【摘要】：目的:通過(guò)多層螺旋CT掃描(Multi-Slice CT,MSCT)及多平面重組(Multi-planar Reformation,MPR)觀察經(jīng)皮穿刺椎體后凸成形術(shù)(Percutaneous Kyphoplasty,PKP)后椎弓根穿刺的安全性與準(zhǔn)確性。方法:回顧性分析瀘州醫(yī)學(xué)院脊柱外科2005年1月~2014年12月行PKP術(shù)治療的胸腰椎壓縮性骨折患者945例。根據(jù)病例納入標(biāo)準(zhǔn),最終784例共823個(gè)手術(shù)椎體納入研究范圍,男108例,女676例,年齡58歲~84歲,平均71.8歲。所有PKP手術(shù)均在C型臂X線機(jī)全程透視下完成,手術(shù)均由具有多年手術(shù)經(jīng)驗(yàn)的高年資醫(yī)生完成,術(shù)后2~4天手術(shù)椎體均行MSCT掃描及MPR。通過(guò)分析手術(shù)椎體的術(shù)后多平面重組CT圖像,觀察穿刺通路與椎弓根骨壁之間的位置關(guān)系,記錄穿刺器械穿破椎弓根內(nèi)壁的數(shù)目和位置。在CT橫軸位圖像上測(cè)量穿刺通路至椎弓根內(nèi)壁內(nèi)緣的距離,將內(nèi)側(cè)壁穿破(Medial Cortical Perforation,MCP)分為4級(jí):I級(jí)椎弓根內(nèi)側(cè)皮質(zhì)斷裂或移位但穿刺通路未進(jìn)入椎管,II級(jí)穿刺通路進(jìn)入椎管0~2.0 mm,III級(jí)穿刺通路進(jìn)入椎管2.1~4.0 mm,IV級(jí)穿刺通路進(jìn)入椎管≥4.1mm。記錄各級(jí)患者術(shù)中、術(shù)后的相關(guān)并發(fā)癥。結(jié)果:784例共823個(gè)手術(shù)脊椎,穿刺通路完全位于椎弓根內(nèi)679例共713個(gè)椎體,穿刺成功率為86.6%。105例共110個(gè)脊椎(13.4%)的椎弓根內(nèi)壁被穿破,本研究中無(wú)椎間孔穿破的病例。結(jié)合分級(jí)、椎弓根毗鄰解剖結(jié)構(gòu)以及穿刺相關(guān)并發(fā)癥,將椎弓根MCP分為可接受的穿破(Acceptable Perforation,AP),包括I級(jí)和II級(jí);不可接受的穿破(Unacceptable Perforation,UAP),包括III級(jí)和IV級(jí)。在總體穿刺中:I級(jí)占1.5%(12/823),II級(jí)占8.4%(69/823),III級(jí)占2.9%(24/823),IV級(jí)占0.6%(5/823)。110個(gè)椎弓根內(nèi)壁穿出距離總體呈正偏態(tài)分布(Positive Skewness Distribution,PSD),即絕大多數(shù)MCP為AP,占穿破總數(shù)的73.6%(81/110),其中I級(jí)占10.9%,II級(jí)占62.7%,穿刺通路骨水泥滲漏(Bone Cement Leakage,BCL)至椎管2例,其余均未出現(xiàn)穿刺相關(guān)并發(fā)癥;少數(shù)MCP為UAP,占穿破總數(shù)的26.4%(29/110),其中III級(jí)占21.8%,IV級(jí)占4.5%,穿刺通路骨水泥滲漏至椎管3例,腦脊液(Cerebrospinal Fluid,CSF)漏14例,一過(guò)性神經(jīng)根支配區(qū)域麻木疼痛11例,神經(jīng)根損傷1例,硬膜外血腫1例,無(wú)內(nèi)壁穿出距離超過(guò)5.0mm和脊髓損傷(Spinal Cord Injury,SCI)病例。結(jié)論:1、MSCT及MPR能準(zhǔn)確評(píng)價(jià)穿刺通路在椎弓根內(nèi)的位置。2、在總體穿刺中:椎弓根內(nèi)壁穿破的發(fā)生率為13.4%(110/823),I級(jí)12個(gè)(1.5%),II級(jí)69個(gè)(8.4%),III級(jí)24個(gè)(2.9%),IV級(jí)5個(gè)(0.6%)。胸椎的內(nèi)壁穿破率高于腰椎。3、絕大多數(shù)MCP為AP,占穿破總數(shù)的73.6%(81/110),少數(shù)MCP為UAP,占穿破總數(shù)的26.4%(29/110),無(wú)穿出距離超過(guò)5.0mm病例。4、在臨床實(shí)際操作中,椎弓根內(nèi)壁穿破損傷并不少見(jiàn),分級(jí)程度越高,硬膜囊、神經(jīng)根、脊髓損傷的可能性越大。5、新的分級(jí)、分類系統(tǒng)緊密的結(jié)合了影像、解剖和臨床,能為手術(shù)操作和臨床療效及并發(fā)癥的評(píng)估提供參考。
[Abstract]:Objective: to observe the safety and accuracy of pedicle puncture after percutaneous kyphoplasty (Percutaneous Kyphoplasty,PKP) by multislice spiral CT scanning (Multi-Slice CT,MSCT) and multiplanar recombination (Multi-planar Reformation,MPR). Methods: a retrospective analysis of 945 cases of thoracolumbar vertebral compression fractures treated by PKP from January 2005 to December 2014 was performed in spine surgery of Luzhou Medical College. According to the inclusion criteria, 823 vertebrae were included in 784 cases, 108 males and 676 females, ranging in age from 58 to 84 years (mean 71.8 years). All PKP operations were performed under the fluoroscopy of the C-arm X-ray machine. The operation was performed by an elderly doctor with many years of experience. The vertebral body was scanned with MSCT and MPR. 2 and 4 days after operation. The relationship between the puncture pathway and the pedicle bone wall was observed by analyzing the multiplanar reconstructed CT images of the surgical vertebrae, and the number and location of the puncture instrument perforating the internal wall of the pedicle were recorded. The distance between the puncture pathway and the inner edge of the pedicle wall was measured on the CT axial image. The medial cortex of the pedicle was broken or shifted but the puncture pathway did not enter the spinal canal, the medial cortex of the pedicle was broken or shifted in the grade I, and the medial wall of the pedicle was broken through the inner edge of the pedicle wall. The II grade puncture pathway entered the spinal canal 0. 0 mm,III level and entered the spinal canal 2. 1 ~ 4. 0 mm,IV puncture pathway into the spinal canal 鈮，

本文編號(hào)：2400148