發(fā)布時(shí)間：2018-08-25 11:46

【摘要】：脊柱側(cè)凸矯形一直以來都是脊柱外科領(lǐng)域含金量最高的“高階”手術(shù)。脊柱畸形病因復(fù)雜,形態(tài)多樣,年齡分布廣,使得脊柱側(cè)彎的治療既有法可循又情況多變,個(gè)體化強(qiáng),成為很多脊柱外科醫(yī)生的手術(shù)禁區(qū)。近10年來,椎弓根螺釘系統(tǒng)的得以廣泛應(yīng)用,配合多級截骨技術(shù)的推廣,脊柱側(cè)凸后路三維截骨矯形手術(shù)取得了前所未有的進(jìn)步。椎弓根螺釘準(zhǔn)確置入,是釘棒系統(tǒng)完成良好矯形的前提,而脊柱畸形的患者由于椎體合并了旋轉(zhuǎn)和畸形,使得置釘準(zhǔn)確性大大折扣,由此給患者帶來了很多不可逆損傷甚至癱瘓。為了提高脊柱畸形患者椎弓根螺釘?shù)闹冕敎?zhǔn)確性,減少神經(jīng)血管及臟器損傷,提高手術(shù)成功率,各式各樣的脊柱導(dǎo)航系統(tǒng)得以研發(fā)應(yīng)用,包括神經(jīng)電生理檢測、計(jì)算機(jī)輔助術(shù)中CT三維重建導(dǎo)航、Mazor機(jī)器人導(dǎo)航以及基于椎體電阻抗的電子導(dǎo)航等等。脊柱導(dǎo)航系統(tǒng)的出現(xiàn),有望提高置釘?shù)臏?zhǔn)確性,縮短手術(shù)時(shí)間,減少術(shù)后并發(fā)癥,成為脊柱“高階”手術(shù)的保護(hù)傘。研究目的:本研究前期通過對脊柱機(jī)器人導(dǎo)航系統(tǒng)和基于生物電阻抗導(dǎo)航系統(tǒng)的學(xué)習(xí),熟練掌握兩種導(dǎo)航系統(tǒng)的操作方法。在脊柱側(cè)彎后路矯形術(shù)中分別應(yīng)用兩種不同的導(dǎo)航系統(tǒng)進(jìn)行椎弓根螺釘?shù)闹萌?分別就螺釘?shù)钠骄萌霑r(shí)間,螺釘?shù)臏?zhǔn)確性,電輻射量等參數(shù)進(jìn)行統(tǒng)計(jì)分析,進(jìn)一步驗(yàn)證脊柱導(dǎo)航新技術(shù)的實(shí)用性與安全性,為復(fù)雜脊柱畸形的矯形提供安全保障。研究方法:1、應(yīng)用脊柱機(jī)器人導(dǎo)航技術(shù)輔助脊柱側(cè)彎螺釘置入。首先完成脊柱機(jī)器人操作的理論學(xué)習(xí),熟悉脊柱機(jī)器人Renaissance系統(tǒng)(術(shù)前計(jì)劃、平臺(tái)固定、3D匹配、手術(shù)操作)及手術(shù)適應(yīng)癥;通過尸體的臨床培訓(xùn),熟練掌握機(jī)器人的實(shí)際操作。收集病例,針對需要手術(shù)矯形的脊柱側(cè)彎患者,術(shù)前完善影像學(xué)檢查并制定手術(shù)計(jì)劃。采用脊柱機(jī)器人導(dǎo)航技術(shù)進(jìn)行脊柱后路椎弓根螺釘?shù)闹萌?統(tǒng)計(jì)收集脊柱機(jī)器人導(dǎo)航輔助下置入的椎弓根螺釘?shù)臄?shù)量,術(shù)中電透視次數(shù),置釘時(shí)間,術(shù)后通過脊柱CT平掃,判定椎弓根螺釘?shù)臏?zhǔn)確性。分析數(shù)據(jù),完成脊柱機(jī)器人導(dǎo)航技術(shù)輔助置釘?shù)臏?zhǔn)確率及安全性統(tǒng)計(jì)。2、應(yīng)用基于椎體電阻抗的電子導(dǎo)航開路器輔助脊柱側(cè)彎螺釘置入。熟練掌握基于椎體電阻抗導(dǎo)航的設(shè)計(jì)原理及使用方法,隨機(jī)將脊柱側(cè)彎患者平均分配到實(shí)驗(yàn)組(電子導(dǎo)航組)與對照組(徒手置釘組)。分別用兩種不同的開路設(shè)備進(jìn)行椎弓根螺釘?shù)闹萌?對比電子導(dǎo)航開路器與傳統(tǒng)徒手開路器兩者之間置釘?shù)臏?zhǔn)確性(術(shù)后CT平掃),置釘時(shí)間及電輻射量的差別。整理數(shù)據(jù),分析電子導(dǎo)航開路器的臨床優(yōu)劣性。研究結(jié)果:1、本組共收集26例青少年特發(fā)性脊柱側(cè)彎患者,男性4例,女性22例,平均年齡(14.6±2.8)歲,主彎Cobb角平均值(68.8±7.2)°,機(jī)器人導(dǎo)航輔助下共置入221枚椎弓根螺釘,其余螺釘經(jīng)傳統(tǒng)徒手操作,平均匹配次數(shù)為(1.5±0.7)次,平均電透視次數(shù)為(9.6±2.5)次,每枚螺釘?shù)钠骄萌霑r(shí)間為(3.3±0.9)min,平均匹配時(shí)間(平臺(tái)固定+3D匹配)為(20.3±5.6)min,術(shù)后CT平掃驗(yàn)證,機(jī)器人導(dǎo)航輔助下椎弓根螺釘?shù)臏?zhǔn)確率高達(dá)96.8%(214/221)。2、本部分共收集48例青少年特發(fā)性脊柱側(cè)彎患者,男性7例,女性41例,平均年齡(15.2±2.6)歲;主彎Cobb角平均值(58.3±9.0)°,電子導(dǎo)航組置入161枚椎弓根螺釘,徒手置釘158枚,電子導(dǎo)航組螺釘準(zhǔn)確率97.5%(157/161),徒手置釘準(zhǔn)確性93.0%(147/158),電子導(dǎo)航組平均電透視次數(shù)(3.3±0.7)次,徒手操作組(5.5±0.8)次,電子導(dǎo)航組平均置釘時(shí)間(2.7±0.4)min,徒手組(3.2±0.6)min。研究結(jié)論:脊柱畸形復(fù)雜多樣,無論是冠狀位、矢狀位還是軸壯位都存在著一定的旋轉(zhuǎn)畸形,致使椎弓根螺釘?shù)闹萌胪耆揽啃g(shù)者的經(jīng)驗(yàn)和三維構(gòu)想�，F(xiàn)在的機(jī)器人導(dǎo)航技術(shù)通過術(shù)前術(shù)中的脊柱三維重建,指導(dǎo)置釘,大大減小了螺釘?shù)拇┛茁?基于阻抗的電子導(dǎo)航開路器,將不同組織的阻抗信息轉(zhuǎn)化為聲音和頻率,術(shù)者可以借此參考來尋找最佳的進(jìn)釘通路,降低了螺釘?shù)奈鹬寐?同時(shí)減少了醫(yī)生和患者的電輻射量。
[Abstract]:Scoliosis correction has always been the most gold-rich "high-level" surgery in the field of spinal surgery. The causes of spinal deformities are complex, diverse in shape, and widely distributed in age, making the treatment of scoliosis both feasible and changeable, with strong individualization, and becoming a forbidden area for many spine surgeons. In the past 10 years, the pedicle screw system has been widely used. Accurate placement of pedicle screws is a prerequisite for good orthodontics of the screw-rod system, and the accuracy of screw placement is greatly reduced in patients with spinal deformities due to the combination of rotation and deformity of the vertebral body. In order to improve the accuracy of pedicle screw placement in patients with spinal deformities, reduce the injury of nerves, blood vessels and organs, and improve the success rate of surgery, various spinal navigation systems have been developed and applied, including neuroelectrophysiological detection, computer-assisted intraoperative CT three-dimensional reconstruction navigation, Mazor. The emergence of spine navigation system is expected to improve the accuracy of screw placement, shorten the operation time, reduce postoperative complications, and become the umbrella for spinal "high-level" surgery. Objective: In the early part of this study, through the spine robot navigation system and based on bioelectrical impedance guidance. In the posterior spinal curvature surgery, two different navigation systems were used for the placement of pedicle screws. The average placement time, the accuracy of screws, electrical radiation and other parameters were statistically analyzed to further verify the new spinal navigation technology. Methods: 1. Robot-assisted scoliosis screw placement. First, complete the theoretical study of spinal robot manipulation, familiar with the Renaissance system (preoperative planning, platform fixation, 3D matching, operation) and hand manipulation. Surgical indications; clinical training of cadavers to master the actual operation of robots. Case collection, preoperative imaging examination and surgical planning for patients with scoliosis requiring surgical correction. Posterior pedicle screw placement using spinal robot navigation technology, statistical collection of spinal robot navigation assistance. The number of pedicle screws, the number of electro-fluoroscopy during operation, the time of screw placement, and the accuracy of pedicle screws were determined by CT plain scan after operation. The accuracy and safety of robot-assisted screw placement were statistically analyzed by analyzing the data. 2. The patients with scoliosis were randomly assigned to the experimental group (electronic navigation group) and the control group (unarmed screw group). Two different open-circuit devices were used to insert pedicle screws. The electronic navigation opener and the traditional one were compared. Results: 1. A total of 26 adolescent patients with idiopathic scoliosis were collected, including 4 males and 22 females, with an average age of (14.6 (+ 2.8) years, and the mean Cobb angle of the main curve (68.8 (+ 7.2)). A total of 221 pedicle screws were implanted with the aid of robot navigation. The other screws were operated by traditional bare hands. The average matching times were (1.5 The accuracy of pedicle screws assisted by human navigation was 96.8% (214/221). In this section, 48 adolescent idiopathic scoliosis patients, 7 males and 41 females, with an average age of (15.2 (+ 2.6) years, the average Cobb angle of the main curve (58.3 (+ 9.0)degrees), 161 pedicle screws, 158 bare-handed screws and 158 screws in the electronic navigation group were collected. The accuracy rate was 97.5% (157/161), 93.0% (147/158) for unarmed nailing, 3.3 (+ 0.7) for electrofluoroscopy, 5.5 (+ 0.8) for unarmed navigation, 2.7 (+ 0.4) min for electronic navigation, and 3.2 (+ 0.6) min for unarmed navigation. Because of the deformity of rotation, the placement of pedicle screws depends entirely on the experience and three-dimensional conception of the surgeon. Robotic navigation technology guides the placement of screws through preoperative and intraoperative three-dimensional reconstruction of the spine, which greatly reduces the penetration rate of the screws. Impedance-based electronic navigation opener converts the impedance information of different tissues into sound. And frequency, the surgeon can use this reference to find the best way to enter the screw, reduce the screw not to place rate, while reducing the doctor and patients with electrical radiation.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R687.3

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