不同棘突間撐開高度對(duì)融合椎上位椎間穩(wěn)定性的生物力學(xué)作用研究
發(fā)布時(shí)間：2019-06-02 07:58
【摘要】：目的:腰椎間盤突出癥是骨科的常見病、多發(fā)病之一,自1934年提出至今,發(fā)病率呈上升趨勢(shì)。腰椎融合術(shù)在治療腰椎退行性變方面療效顯著,其主要的遠(yuǎn)期并發(fā)癥為鄰近節(jié)段退變。棘突間動(dòng)態(tài)穩(wěn)定系統(tǒng),作為一種腰椎后路的非融合技術(shù)具有手術(shù)創(chuàng)傷小,可進(jìn)行二次手術(shù)等特點(diǎn)。棘突間動(dòng)態(tài)固定系統(tǒng)常用于治療間歇性跛行等輕度腰椎管狹窄而引起的癥狀。本研究主要探究棘突間動(dòng)態(tài)固定系統(tǒng)在延緩鄰近節(jié)段退變過程當(dāng)中的生物力學(xué)作用,為臨床應(yīng)用提供實(shí)驗(yàn)依據(jù)。方法:選用新鮮羊腰椎脊柱(L1-L5)樣本,剔除附著肌肉,兩端(L1頭端、L5尾端)進(jìn)行牙托粉包埋固定。分為4組進(jìn)行實(shí)驗(yàn):正常對(duì)照組—(CG組)脊柱骨性結(jié)構(gòu)及韌帶結(jié)構(gòu)完整;不穩(wěn)定組—(IG組)行L3/4節(jié)段雙側(cè)關(guān)節(jié)突關(guān)節(jié)切除;置釘組—(FG組)行L3/4節(jié)段雙側(cè)關(guān)節(jié)突關(guān)節(jié)切除、L3/4后路椎弓跟釘固定;混合固定組—(HG組)在FG組干預(yù)基礎(chǔ)上,行L2/3節(jié)段間不同撐開高度的棘突間撐開(6mm、8mm、10mm、12mm、14mm、16mm、18mm)。樣本包埋后用X線片確認(rèn)脊柱完整性,然后在關(guān)節(jié)突關(guān)節(jié)處貼電阻應(yīng)變片,貼片位置選取脊柱運(yùn)動(dòng)時(shí)關(guān)節(jié)突關(guān)節(jié)應(yīng)變最大處。貼片完成后,校準(zhǔn)三維動(dòng)態(tài)捕捉系統(tǒng),定義空間三維坐標(biāo)系和脊柱轉(zhuǎn)動(dòng)角度正負(fù)值,應(yīng)用克式針把剛體與椎體相連接,并通過軟件定義克式針針尖為剛體的運(yùn)動(dòng)中心,克式針植入椎體中心。此后把樣本固定在多自由度脊柱力學(xué)試驗(yàn)機(jī)上,調(diào)整機(jī)器參數(shù),設(shè)定運(yùn)行程序,采用扭矩控制,每組動(dòng)作重復(fù)3次測(cè)定脊柱屈伸、側(cè)彎和扭轉(zhuǎn)方向上的活動(dòng)度。實(shí)驗(yàn)開始后,應(yīng)用MTS多自由度力學(xué)試驗(yàn)機(jī)在最大扭矩為5N·M的工況下測(cè)量脊柱前屈、后伸、側(cè)屈、軸向旋轉(zhuǎn)的活動(dòng)度,同時(shí)應(yīng)用NDI三維動(dòng)態(tài)捕捉系統(tǒng)獲取單個(gè)腰椎節(jié)段(L2、L3、L4)的活動(dòng)度變化,應(yīng)用電阻應(yīng)變片測(cè)量關(guān)節(jié)突關(guān)節(jié)的應(yīng)力值變化。各實(shí)驗(yàn)組順次進(jìn)行。結(jié)果:(1)全腰椎活動(dòng)度:后伸活動(dòng)度、軸向旋轉(zhuǎn)活動(dòng)度組間有統(tǒng)計(jì)學(xué)差異。16mm、18mm HG組與CG組、IG組、FG組相比,后伸活動(dòng)度有統(tǒng)計(jì)學(xué)差異;18mm HG組與10mm、12mm HG組相比,后伸活動(dòng)度有統(tǒng)計(jì)學(xué)差異。IG組與FG組、HG組相比,軸向旋轉(zhuǎn)活動(dòng)度有統(tǒng)計(jì)學(xué)差異(P0.05)。(2)單節(jié)段椎體活動(dòng)度:各組L2、L3、L4節(jié)段活動(dòng)度在前屈、后伸、側(cè)彎、軸向旋轉(zhuǎn)方向上差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。線性回歸分析顯示,前屈工況下L3活動(dòng)度、后伸工況下L2活動(dòng)度與撐開距離呈正相關(guān)(P0.05)。(3)關(guān)節(jié)突關(guān)節(jié)應(yīng)變值:在前屈、同側(cè)側(cè)彎、對(duì)側(cè)側(cè)彎工況下時(shí),18mm HG組L4下關(guān)節(jié)突關(guān)節(jié)應(yīng)變值與其他各組有統(tǒng)計(jì)學(xué)差異(P0.05)。在軸向旋轉(zhuǎn)時(shí),18mm HG對(duì)側(cè)組L2上關(guān)節(jié)突關(guān)節(jié)應(yīng)變值與CG組和FG組及其他撐開距離HG組間差異有統(tǒng)計(jì)學(xué)意義(P0.05);IG組L2上關(guān)節(jié)突關(guān)節(jié)應(yīng)變值與8mm、12mm HG組有統(tǒng)計(jì)學(xué)差異(圖2.5,P0.05)。結(jié)論:(1)聯(lián)合應(yīng)用單節(jié)段椎弓根釘固定和棘突間撐開裝置能夠在后伸工況下限制脊柱的運(yùn)動(dòng)。較小的棘突間撐開距離不會(huì)影響全腰椎活動(dòng)度,較大的撐開距離能夠限制腰椎矢狀面活動(dòng)度,顯著減少腰椎活動(dòng)度。(2)聯(lián)合應(yīng)用單節(jié)段椎弓根釘固定和棘突間撐開裝置能夠使融合節(jié)段的頭側(cè)節(jié)段以及融合節(jié)段的上位節(jié)段的活動(dòng)度隨著撐開距離的不斷增大而減小,有利于提高腰椎的穩(wěn)定性。單節(jié)段固定組與完整組相比,在后伸工況下,椎弓根釘固定節(jié)段頭側(cè)段和上位節(jié)段活動(dòng)度均增加且兩者運(yùn)動(dòng)方向相反,而固定節(jié)段的尾側(cè)段活動(dòng)度減少,這些都會(huì)加速上位鄰近節(jié)段退變的發(fā)生。(3)聯(lián)合應(yīng)用單節(jié)段椎弓根釘固定和棘突間撐開裝置,能夠使鄰近節(jié)段的關(guān)節(jié)突關(guān)節(jié)應(yīng)力減小、減少非融合裝置上位節(jié)段的應(yīng)力,從而延緩鄰近節(jié)段退變。臨床工作中選擇合適的撐開器,能夠限制腰椎運(yùn)動(dòng)的同時(shí)減輕固定節(jié)段鄰近節(jié)段以及撐開節(jié)段頭側(cè)節(jié)段的應(yīng)力。(4)聯(lián)合應(yīng)用單節(jié)段椎弓根釘固定和棘突間撐開裝置能夠改變腰椎關(guān)節(jié)突關(guān)節(jié)的應(yīng)力分布,限制某些節(jié)段的活動(dòng),進(jìn)而延緩鄰近節(jié)段退變。
[Abstract]:Objective: The protrusion of the lumbar intervertebral disc is one of the common diseases in the department of orthopedics, and the incidence of lumbar disc herniation has been on the rise since 1934. The major long-term complications of the lumbar interbody fusion in the treatment of lumbar degenerative changes are the degeneration of the adjacent segments. The dynamic stabilization system between the spinous processes has the characteristics of small operation wound and secondary operation and the like as a non-fusion technique of the posterior lumbar vertebra. The dynamic fixation system of interspinous processes is commonly used for the treatment of the symptoms caused by the narrow lumbar spinal stenosis such as intermittent claudication. The purpose of this study is to explore the biomechanical function of the interspinous dynamic fixation system in the process of delaying the degeneration of the adjacent segment, and to provide the experimental basis for clinical application. Methods: The specimens of the lumbar spine (L1-L5) of the fresh sheep were selected to remove the attached muscle and the two ends (the end of the L1 and the L5) were embedded and fixed. Four groups were divided into four groups: the normal control group (CG), the bony structure of the spinal column and the structure of the ligament, and the two-sided joint resection of the L3/4 segment in the non-stable group (IG group). The interspinous process (6 mm,8 mm,10 mm,12 mm,14 mm,16 mm,18 mm) was performed on the base of the FG group. The integrity of the spine was confirmed with x-rays after the sample was embedded, and then the strain gauge was applied to the joint of the articular process, and the joint strain at the joint was the largest at the location of the patch. After the patch is completed, the three-dimensional dynamic capturing system is calibrated, the three-dimensional coordinate system of the space and the rotation angle of the spinal column are positive and negative values are defined, the rigid body is connected with the vertebral body by using a gram-type needle, and a movement center of a rigid body is defined by a software-defined gram-type needle tip, and a gram-type needle is implanted into the vertebral body center. After that, the sample was fixed on the multi-degree-of-freedom spinal mechanical testing machine, the parameters of the machine were adjusted, the running procedure was set, and the torque control was adopted, and the motion of the spine in the flexion extension, the lateral bending and the torsion direction was repeated 3 times in each group. After the experiment, the range of motion of the anterior and posterior, lateral and axial rotation of the spine was measured with the MTS multi-degree-of-freedom mechanical testing machine at the maximum torque of 5 N 路 M, and the range of motion of the single lumbar segment (L2, L3, L4) was obtained by using the NDI three-dimensional dynamic capture system. The stress value of the articular process joint was measured by using a resistance strain gauge. The experimental groups were carried out in sequence. Results: (1) There was a statistical difference between the range of motion of the whole lumbar spine and the range of motion in the axial direction. Compared with the group of FG and HG, there was a significant difference in the range of axial rotation (P <0.05). (2) The range of motion of the single-segment vertebral body: the range of motion of L2, L3 and L4 in each group was not statistically significant in the anterior and posterior, lateral and axial directions (P0.05). The linear regression analysis showed that there was positive correlation between the range of activity of L2 and the distance of distraction under the pre-bending condition (P0.05). (3) Joint strain value of the joint process: the joint strain value of the articular process at the L4 lower joint of the 18 mm HG group was significantly different from the other groups (P0.05). At the time of axial rotation, there was a significant difference between the strain value of the articular process joint on the side group (L2) of the 18 mm HG group (P <0.05) and the difference between the group of CG and the group of FG (P <0.05), and the joint strain value of the articular process on the L2 of the IG group was significantly different from that in the group of 8 mm and 12 mm (Fig. 2.5, P0.05). Conclusion: (1) The fixation of the single-segment pedicle screw and the distraction device of the interspinous process can limit the movement of the spinal column under the post-extension condition. The distance between the smaller spinous processes does not affect the full-lumbar motion, and the larger distraction distance can limit the range of motion of the lumbar sagittal plane and significantly reduce the range of motion of the lumbar vertebra. And (2) the joint application of the single-segment pedicle screw fixation and the interspinous process distraction device can reduce the range of motion of the head-side segment of the fusion segment and the upper segment of the fusion segment with the increasing of the distraction distance, and is beneficial to the improvement of the stability of the lumbar vertebra. Compared with the whole group in the single-segment fixation group, the range of motion of the head and the upper segment of the pedicle screw in the post-extension condition is increased and the motion direction of the two segments is opposite, and the range of motion of the caudal segment of the fixed segment is reduced, which can accelerate the occurrence of the degeneration of the upper adjacent segment. And (3) the joint application of the single-segment pedicle screw fixation and the interspinous process distraction device can reduce the stress of the joint process joint of the adjacent segment and reduce the stress of the upper segment of the non-fusion device, thereby delaying the degeneration of the adjacent segment. The proper distractor is selected in clinical work, and the stress of the adjacent segment of the fixed segment and the segment head-side segment can be reduced while the lumbar motion is limited. And (4) the joint application of the single-segment pedicle screw fixation and the interspinous process distraction device can change the stress distribution of the lumbar joint process joint, limit the activity of certain segments, and further delay the degeneration of the adjacent segment.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3
[Abstract]:Objective: The protrusion of the lumbar intervertebral disc is one of the common diseases in the department of orthopedics, and the incidence of lumbar disc herniation has been on the rise since 1934. The major long-term complications of the lumbar interbody fusion in the treatment of lumbar degenerative changes are the degeneration of the adjacent segments. The dynamic stabilization system between the spinous processes has the characteristics of small operation wound and secondary operation and the like as a non-fusion technique of the posterior lumbar vertebra. The dynamic fixation system of interspinous processes is commonly used for the treatment of the symptoms caused by the narrow lumbar spinal stenosis such as intermittent claudication. The purpose of this study is to explore the biomechanical function of the interspinous dynamic fixation system in the process of delaying the degeneration of the adjacent segment, and to provide the experimental basis for clinical application. Methods: The specimens of the lumbar spine (L1-L5) of the fresh sheep were selected to remove the attached muscle and the two ends (the end of the L1 and the L5) were embedded and fixed. Four groups were divided into four groups: the normal control group (CG), the bony structure of the spinal column and the structure of the ligament, and the two-sided joint resection of the L3/4 segment in the non-stable group (IG group). The interspinous process (6 mm,8 mm,10 mm,12 mm,14 mm,16 mm,18 mm) was performed on the base of the FG group. The integrity of the spine was confirmed with x-rays after the sample was embedded, and then the strain gauge was applied to the joint of the articular process, and the joint strain at the joint was the largest at the location of the patch. After the patch is completed, the three-dimensional dynamic capturing system is calibrated, the three-dimensional coordinate system of the space and the rotation angle of the spinal column are positive and negative values are defined, the rigid body is connected with the vertebral body by using a gram-type needle, and a movement center of a rigid body is defined by a software-defined gram-type needle tip, and a gram-type needle is implanted into the vertebral body center. After that, the sample was fixed on the multi-degree-of-freedom spinal mechanical testing machine, the parameters of the machine were adjusted, the running procedure was set, and the torque control was adopted, and the motion of the spine in the flexion extension, the lateral bending and the torsion direction was repeated 3 times in each group. After the experiment, the range of motion of the anterior and posterior, lateral and axial rotation of the spine was measured with the MTS multi-degree-of-freedom mechanical testing machine at the maximum torque of 5 N 路 M, and the range of motion of the single lumbar segment (L2, L3, L4) was obtained by using the NDI three-dimensional dynamic capture system. The stress value of the articular process joint was measured by using a resistance strain gauge. The experimental groups were carried out in sequence. Results: (1) There was a statistical difference between the range of motion of the whole lumbar spine and the range of motion in the axial direction. Compared with the group of FG and HG, there was a significant difference in the range of axial rotation (P <0.05). (2) The range of motion of the single-segment vertebral body: the range of motion of L2, L3 and L4 in each group was not statistically significant in the anterior and posterior, lateral and axial directions (P0.05). The linear regression analysis showed that there was positive correlation between the range of activity of L2 and the distance of distraction under the pre-bending condition (P0.05). (3) Joint strain value of the joint process: the joint strain value of the articular process at the L4 lower joint of the 18 mm HG group was significantly different from the other groups (P0.05). At the time of axial rotation, there was a significant difference between the strain value of the articular process joint on the side group (L2) of the 18 mm HG group (P <0.05) and the difference between the group of CG and the group of FG (P <0.05), and the joint strain value of the articular process on the L2 of the IG group was significantly different from that in the group of 8 mm and 12 mm (Fig. 2.5, P0.05). Conclusion: (1) The fixation of the single-segment pedicle screw and the distraction device of the interspinous process can limit the movement of the spinal column under the post-extension condition. The distance between the smaller spinous processes does not affect the full-lumbar motion, and the larger distraction distance can limit the range of motion of the lumbar sagittal plane and significantly reduce the range of motion of the lumbar vertebra. And (2) the joint application of the single-segment pedicle screw fixation and the interspinous process distraction device can reduce the range of motion of the head-side segment of the fusion segment and the upper segment of the fusion segment with the increasing of the distraction distance, and is beneficial to the improvement of the stability of the lumbar vertebra. Compared with the whole group in the single-segment fixation group, the range of motion of the head and the upper segment of the pedicle screw in the post-extension condition is increased and the motion direction of the two segments is opposite, and the range of motion of the caudal segment of the fixed segment is reduced, which can accelerate the occurrence of the degeneration of the upper adjacent segment. And (3) the joint application of the single-segment pedicle screw fixation and the interspinous process distraction device can reduce the stress of the joint process joint of the adjacent segment and reduce the stress of the upper segment of the non-fusion device, thereby delaying the degeneration of the adjacent segment. The proper distractor is selected in clinical work, and the stress of the adjacent segment of the fixed segment and the segment head-side segment can be reduced while the lumbar motion is limited. And (4) the joint application of the single-segment pedicle screw fixation and the interspinous process distraction device can change the stress distribution of the lumbar joint process joint, limit the activity of certain segments, and further delay the degeneration of the adjacent segment.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3
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