腰椎管狹窄的動態(tài)MRI研究及手術(shù)模型的有限元分析
發(fā)布時間：2018-09-04 20:40
【摘要】：目的:探討腰椎椎管狹窄癥患者硬膜囊、側(cè)隱窩等隨體位變化的規(guī)律;并解釋其癥狀與影像學(xué)表現(xiàn)的“分離現(xiàn)象”。構(gòu)建腰椎有限元模型;比較后路全椎板切減壓與椎板切除+椎弓根釘內(nèi)固定的應(yīng)力分布及對腰椎度的影響,探討減壓手術(shù)對腰椎穩(wěn)定性的影響、以及輔以椎弓根釘內(nèi)固定的必要性。方法:隨機(jī)選取2016年7月-2017年1月就診于天津醫(yī)院的腰椎管狹窄癥患者進(jìn)行全腰椎動態(tài)位MRI檢查,采用Mimics17.0進(jìn)行測量收集椎管橫截面積、椎管矢徑等參數(shù),分析其變化規(guī)律。以CT資料為基礎(chǔ),利用Mimics10.01、Rhino5.0、Abaqus6.12等軟件進(jìn)行建模并驗(yàn)證模型有效性。以L3椎體為主要手術(shù)節(jié)段,分別構(gòu)建全椎板切除組、內(nèi)固定組有限元模型。設(shè)定S1椎體下部自由度為0,在L1椎體上部施加400N預(yù)載荷模擬人體自身負(fù)荷,然后分別施加8N·m,6N·m,4N·m彎矩模擬屈伸、旋轉(zhuǎn)等運(yùn)動。結(jié)果:共記8例患者(5女3男)完成檢查。測量分析結(jié)果:1)骨性椎管矢徑不隨體位發(fā)生明顯變化;硬膜囊矢徑、硬膜囊矢徑/骨性椎管矢徑比值在前屈位最大,后伸位最小。2)骨性椎管橫截面積不隨體位發(fā)生明顯變化;硬膜囊橫截面積、硬膜囊橫截面積/骨性椎管橫截面積在前屈位最大,后伸位最小。3)左、右兩側(cè)盤黃間隙在前屈位時均顯著增加,下腰椎尤其顯著;左、右兩側(cè)盤黃間隙比值未表現(xiàn)出明顯規(guī)律,均在1.0左右。有限元研究顯示:1)正常組在后伸、扭轉(zhuǎn)時較部分體外實(shí)驗(yàn)數(shù)據(jù)偏大,但無統(tǒng)計學(xué)差異,不影響后續(xù)分析。2)全椎板切除組各工況下ROM及椎間盤平均應(yīng)力較術(shù)前升高,手術(shù)節(jié)段較明顯,屈伸、旋轉(zhuǎn)運(yùn)動尤為顯著;3)內(nèi)固定組各工況下ROM及椎間盤平均應(yīng)力較術(shù)前減小,手術(shù)節(jié)段較明顯,在屈伸及側(cè)屈運(yùn)動時較為顯著;4)全椎板切除組各工況下ROM較內(nèi)固定組均不同程度升高,前屈運(yùn)動最明顯;全椎板切除組各椎間盤平均應(yīng)力較內(nèi)固定組增加,手術(shù)節(jié)段更顯著;5)兩組的非手術(shù)節(jié)段在各工況下ROM變化不顯著,椎間盤平均應(yīng)力均增加,尤其L5S1節(jié)段顯著。結(jié)論:1)硬膜囊矢徑、橫截面積、盤黃間隙等在腰椎前屈時最大,后伸時最小;2)纖維性椎管的體位性變化與椎間盤、硬膜外脂肪等的變化相關(guān);3)骨性椎管的徑線不隨體位發(fā)生顯著變化;4)腰椎管狹窄是退變基礎(chǔ)上發(fā)生的,上位腰椎節(jié)段性活動造成的椎間孔動態(tài)性狹窄;5)全椎板切除減壓可造成腰椎活動度、各椎間盤平均應(yīng)力增加,可導(dǎo)致腰椎穩(wěn)定性下降,甚至失穩(wěn);6)椎弓根內(nèi)固定可改善腰椎穩(wěn)定性,但非手術(shù)節(jié)段可出現(xiàn)應(yīng)力集中,可加速退變;7)臨床實(shí)踐中應(yīng)考慮人體自身的代償修復(fù)能力,嚴(yán)格把握內(nèi)固定融合指征及節(jié)段,避免鄰近節(jié)段病變。
[Abstract]:Objective: to investigate the changes of dural sac and lateral recess in patients with lumbar spinal stenosis, and to explain the "separation phenomenon" between symptoms and imaging manifestations. The finite element model of lumbar vertebrae was established, the stress distribution of posterior total laminectomy and pedicle screw fixation was compared with that of laminectomy, and the effect of decompression on lumbar stability was discussed. And the necessity of pedicle screw internal fixation. Methods: the lumbar spinal stenosis patients in Tianjin Hospital from July 2016 to January 2017 were randomly selected for the whole lumbar dynamic MRI examination. The cross-sectional area and the sagittal diameter of the spinal canal were measured by Mimics17.0, and the change rules were analyzed. Based on CT data, Mimics10.01,Rhino5.0,Abaqus6.12 and other software are used to model and verify the validity of the model. The finite element models of laminectomy group and internal fixation group were constructed with L3 vertebrae as the main segment. The degree of freedom in the lower part of S1 vertebra is 0, and 400N preload is applied to the upper part of L1 vertebra to simulate the human body's own load, and then the bending moment is applied to simulate the motion of flexion and extension, rotation and so on, respectively. Results: 8 patients (5 women and 3 men) completed the examination. The ratio of sagittal diameter of dural sac to sagittal diameter of bony vertebral canal was the largest in anterior flexion position, and the minimum in extension position was 2. 2) the cross-sectional area of osseous spinal canal did not change significantly with postural position, and the ratio of sagittal diameter of dural sac to sagittal diameter of bony vertebral canal was the largest in anterior flexion position and the smallest in posterior extension position. The cross sectional area of dural sac, the cross sectional area of dural sac / osseous spinal canal was the largest in anterior flexion position and the smallest in posterior extension position. The ratio of the right side of the disc to the yellow space showed no obvious regularity, which was about 1.0. The finite element analysis showed that the ROM and average stress of intervertebral disc in the normal group were higher than those in the pre-operation group, but there was no statistical difference in the extension and torsion of the normal group, but there was no significant difference in the follow-up analysis of the two groups, and the mean stress of the ROM and intervertebral disc in the total laminectomy group was higher than that before the operation. The mean stress of ROM and intervertebral disc in the internal fixation group was significantly lower than that in the preoperative group, and the operative segment was more obvious than that in the operation group, and the mean stress of the intervertebral disc in the internal fixation group was significantly lower than that in the preoperative group. In flexion, extension and lateral flexion movement, the ROM in the laminectomy group was higher than that in the internal fixation group, and the anterior flexion movement was the most obvious, and the average stress of each disc in the total laminectomy group was higher than that in the internal fixation group, and that in the laminectomy group was higher than that in the internal fixation group. There was no significant change in ROM and the mean stress of intervertebral disc increased in both groups, especially in L5S1 segment. Conclusion: the sagittal diameter of dural capsule, cross sectional area, yellow disc space and so on are the largest in anterior flexion of lumbar vertebrae and the smallest in extension of lumbar vertebrae. 2) the changes of position and intervertebral disc in fibrous spinal canal. The change of epidural fat was related to the change of epidural fat (3) the diameter of the bony spinal canal did not change significantly with the position. 4) the stenosis of the lumbar spinal canal occurred on the basis of degeneration. The dynamic stenosis of intervertebral foramen caused by segmental activity of upper lumbar vertebrae 5) total laminectomy and decompression can result in lumbar movement, the average stress of each intervertebral disc increases, and the stability of lumbar vertebrae decreases. Even instability 6) pedicle internal fixation can improve the stability of lumbar vertebrae, but stress concentration may occur in non-operative segment and accelerate degeneration. 7) in clinical practice, the compensatory repair ability of human body itself should be considered, and the indication and segment of internal fixation fusion should be strictly grasped. Avoid adjacent lesions.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R687.3
本文編號：2223270
[Abstract]:Objective: to investigate the changes of dural sac and lateral recess in patients with lumbar spinal stenosis, and to explain the "separation phenomenon" between symptoms and imaging manifestations. The finite element model of lumbar vertebrae was established, the stress distribution of posterior total laminectomy and pedicle screw fixation was compared with that of laminectomy, and the effect of decompression on lumbar stability was discussed. And the necessity of pedicle screw internal fixation. Methods: the lumbar spinal stenosis patients in Tianjin Hospital from July 2016 to January 2017 were randomly selected for the whole lumbar dynamic MRI examination. The cross-sectional area and the sagittal diameter of the spinal canal were measured by Mimics17.0, and the change rules were analyzed. Based on CT data, Mimics10.01,Rhino5.0,Abaqus6.12 and other software are used to model and verify the validity of the model. The finite element models of laminectomy group and internal fixation group were constructed with L3 vertebrae as the main segment. The degree of freedom in the lower part of S1 vertebra is 0, and 400N preload is applied to the upper part of L1 vertebra to simulate the human body's own load, and then the bending moment is applied to simulate the motion of flexion and extension, rotation and so on, respectively. Results: 8 patients (5 women and 3 men) completed the examination. The ratio of sagittal diameter of dural sac to sagittal diameter of bony vertebral canal was the largest in anterior flexion position, and the minimum in extension position was 2. 2) the cross-sectional area of osseous spinal canal did not change significantly with postural position, and the ratio of sagittal diameter of dural sac to sagittal diameter of bony vertebral canal was the largest in anterior flexion position and the smallest in posterior extension position. The cross sectional area of dural sac, the cross sectional area of dural sac / osseous spinal canal was the largest in anterior flexion position and the smallest in posterior extension position. The ratio of the right side of the disc to the yellow space showed no obvious regularity, which was about 1.0. The finite element analysis showed that the ROM and average stress of intervertebral disc in the normal group were higher than those in the pre-operation group, but there was no statistical difference in the extension and torsion of the normal group, but there was no significant difference in the follow-up analysis of the two groups, and the mean stress of the ROM and intervertebral disc in the total laminectomy group was higher than that before the operation. The mean stress of ROM and intervertebral disc in the internal fixation group was significantly lower than that in the preoperative group, and the operative segment was more obvious than that in the operation group, and the mean stress of the intervertebral disc in the internal fixation group was significantly lower than that in the preoperative group. In flexion, extension and lateral flexion movement, the ROM in the laminectomy group was higher than that in the internal fixation group, and the anterior flexion movement was the most obvious, and the average stress of each disc in the total laminectomy group was higher than that in the internal fixation group, and that in the laminectomy group was higher than that in the internal fixation group. There was no significant change in ROM and the mean stress of intervertebral disc increased in both groups, especially in L5S1 segment. Conclusion: the sagittal diameter of dural capsule, cross sectional area, yellow disc space and so on are the largest in anterior flexion of lumbar vertebrae and the smallest in extension of lumbar vertebrae. 2) the changes of position and intervertebral disc in fibrous spinal canal. The change of epidural fat was related to the change of epidural fat (3) the diameter of the bony spinal canal did not change significantly with the position. 4) the stenosis of the lumbar spinal canal occurred on the basis of degeneration. The dynamic stenosis of intervertebral foramen caused by segmental activity of upper lumbar vertebrae 5) total laminectomy and decompression can result in lumbar movement, the average stress of each intervertebral disc increases, and the stability of lumbar vertebrae decreases. Even instability 6) pedicle internal fixation can improve the stability of lumbar vertebrae, but stress concentration may occur in non-operative segment and accelerate degeneration. 7) in clinical practice, the compensatory repair ability of human body itself should be considered, and the indication and segment of internal fixation fusion should be strictly grasped. Avoid adjacent lesions.
【學(xué)位授予單位】：天津醫(yī)科大學(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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