【摘要】：背景與目的:顱頸交界區(qū)畸形是從顱底到樞椎C2(Cervical 2)和第三頸椎C3(Cervical 3)椎間盤之間的病變,如寰樞椎脫位、顱底凹陷等,造成神經(jīng)功能損傷,使患者出現(xiàn)四肢乏力,行走不穩(wěn)等癥狀。顱頸交界區(qū)后路內(nèi)固定是目前治療畸形的有效方法,通常包括寰樞椎內(nèi)固定術(shù)和枕頸后路內(nèi)固定術(shù),具有穩(wěn)定的生物力學(xué)和廣泛的適用性,但對于顱頸交界區(qū)畸形患者,常存在寰枕融合、椎動(dòng)脈走行存在廣泛異常等畸形解剖情況,造成螺釘植釘位置選擇不同于正常人,例如樞椎椎弓根解剖變異,此時(shí)如果行椎弓根固定,臨床上易造成脊髓和椎動(dòng)脈損傷,或者根本無法固定,癱瘓及死亡的發(fā)生率較高。一般的內(nèi)固定器械基于椎弓根螺釘設(shè)計(jì),畸形時(shí)樞椎椎弓根常存在變異問題,不能滿足對于顱頸交界區(qū)畸形的復(fù)位和固定治療要求,而樞椎椎板在具有良好植釘條件。針對以上問題,本文從顱頸交界區(qū)畸形醫(yī)學(xué)數(shù)據(jù)出發(fā),建立幾何精度較高和參數(shù)設(shè)定可靠的顱頸交界區(qū)畸形有限元模型,通過對其生物力學(xué)的分析獲得了不同生理狀況下畸形有限元模型寰樞椎外側(cè)關(guān)節(jié)面的應(yīng)力分布情況,為下一步手術(shù)方案的選擇以及內(nèi)固定裝置的設(shè)計(jì)提供了一個(gè)思路。方法:獲取1例顱頸交界區(qū)畸形枕骨和頸椎的CT掃描圖像,利用三維造型和有限元軟件建立顱頸交界區(qū)的三維有限元模型。施加生理載荷和邊界條件,通過比較該模型與正常模型活動(dòng)度的差異結(jié)合臨床觀察經(jīng)驗(yàn),驗(yàn)證模型的有效性,同時(shí)分析寰樞椎外側(cè)關(guān)節(jié)應(yīng)力分布;選取38例顱頸交界區(qū)畸形的患者,根據(jù)解剖學(xué)測量、有限元分析的結(jié)果,術(shù)中在數(shù)字化導(dǎo)航的幫助下進(jìn)行手術(shù)。結(jié)果:建立幾何精度較高和參數(shù)設(shè)定可靠的顱頸交界區(qū)畸形有限元模型,各節(jié)段的活動(dòng)度與相關(guān)尸體實(shí)驗(yàn)和有限元模型數(shù)據(jù)的結(jié)果相比總體呈偏小趨勢,與一般顱頸交界區(qū)畸形患者臨床實(shí)際運(yùn)動(dòng)表現(xiàn)相符合。獲得了不同生理狀況下畸形有限元模型寰樞椎外側(cè)關(guān)節(jié)面的應(yīng)力分布情況,可以合理解釋寰樞外側(cè)關(guān)節(jié)結(jié)構(gòu)變異及其在維持寰樞椎之間穩(wěn)定的重要作用;根據(jù)解剖測量及有限元分析,術(shù)中分4種方式進(jìn)行手術(shù),術(shù)后復(fù)查CT及MRI顯示手術(shù)成功。結(jié)論:顱頸交界區(qū)畸形患者寰樞外側(cè)關(guān)節(jié)結(jié)構(gòu)發(fā)生變異,其生物力學(xué)穩(wěn)定性對于術(shù)前的診斷和術(shù)中治療操作具有一定價(jià)值;在臨床中創(chuàng)新性提出了手術(shù)4種分型,為醫(yī)生提供了一種全新準(zhǔn)確、安全、可靠的方法,在脊柱外科具有較大的應(yīng)用前景。
[Abstract]:Background & objective: Craniocervical junction malformation is a lesion from the base of the skull to the disc of C _ 2 (Cervical _ 2) and C _ 3 (Cervical _ 3) of the third cervical spine, such as atlantoaxial dislocation, skull base depression and so on. A symptom of unsteady walking. Posterior internal fixation of the craniocervical junction is an effective method for the treatment of deformities. It usually includes atlantoaxial internal fixation and posterior occipitocervical internal fixation. It has stable biomechanics and wide applicability, but it can be used in patients with craniocervical junction malformation. There is often atlantooccipital fusion, extensive malformation of vertebral artery and so on, which result in the screw placement being different from that of normal people, such as the anatomical variation of pedicle of axial vertebrae, if pedicle fixation is performed at this time, Clinically, spinal cord and vertebral artery injuries are likely to occur, or no fixation at all, with a high incidence of paralysis and death. The common internal fixation device is based on pedicle screw design. When the pedicle is malformed, the pedicle often has the problem of variation, which can not meet the requirement of reduction and fixation for the deformity of craniocervical junction, and the axial lamina has good screw planting condition. Based on the medical data of craniocervical junction malformation, a finite element model of craniocervical junction malformation with high geometric accuracy and reliable parameter setting is established in this paper. The stress distribution of atlantoaxial lateral articular surface under different physiological conditions was obtained by analyzing its biomechanics, which provided a way for the choice of operation plan and the design of internal fixation device. Methods: the CT scanning images of occipital bone and cervical vertebrae in a case of craniocervical junction malformation were obtained, and the three-dimensional finite element model of craniocervical junction was established by using 3D modeling and finite element software. Applying physiological load and boundary condition, the difference between the model and the normal model was compared with the clinical observation experience to verify the validity of the model, and the stress distribution of the lateral atlantoaxial joint was analyzed at the same time. 38 patients with craniocervical junction malformation were operated with the help of digital navigation according to the results of anatomical measurement and finite element analysis. Results: a finite element model of craniocervical junction deformity with high geometric accuracy and reliable parameter setting was established. The range of motion of each segment was smaller than that of related cadaveric experiment and finite element model data. It is consistent with the clinical manifestation of general craniocervical junction malformation. The stress distribution of atlantoaxial lateral articular surface was obtained under different physiological conditions, which can reasonably explain the structural variation of the lateral atlantoaxial joint and its important role in maintaining the stability between atlantoaxial joints. According to anatomical measurement and finite element analysis, the operation was performed in 4 different ways. Ct and MRI showed that the operation was successful. Conclusion: the structure of atlantoaxial lateral joint changes in patients with craniocervical junction malformation, and its biomechanical stability is valuable for preoperative diagnosis and intraoperative treatment. It provides a new accurate, safe and reliable method for doctors and has great application prospect in spinal surgery.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687

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