,探討分析樞椎徒手椎弓根螺釘固定技術與術中CT導航下顱頸交界區(qū)畸形后路釘棒固定手術中的優(yōu)缺點。資料與方法:本研究患者為沈陽軍區(qū)總醫(yī)院神經外科2011年10月-2015年2月收治顱頸交界畸形患者26例,其中男性8例,女性18例。年齡24~68歲,平均46.5歲,病程4個月~60年,平均5.6年。單純顱底凹陷9例,伴小腦扁桃體下疝者13例,寰樞椎側塊脫位者4例,伴脊髓空洞癥7例,臨床表現(xiàn):頸短伴偏斜、發(fā)跡偏低2例;頸枕肩部持續(xù)性疼痛18例,喉返神經受損癥狀3例。其14例出現(xiàn)感覺分離和骨骼肌萎縮等癥狀;23例表現(xiàn)為共濟失調,眼球震顫、Romberg征陽性。將患者隨機分為A、B兩組,均采用術背側減壓手術,A組男3例,女10例,年齡24~59歲(36.3±7.1歲),B組男5例,女8例,年齡24~68歲(31.5±10.6),其中A組行徒手經驗螺釘固定,B組采用術中CT聯(lián)合神經導航下確定螺釘進釘點及固定入路。A組徒手根據術前普通CT檢查確定進釘位置及角度后手錐鉆取進釘入路,探針植入,B組在CT導航下直接固定釘棒。應用術中CT掃描進一步驗證椎弓根螺釘位置,無螺釘穿出皮質結束螺釘植入。A組根據術中CT結果,將所檢測到釘棒穿透骨皮質、壓迫脊髓、神經、椎動脈的釘棒重新調整,再次行CT導航滿意后固定結束。結果:術后22例(84.6%)患者Nurick分級癥狀至少改善l級以上,2例(7.7%)患者癥狀無明顯改善,2例(7.7%)患者失訪。所有病例術中均未發(fā)生椎動脈及神經功能損上,A組平均手術時間為146min,出血量平均為194ml,B組平均手術時間為187min,出血量平均為214ml。所有患者術程順利,術中均未輸血。術后A組有5例出現(xiàn)并發(fā)癥:硬脊膜破損致腦脊液切口漏1例,切口感染1例,切口脂肪液化1例,肺部感染2例,給予對癥處理后均恢復良好,B組有1例出現(xiàn)肺部感染并發(fā)癥,給予對癥治療后癥狀好轉。術后三月門診復查19例,電話隨訪5例,失訪2例。術后3月門診復查均未見螺釘松動,所有隨訪患者癥狀明顯緩解。結論:1.術中CT可準確評價寰樞關節(jié)復位情況和植入螺釘的軌跡、植入深度及是否穿出皮質情況,避免了患者二次手術的風險;對于提高手術定位準確性、手術路徑及提高手術成功率和有效率等具有重要意義。但術中患者輻射暴露時間相對較長,且手術費用相對較高。2.徒手植釘對技術要求高,需扎實的專業(yè)知識及影像學定位技能。雖患者手術時間、放射線暴露時間短,但穿透皮質的風險較術中CT導航明顯偏高。
[Abstract]:Objective: to compare and analyze the postoperative imaging changes, the number of cortical perforations with screws and complications in patients with craniocervical junction malformation (Crani overtebral Junction malformation). Objective: to analyze the advantages and disadvantages of pedicle screw fixation technique and posterior screw fixation of craniocervical junction malformation under CT guidance. Materials and methods: a total of 26 patients with craniocervical junction malformation were admitted to the Department of Neurosurgery, Shenyang military region General Hospital from October 2011 to February 2015, including 8 males and 18 females. The average age was 46.5 years. The course of disease ranged from 4 months to 60 years with an average of 5.6 years. There were 9 cases of simple skull base depression, 13 cases of subtonsillar hernia, 4 cases of atlantoaxial lateral mass dislocation and 7 cases of syringomyelia. There were 3 cases of recurrent laryngeal nerve injury. The symptoms of sensory separation and skeletal muscle atrophy in 14 cases were ataxia and nystagmus Romberg sign positive. The patients were randomly divided into two groups: group A (n = 3) and group A (n = 10), group A (n = 5) and group B (n = 8), aged 24 to 59 years (n = 36.3 鹵7.1), group B (n = 8). The age of group A was 31.5 鹵10.6 years old. Group A was treated with manual experience screw fixation and group B was treated with intraoperative CT combined with neuronavigation to determine the point of screw entry and fixation approach. Group A was performed to determine the position and angle of the screw entry and the posterior hand cone drilling approach according to the conventional CT examination before operation. The probe was implanted into group B and fixed directly under CT guidance. The position of pedicle screw was further verified by intraoperative CT scan. According to the results of CT during operation, the screw rod was detected to penetrate the cortex of bone, compress the spinal cord, nerve and vertebral artery, and adjust the screw rod in group A according to the results of CT during the operation. Ct navigation was performed again after satisfactory fixation. Results: 22 cases (84.6%) with Nurick grade symptoms improved at least 2 cases (7. 7%) there were no significant improvement in 2 cases (7. 7%). The mean operative time was 146min in group A, 18.7 min in group B, and 214ml in group B. All patients had a smooth procedure and no blood transfusion was performed during the operation. In group A, complications were found in 5 cases: cerebrospinal fluid incision leakage (1 case), incision infection (1 case), incision fat liquefaction (1 case), pulmonary infection (2 cases). One patient in group B had pulmonary infection complications after symptomatic treatment, and the symptoms were improved after treatment. Three months after operation, 19 cases were checked out by telephone, 5 cases were followed up by telephone, 2 cases were lost. No screw loosening was found in the outpatient examination 3 months after operation, and the symptoms of all the patients were obviously relieved. Conclusion 1. Ct can accurately evaluate the reduction of atlantoaxial joint and the track of screw implantation, the depth of implantation and whether the cortex is perforated, thus avoiding the risk of secondary operation. It is of great significance to improve the successful rate and effective rate of operation. However, the duration of radiation exposure was relatively long and the operation cost was relatively high. 2. 2. High technical requirements, solid professional knowledge and imaging positioning skills are required. Although the operative time and radiation exposure time were shorter, the risk of penetrating cortex was significantly higher than that of CT navigation.
【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2015
【分類號】：R687.3

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