本文選題：術(shù)中CT導(dǎo)航 + 徒手置釘�。� 參考：《大連醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的:通過對(duì)比分析顱頸交界畸形(Craniovertebral Junction Malformation)患者術(shù)后影像學(xué)改變及有螺釘穿出皮質(zhì)數(shù)量及并發(fā)癥,探討分析樞椎徒手椎弓根螺釘固定技術(shù)與術(shù)中CT導(dǎo)航下顱頸交界區(qū)畸形后路釘棒固定手術(shù)中的優(yōu)缺點(diǎn)。資料與方法:本研究患者為沈陽軍區(qū)總醫(yī)院神經(jīng)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(gè)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(cè)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(jīng)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(jì)失調(diào),眼球震顫、Romberg征陽性。將患者隨機(jī)分為A、B兩組,均采用術(shù)背側(cè)減壓手術(shù),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(jīng)驗(yàn)螺釘固定,B組采用術(shù)中CT聯(lián)合神經(jīng)導(dǎo)航下確定螺釘進(jìn)釘點(diǎn)及固定入路。A組徒手根據(jù)術(shù)前普通CT檢查確定進(jìn)釘位置及角度后手錐鉆取進(jìn)釘入路,探針植入,B組在CT導(dǎo)航下直接固定釘棒。應(yīng)用術(shù)中CT掃描進(jìn)一步驗(yàn)證椎弓根螺釘位置,無螺釘穿出皮質(zhì)結(jié)束螺釘植入。A組根據(jù)術(shù)中CT結(jié)果,將所檢測(cè)到釘棒穿透骨皮質(zhì)、壓迫脊髓、神經(jīng)、椎動(dòng)脈的釘棒重新調(diào)整,再次行CT導(dǎo)航滿意后固定結(jié)束。結(jié)果:術(shù)后22例(84.6%)患者Nurick分級(jí)癥狀至少改善l級(jí)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(shù)中均未發(fā)生椎動(dòng)脈及神經(jīng)功能損上,A組平均手術(shù)時(shí)間為146min,出血量平均為194ml,B組平均手術(shù)時(shí)間為187min,出血量平均為214ml。所有患者術(shù)程順利,術(shù)中均未輸血。術(shù)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(duì)癥處理后均恢復(fù)良好,B組有1例出現(xiàn)肺部感染并發(fā)癥,給予對(duì)癥治療后癥狀好轉(zhuǎn)。術(shù)后三月門診復(fù)查19例,電話隨訪5例,失訪2例。術(shù)后3月門診復(fù)查均未見螺釘松動(dòng),所有隨訪患者癥狀明顯緩解。結(jié)論:1.術(shù)中CT可準(zhǔn)確評(píng)價(jià)寰樞關(guān)節(jié)復(fù)位情況和植入螺釘?shù)能壽E、植入深度及是否穿出皮質(zhì)情況,避免了患者二次手術(shù)的風(fēng)險(xiǎn);對(duì)于提高手術(shù)定位準(zhǔn)確性、手術(shù)路徑及提高手術(shù)成功率和有效率等具有重要意義。但術(shù)中患者輻射暴露時(shí)間相對(duì)較長(zhǎng),且手術(shù)費(fèi)用相對(duì)較高。2.徒手植釘對(duì)技術(shù)要求高,需扎實(shí)的專業(yè)知識(shí)及影像學(xué)定位技能。雖患者手術(shù)時(shí)間、放射線暴露時(shí)間短,但穿透皮質(zhì)的風(fēng)險(xiǎn)較術(shù)中CT導(dǎo)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(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R687.3

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