發(fā)布時(shí)間：2018-09-13 11:17

【摘要】：背景:多節(jié)段頸椎病的術(shù)式選擇一直存在爭(zhēng)議。選擇多節(jié)段融合術(shù)不可避免的造成融合節(jié)段活動(dòng)度的丟失,生物力學(xué)已證實(shí)其對(duì)鄰近節(jié)段的影響比單節(jié)段融合更大。選擇多節(jié)段人工頸椎間盤(pán)置換術(shù)理論上是更好的選擇。但是人工頸椎間盤(pán)置換的手術(shù)指針?lè)浅?yán)格,多節(jié)段頸椎病中的某一節(jié)段可能不適合置換。另外,多節(jié)段置換手術(shù)操作難度增加、時(shí)間延長(zhǎng),其可能的并發(fā)癥還未知。鑒于這種權(quán)衡,聯(lián)合椎間盤(pán)置換與節(jié)段融合(Hybrid手術(shù))治療多節(jié)段頸椎病既是一個(gè)折中的方案,又可能是一個(gè)很有希望的手術(shù)。目前有少數(shù)學(xué)者的臨床研究報(bào)道了Hybrid手術(shù)的近期效果至少不差于傳統(tǒng)的多節(jié)段融合術(shù)。詳細(xì)比較兩節(jié)段置換、兩節(jié)段融合、Hybrid手術(shù)的生物力學(xué)特性的研究還比較缺乏,且結(jié)論還不一致;關(guān)于Hybrid手術(shù)本身因位置組合方式的不同造成生物力學(xué)差異的研究還未見(jiàn)報(bào)道。有鑒于此,我們?cè)O(shè)計(jì)本課題。目的:一、以有限元法分析兩節(jié)段置換、兩節(jié)段融合、Hybrid手術(shù)的生物力學(xué)特性,比較三種術(shù)式在手術(shù)節(jié)段、鄰近節(jié)段的生物力學(xué)差異,為臨床術(shù)式選擇提供生物力學(xué)基礎(chǔ)。二、在連續(xù)兩節(jié)段頸椎中通過(guò)融合與置換互換位置構(gòu)建相互對(duì)應(yīng)的兩種Hybrid手術(shù),比較相互對(duì)應(yīng)的兩種Hybrid手術(shù)之間的生物力學(xué)差異,進(jìn)而探討這種生物力學(xué)差異的根源,為臨床實(shí)施Hybrid手術(shù)時(shí)選擇怎樣的置換與融合的位置組合方式提供力學(xué)參考。方法:1.C2-T1頸椎有限元模型的建立和驗(yàn)證以健康志愿者薄層CT掃描圖像為數(shù)據(jù)源,利用Mimics 10.1軟件、Rapidform 2006軟件、Abaqus 6.11軟件構(gòu)建C2-T1有限元模型,進(jìn)而加載運(yùn)算。將實(shí)驗(yàn)結(jié)果與既往文獻(xiàn)對(duì)比驗(yàn)證。當(dāng)驗(yàn)證有效后用于后續(xù)實(shí)驗(yàn)。2.C4-C6兩節(jié)段置換、兩節(jié)段融合、Hybrid手術(shù)的有限元法生物力學(xué)對(duì)比分析以Prestige-LP假體模擬置換,以頸椎前路鋼板系統(tǒng)加松質(zhì)骨植骨模擬節(jié)段融合。根據(jù)實(shí)驗(yàn)設(shè)計(jì)構(gòu)建C4-C6雙節(jié)段融合組、C4-C6雙節(jié)段置換組、C4-C6 Hybrid手術(shù)組(C4-C5置換聯(lián)合C5-C6融合,Hybrid-M1組),以位移控制為加載條件,計(jì)算各組模型的整體剛度、節(jié)段活動(dòng)度、椎間盤(pán)壓力、小關(guān)節(jié)Von Mises應(yīng)力。以正常對(duì)照組為參照,對(duì)比分析各組之間的力學(xué)參數(shù)。3.連續(xù)兩節(jié)段頸椎中互換位置的hybrid手術(shù)的有限元法生物力學(xué)對(duì)比分析同上述方法構(gòu)建c3-c4置換聯(lián)合c4-c5融合的hybrid-s1組、c3-c4融合聯(lián)合c4-c5置換的hybrid-s2組,c5-c6置換聯(lián)合c6-c7融合的hybrid-u1組、c5-c6融合聯(lián)合c6-c7置換的hybrid-u2組。c4-c5融合聯(lián)合c5-c6置換的hybrid-m2組。以位移控制為加載條件,計(jì)算各組模型的整體剛度、節(jié)段活動(dòng)度、椎間盤(pán)壓力、小關(guān)節(jié)vonmises應(yīng)力。以正常對(duì)照組為參照,hybrid-s1與hybrid-s2進(jìn)行力學(xué)參數(shù)比較,hybrid-u1與hybrid-u2進(jìn)行力學(xué)參數(shù)比較,hybrid-m1與hybrid-m2進(jìn)行力學(xué)參數(shù)比較。結(jié)果:1.c2-t1頸椎有限元模型的建立和驗(yàn)證c2-t1幾何模型的成功構(gòu)建,包括椎體骨性結(jié)構(gòu),小關(guān)節(jié)突上覆蓋軟骨,椎間盤(pán)包括髓核和纖維環(huán),纖維環(huán)分成纖維環(huán)基質(zhì)和纖維環(huán)纖維,韌帶包括前縱韌帶、后縱韌帶、黃韌帶、棘間韌帶、小關(guān)節(jié)突關(guān)節(jié)囊韌帶。c2-t1有限元模型節(jié)點(diǎn)78631,單元數(shù)190608。c2-t1三維有限元模型施加前負(fù)荷75n,再施加1.0n*m驅(qū)動(dòng)力矩,得到前屈、后伸、左軸轉(zhuǎn)、右側(cè)彎四種工況的活動(dòng)度,模型整體活動(dòng)度分別為35.24°、17.22°、17.14°、14.29°。與既往體外實(shí)驗(yàn)數(shù)據(jù)基本一致。即本有限元模型驗(yàn)證有效。2.c4-c6兩節(jié)段置換、兩節(jié)段融合、hybrid手術(shù)的有限元法生物力學(xué)對(duì)比分析雙節(jié)段置換組整體剛度均低于正常對(duì)照組。hybrid手術(shù)組除前屈外整體剛度均低于正常對(duì)照組。雙節(jié)段融合組整體剛度均高于正常對(duì)照組。以正常對(duì)照組為參照,雙節(jié)段置換組的rom在置換節(jié)段均有增加,在鄰近節(jié)段則降低。雙節(jié)段融合組的rom在融合節(jié)段極度降低,在鄰近節(jié)段則均有增加。hybrid-m1的rom在置換節(jié)段增加、融合節(jié)段降低,除前屈外其鄰近節(jié)段均降低。以正常對(duì)照組為參照,雙節(jié)段置換組的鄰近節(jié)段idp降低。雙節(jié)段融合組的鄰近節(jié)段idp增加。hybrid-m1除前屈外鄰近節(jié)段idp降低。以正常對(duì)照組為參照,雙節(jié)段置換組的置換節(jié)段的小關(guān)節(jié)vonmises應(yīng)力僅在后伸和左軸轉(zhuǎn)時(shí)增加,其鄰近節(jié)段均降低。雙節(jié)段融合組的小關(guān)節(jié)vonmises應(yīng)力在融合節(jié)段極度降低,其鄰近節(jié)段則都有增加。hybrid-m1的小關(guān)節(jié)vonmises應(yīng)力在置換節(jié)段增加,在鄰近節(jié)段除前屈外均降低。3.連續(xù)兩節(jié)段頸椎中互換位置的hybrid手術(shù)的有限元法生物力學(xué)對(duì)比分析各hybrid手術(shù)組在前屈時(shí)c2-t1整體剛度均大于正常對(duì)照組,而在后伸、左軸轉(zhuǎn)、右側(cè)彎時(shí)c2-t1整體剛度均小于正常對(duì)照組。(1)c3-c5hybrid手術(shù):屈伸、左軸轉(zhuǎn)、右側(cè)彎時(shí)置換節(jié)段的ROM增加,C3-C4置換分別增加146.5%、207.9%、172.7%;C4-C5置換分別增加193.0%、251.4%、163.6%。后伸、左軸轉(zhuǎn)、右側(cè)彎時(shí)置換節(jié)段小關(guān)節(jié)Von Mises應(yīng)力增加,C3-C4置換分別增加256.5%、186.9%、185.1%;C4-C5置換分別增加50.1%、54.1%、124.4%。前屈時(shí)鄰近節(jié)段IDP增加,C3-C4置換導(dǎo)致C2-C3增加45.2%,C4-C5置換導(dǎo)致C2-C3增加38.7%。(2)C4-C6 Hybrid手術(shù):在屈伸、左軸轉(zhuǎn)、右側(cè)彎時(shí)置換節(jié)段的ROM增加,C4-C5置換分別增加146.4%、237.6%、145.0%。;C5-C6置換分別增加93.6%、146.9%、110.8%。C4-C5置換小關(guān)節(jié)Von Mises應(yīng)力在后伸、左軸轉(zhuǎn)、右側(cè)彎時(shí)分別增加20%、53%、111%;C5-C6置換小關(guān)節(jié)Von Mises應(yīng)力在后伸時(shí)降低8%,軸轉(zhuǎn)、側(cè)彎時(shí)分別增加297%、60%。前屈時(shí)鄰近節(jié)段IDP增加,C4-C5置換導(dǎo)致C3-C4增加2.7%,C5-C6置換導(dǎo)致C3-C4增加2.1%。(3)C5-C7Hybrid手術(shù):在前屈、后伸、左軸轉(zhuǎn)、右側(cè)彎時(shí)置換節(jié)段的ROM增加,C5-C6置換分別增加116.7%、179.2%、122.3%;C6-C7置換分別增加154.7%、323.6%、229.8%。C5-C6置換節(jié)段小關(guān)節(jié)Von Mises應(yīng)力在左軸轉(zhuǎn)、右側(cè)彎時(shí)分別增加267%、63%;C6-C7置換節(jié)段小關(guān)節(jié)Mises應(yīng)力在前屈、后伸、左軸轉(zhuǎn)、右側(cè)彎時(shí)分別增加202%、155%、204%、145%。前屈時(shí)鄰近節(jié)段IDP增加,C5-C6置換導(dǎo)致C4-C5增加13.9%,C6-C7置換導(dǎo)致C4-C5增加20.1%。結(jié)論:1.C2-T1有限元模型成功建立,包含了比較精細(xì)的椎體、椎間盤(pán)、韌帶和小關(guān)節(jié)等結(jié)構(gòu)。模型經(jīng)驗(yàn)證有效。2.與正常對(duì)照組相比,雙節(jié)段融合導(dǎo)致整體剛度增加,鄰近節(jié)段ROM、IDP、小關(guān)節(jié)Von Mises應(yīng)力均增加。從生物力學(xué)角度看可能導(dǎo)致鄰椎病的發(fā)生。3.雙節(jié)段置換組的置換節(jié)段ROM、小關(guān)節(jié)Von Mises應(yīng)力高于正常對(duì)照組,對(duì)鄰近節(jié)段ROM、IDP和小關(guān)節(jié)Von Mises應(yīng)力無(wú)明顯不利影響。從生物力學(xué)角度看可以保護(hù)鄰近節(jié)段。4.Hybrid手術(shù)組的置換節(jié)段ROM、小關(guān)節(jié)Von Mises應(yīng)力高于正常對(duì)照組,對(duì)鄰近節(jié)段的ROM、小關(guān)節(jié)Von Mises應(yīng)力影響小,對(duì)鄰近節(jié)段IDP有一定影響。從生物力學(xué)角度看可一定程度保護(hù)鄰近節(jié)段。5.選擇生理動(dòng)度較大的節(jié)段予以置換,而相對(duì)較小的節(jié)段予以融合,這種Hybrid組合形式對(duì)頸椎生物力學(xué)的影響相對(duì)較小。
[Abstract]:BACKGROUND: The choice of surgical procedures for multilevel cervical spondylosis has been controversial. The choice of multilevel fusion inevitably results in loss of fusion motion. Biomechanics has shown that it has a greater impact on adjacent segments than single-level fusion. The choice of multilevel artificial cervical disc replacement is theoretically a better choice. The surgical guidelines for disc replacement are very strict, and one segment of the multilevel cervical spondylosis may not be suitable for replacement. In addition, the complications of multilevel replacement are unknown because of the increased difficulty and prolonged time. Given this trade-off, the combination of disc replacement and segmental fusion (Hybrid) for multilevel cervical spondylosis is is a compromise. A few clinical studies have reported that the short-term effect of Hybrid surgery is at least as good as that of conventional multilevel fusion. In view of this, we have designed this project. Objective: First, to analyze the biomechanical characteristics of two-segment replacement, two-segment fusion and Hybrid operation by finite element method, and to compare the biomechanical differences of the adjacent segments of the three methods. Two consecutive cervical hybrids were constructed by fusion and replacement in two consecutive segments of the cervical spine. The biomechanical differences between the two hybrids were compared, and the causes of the biomechanical differences were discussed. Methods: 1. The finite element model of C2-T1 cervical spine was established and validated by using thin-slice CT scans of healthy volunteers as data source. The C2-T1 finite element model was constructed by using Mimics 10.1 software, Rapidform 2006 software and Abaqus 6.11 software, and then loaded. Two-segment replacement, two-segment fusion, finite element biomechanical comparative analysis of Hybrid surgery with Prestige-LP prosthesis, anterior cervical plate system plus cancellous bone graft to simulate segmental fusion. According to the experimental design, a C4-C6 double-segment fusion group was constructed, C4-C6 double-segment fusion. Segmental replacement group, C4-C6 Hybrid operation group (C4-C5 replacement combined with C5-C6 fusion, Hybrid-M1 group), with displacement control as loading conditions, calculated the overall stiffness, segmental mobility, intervertebral disc pressure, Von Mises stress of facet joints. Contrast analysis of mechanical parameters between the normal control group and the two consecutive segments of the cervical spine. Finite element biomechanical comparative analysis of hybridization with the above method to construct hybrid-s1 group of c_3-c_4 replacement combined with c_4-c_5 fusion, hybrid-s2 group of c_3-c_4 fusion combined with c_4-c_5 replacement, hybrid-u1 group of c_5-c_6 replacement combined with c_6-c_7 fusion, hybrid-u2 group of c_5-c_6 fusion combined with c_6-c_7 replacement, hybrid-c_4-c_5 fusion combined with c_5-c_6 replacement D-m2 group. The stiffness, segmental mobility, intervertebral disc pressure and von Mises stress of facet joints were calculated with displacement control as loading conditions. The mechanical parameters of hybrid-s1 and hybrid-s2 were compared with those of normal control group. The mechanical parameters of hybrid-u1 and hybrid-u2 were compared. The mechanical parameters of hybrid-m1 and hybrid-m2 were compared. C2-t1 cervical finite element model was established and validated the successful construction of c2-t1 geometric model, including vertebral osseous structure, facet process overlying cartilage, intervertebral disc including nucleus pulposus and annulus fibrosus, annulus fibrosus into annulus matrix and annulus fibrous fiber, ligaments including anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, interspinous ligament, facet process joint. C2-t1 finite element model node 78631, the number of elements 190608.c2-t1 three-dimensional finite element model applied preload 75n, and then applied 1.0n*m driving torque, obtained flexion, extension, left axis turn, right bending four working conditions of the activity of the model as a whole is 35.24 degrees, 17.22 degrees, 17.14 degrees, 14.29 degrees. The two-segment replacement, two-segment fusion, hybridization biomechanical comparative analysis of finite element method, hybridization of the two-segment replacement group stiffness were lower than the normal control group. Hybrid surgery group, except for flexion, the overall stiffness was lower than the normal control group. The overall stiffness of the two-segment fusion group was higher than the normal control group. Compared with the normal control group, the ROM of the two-segment replacement group increased in the replacement segment, but decreased in the adjacent segment. The ROM of the two-segment fusion group decreased extremely in the fusion segment, but increased in the adjacent segment. The ROM of hybrid-m1 increased in the replacement segment, decreased in the fusion segment, and decreased in the adjacent segment except flexion in the normal control group. For comparison, the adjacent segment IDP decreased in the two-segment replacement group. The adjacent segment IDP increased in the two-segment fusion group. The adjacent segment IDP decreased in the hybrid-m1 group except for flexion. Vonmises stress in the facet joints of the hybrid-m1 group was increased in the replacement segment, but decreased in the adjacent segment except for flexion. 3. finite element biomechanical analysis of hybridization in the two consecutive cervical vertebrae in the alternating position The overall stiffness of c2-t1 was greater in the forward flexion than in the normal control group, but lower in the backward extension, left-axis rotation and right-lateral bending. (1) C3-C5 hybridbridization: flexion and extension, left-axis rotation, right-lateral bending, replacement segment ROM increased, C3-C4 replacement increased 146.5%, 207.9%, 172.7%, C4-C5 replacement increased 193.0%, 251.4%, 163.6% respectively. Von Mises stress in facet joints was increased by 256.5%, 186.9% and 185.1% for C3-C4 replacement, 50.1%, 54.1% and 124.4% for C4-C5 replacement, respectively. IDP in adjacent segments was increased during flexion, C3-C4 replacement increased by 45.2% for C2-C3, and C4-C5 replacement increased by 38.7% for C2-C3 during flexion-extension, left-axis rotation and right-axis rotation. The ROM of the replacement segment increased by 146.4%, 237.6% and 145.0% respectively, while that of the replacement segment increased by 93.6%, 146.9% and 110.8% respectively. C3-C4 increased by 2.7% after C4-C5 replacement, and C3-C4 increased by 2.1% after C5-C6 replacement. (3) C5-C7 Hybrid surgery: ROM increased during flexion, extension, left-axis rotation, and right-lateral bending, and C5-C6 replacement increased by 116.7%, 179.2%, 122.3% respectively; C6-C6 replacement increased by 154.7%, 323.6%, 229.8% respectively. The von Mises stress increased by 267% and 63% respectively in the left and right bends, while the Mises stress increased by 202%, 155%, 204% and 145% in the flexion, extension, left and right bends, respectively. The IDP of adjacent segments increased by 13.9% and C4-C5 increased by 20.1% in the C6-C7 displacement and C4-C5 increased by 20.1% in the C6-C7 displacement. The model proved to be effective. 2. Compared with the normal control group, bi-segmental fusion resulted in increased global stiffness, increased adjacent ROM, IDP, and Von Mises stresses in facet joints. Biomechanically, it may lead to the occurrence of adjacent vertebral diseases. 3. Bi-segmental placement. The von Mises stress of replacement segment and facet joint in the replacement group was higher than that in the normal control group, but there was no significant adverse effect on adjacent segment ROM, IDP and Von Mises stress of facet joint. From the biomechanical point of view, the adjacent segment can be protected to a certain extent. 5. Choose the segment with greater physiological mobility to be replaced, and the segment with smaller fusion. This Hybrid combination has a relatively small impact on cervical biomechanics.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R687.3

【共引文獻(xiàn)】

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