【摘要】：目的：在尸體上應(yīng)用圖像融合與電磁導(dǎo)航相結(jié)合的超聲容積導(dǎo)航技術(shù)引導(dǎo)經(jīng)皮后外側(cè)入路椎間孔穿刺并評估其準(zhǔn)確性。在臨床上將這一穿刺引導(dǎo)方法與常規(guī)C臂機引導(dǎo)穿刺作對比,評估超聲容積導(dǎo)航技術(shù)應(yīng)用于引導(dǎo)經(jīng)皮后外側(cè)入路椎間孔穿刺的可行性。方法：解剖學(xué)研究：15具尸體應(yīng)用容積導(dǎo)航引導(dǎo)雙側(cè)L4/5椎間孔穿刺,記錄配準(zhǔn)誤差、超聲所能觀察到針尖的最后位置距靶點距離(distance between needle tip and target, DNT)及總穿刺時間(包括配準(zhǔn)及放置穿刺針時間),CT測量穿刺誤差(導(dǎo)航到位后經(jīng)CT驗證針尖到目標(biāo)靶點的距離)。臨床研究：選擇2012年6月至2013年10月間行經(jīng)皮內(nèi)鏡下腰椎間盤切除術(shù)(percutaneous endoscopic lumbar discectomy,PELD)的腰椎間盤突出癥患者63例,隨機分配至兩組。C臂機引導(dǎo)組30例,利用C臂機引導(dǎo)椎間孔穿刺,記錄穿刺時間及透視次數(shù)；容積導(dǎo)航組33例,利用容積導(dǎo)航技術(shù)引導(dǎo)椎間孔穿刺,記錄配準(zhǔn)誤差、DNT、總穿刺時間和透視次數(shù)。兩組患者采用Oswestry功能障礙指數(shù)(Oswestry disability index, ODI)以及腰腿痛視覺模擬評分(Visual analogue scale, VAS)評定臨床療效。結(jié)果：解剖學(xué)研究中,15具尸體共行30次L4/5椎間孔穿刺,配準(zhǔn)誤差為2.66mm (0.9-4.7mm), DNT為20.08mm (17.8-22.9mm),穿刺誤差為2.91mm (1.1-6. lmm);其中有兩次穿刺誤差為5.3mm及6.1mm,可能有損傷出行神經(jīng)根或置入工作通道困難的風(fēng)險�？偞┐虝r間為22. lmin(16-33min),其中圖像配準(zhǔn)時間19. lmin(14-29min),放置穿刺針時間3min (2-4min)。臨床研究中：C臂機引導(dǎo)組30例患者穿刺時間為27.9min (25-32min),到達(dá)目標(biāo)區(qū)域所需C臂機透視次數(shù)為14.3次(13-17次)。容積導(dǎo)航組中30例患者首次配準(zhǔn)即穿刺成功；3例患者穿刺過程中出現(xiàn)了下肢放射痛,重新配準(zhǔn)后穿刺成功�？偞┐虝r間20.4min (16-28min),圖像配準(zhǔn)時間為15.5min (13-22min),放置穿刺針時間4.9min (3-7min),C臂機透視次數(shù)4.9次(4-7次),配準(zhǔn)誤差為3.25mm (1.9-4.8mm), DNT為20.35mm (16.9-24.9mm)。通過對比兩組患者穿刺過程總用時及透視次數(shù)可以發(fā)現(xiàn),容積導(dǎo)航組穿刺總時間及透視次數(shù)均少于C臂機引導(dǎo)組(P0.001)。C臂機引導(dǎo)組隨訪時間為18.8月(12-28月),容積導(dǎo)航組為18.4月(12-28月)；兩組患者術(shù)前及術(shù)后各個時間點ODI及VAS評分無統(tǒng)計學(xué)差異(P0.05)。兩組患者均無神經(jīng)損傷、傷口感染等并發(fā)癥,隨訪終末兩組患者腰椎間盤突出均無復(fù)發(fā)。結(jié)論：與傳統(tǒng)C臂機導(dǎo)航相比,利用圖像融合與電磁導(dǎo)航相結(jié)合的超聲容積導(dǎo)航技術(shù)可準(zhǔn)確引導(dǎo)經(jīng)皮后外側(cè)入路椎間孔穿刺,且減少穿刺時間及X線輻射量,可應(yīng)用于經(jīng)皮內(nèi)窺鏡下腰椎間盤切除術(shù)。
[Abstract]:Objective: to evaluate the accuracy of percutaneous posterolateral approach of intervertebral foramen puncture by ultrasound volume navigation combined with image fusion and electromagnetic navigation on cadavers. Compared with the conventional C-arm guided puncture in clinic, the feasibility of the application of the ultrasonic volumetric navigation technique to the percutaneous posterolateral approach of intervertebral foramen puncture was evaluated. Methods: anatomical study: bilateral L4 / 5 intervertebral foramen puncture was guided by volumetric navigation in 15 cadavers. Registration errors were recorded. The final position of the needle was observed by ultrasound. The distance from the target to the target was observed by ultrasound. DNT) and total puncture time (including registration and placement of puncture needle time), CT measurement of puncture error (after navigation is in place CT verifies the distance between the needle and the target). Clinical study: Sixty-three patients with lumbar disc herniation underwent percutaneous endoscopic discectomy (percutaneous endoscopic lumbar discectomy,PELD) from June 2012 to October 2013 were randomly assigned to two groups. C-arm machine was used to guide intervertebral foramen puncture to record puncture time and times of fluoroscopy. The volume navigation technique was used to guide intervertebral foramen puncture in 33 cases of volume navigation group. The registration error, the total puncture time of DNT, and the times of fluoroscopy were recorded. The clinical efficacy was evaluated by Oswestry dysfunction index (Oswestry disability index, ODI) and visual analogue score (Visual analogue scale, VAS) of lumbago and leg pain. Results: in the anatomical study, 15 cadavers underwent 30 L 4 / 5 intervertebral foramen puncture, the registration error was 2.66mm (0.9-4.7mm), DNT was 20.08mm (17.8-22.9mm), and the puncture error was 2.91mm (1.1-6). Lmm); has two puncture errors of 5.3mm and 6.1 mm, which may have the risk of damaging nerve roots or difficult placement of working channels. The total puncture time was 22. Lmin (16-33min), where the image registration time is 19. Lmin (14-29min), place needle time 3min (2-4min). In the clinical study, the puncture time was 27.9min (25-32min) in the C-arm guidance group, and the number of fluoroscopy needed to reach the target area was 14.3 times (13-17 times). In the volume navigation group, 30 patients were successfully punctured for the first time, 3 patients had lower extremity radiation pain during the puncture, and the puncture was successful after the alignment. The total puncture time was 20.4min (16-28min), the time of image registration was 15.5min (13-22min), the time of placement of puncture needle was 4.9min (4. 9 times of 3-7min), C arm machine). The registration error is 3.25mm (1.9-4.8mm), DNT is 20.35mm (16.9-24.9mm). By comparing the total time of puncture and the times of fluoroscopy in the two groups, it was found that the total puncture time and the times of fluoroscopy in the volumetric navigation group were less than those in the C-arm guidance group (P 0.001). C arm guide group was 18.8 months (12-28 months). The volume navigation group was 18.4 months (12-28 months); There was no significant difference in ODI and VAS scores between the two groups before and after operation (P0.05). No nerve injury, wound infection and other complications were found in both groups, and no recurrence of lumbar disc herniation was found in the two groups at the end of follow-up. Conclusion: compared with the traditional C-arm navigation, the ultrasonic volume navigation combined with image fusion and electromagnetic navigation can accurately guide the percutaneous posterolateral approach intervertebral foramen puncture, and reduce the puncture time and X-ray radiation. It can be used in percutaneous endoscope lumbar discectomy.
【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】：2015
【分類號】：R687.3

【共引文獻(xiàn)】

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本文編號：2313853