發(fā)布時間：2018-03-13 18:17

  本文選題：腰椎退變　切入點(diǎn)：三維CT　出處：《吉林大學(xué)》2016年博士論文　論文類型：學(xué)位論文

【摘要】：背景:腰椎退行性疾病往往需要手術(shù)治療,手術(shù)方法:開放性手術(shù)或者微創(chuàng)內(nèi)鏡治療,內(nèi)鏡治療已被廣泛應(yīng)用于腰椎退變疾病,出現(xiàn)的并發(fā)癥有:硬膜囊損傷和神經(jīng)根損傷,原因就是由于腰椎后方骨性結(jié)構(gòu)復(fù)雜不規(guī)則,自然孔道小,空間小而且周圍是硬膜囊和脊神經(jīng),器械孔道安放過程中傷害硬膜囊和脊神經(jīng)可能性較大,一旦損傷帶來的傷害是巨大不可逆的,故此項(xiàng)技術(shù)的操作是存在難度的,造成微創(chuàng)技術(shù)發(fā)展上的瓶頸,需要醫(yī)生在牢固掌握解剖結(jié)構(gòu)的同時探討手術(shù)的經(jīng)驗(yàn),包括體位的變化都是我們在實(shí)踐中所需要考慮和摸索的。目的:模擬腰椎退變疾病手術(shù)俯臥位,分別在俯臥0度位和30度位時對于腰椎后柱結(jié)構(gòu)進(jìn)行CT三維測量,分別測量和微創(chuàng)內(nèi)鏡下手術(shù)相關(guān)的數(shù)據(jù):冠狀位椎板間最大距離,矢狀位椎間孔長徑(縱徑),矢狀位下位椎體的上關(guān)節(jié)突尖部和上位椎體后下緣距離,橫軸位下位椎體上關(guān)節(jié)突和上位椎體后下緣中點(diǎn)距離,觀察和研究腰椎退變患者俯臥位0度和30度位腰椎后路結(jié)構(gòu)的變化,尤其和微創(chuàng)內(nèi)鏡下手術(shù)相關(guān)的數(shù)據(jù),尋找不同體位下腰椎側(cè)路和后路置管適合入路的客觀依據(jù),對于不同俯臥位的腰椎后柱結(jié)構(gòu)位置的變化,可以為臨床腰椎退變疾病微創(chuàng)內(nèi)鏡手術(shù)選擇合理的術(shù)式、合適的置管入路,為新型內(nèi)鏡配套器械設(shè)計、研制及應(yīng)用提供解剖學(xué)基礎(chǔ),從而提高微創(chuàng)脊柱內(nèi)鏡手術(shù)的安全性和便捷性。方法:采用50名腰椎退變患者(自愿者),根據(jù)腰痛為主和下肢痛為主的癥狀主訴分成兩組,采用西門子64層螺旋CT行L3-S1平掃,先對所有參加CT檢查的患者進(jìn)行螺旋CT掃描,所有患者先進(jìn)行俯臥0度位CT掃描,然后俯臥30度位進(jìn)行CT掃描,將采集的DICOM數(shù)據(jù)導(dǎo)入寶葫蘆數(shù)字醫(yī)學(xué)影像工作站進(jìn)行三維重建,分別測量:冠狀位椎板間最大距離、矢狀位椎間孔長徑、矢狀位上關(guān)節(jié)突尖部到上位椎體后下緣最下緣距離、橫軸位下位椎體上關(guān)節(jié)突和上位椎體后下緣中點(diǎn)距離。將所得數(shù)據(jù)分別填入相關(guān)表格,統(tǒng)計數(shù)據(jù),分別列入腰痛組和下肢痛組、男女組、俯臥0度位和俯臥30度位置組再分別統(tǒng)計相關(guān)數(shù)據(jù),應(yīng)用SPSS13軟件包進(jìn)行統(tǒng)計學(xué)分析,兩組數(shù)據(jù)采用方差分析。結(jié)果:1.冠狀位椎板間最大距離,L34、L45、L5S1各部位俯臥位0度和30度有顯著性差異;2.矢狀位椎間孔長徑(縱徑),L34、L45、L5S1各部位俯臥位0度和30度亦有顯著性差異;3.矢狀位下位椎體的上關(guān)節(jié)突尖部和上位椎體后下緣距離,L34、L45、L5S1各部位俯臥位0度和30度存在顯著性差異;4.橫軸位下位椎體上關(guān)節(jié)突和上位椎體后下緣中點(diǎn)距離,L34、L45、L5S1各部位俯臥位0度和30度也有明顯的統(tǒng)計學(xué)差異;5.上述四個參數(shù)經(jīng)過分析,在性別(男女)組和癥狀組(腰痛和下肢痛組)無顯著性差異;6.椎板間隙的寬度,矢狀位椎間孔長徑(縱徑)測量表明:俯臥0度小于俯臥30度,差異顯著,所以無論是后路全內(nèi)鏡手術(shù)還是是MED手術(shù),都可以在俯臥30度位加大椎板間隙,快速有效進(jìn)入椎管開展手術(shù),所以俯臥30度體位的擺放對于脊柱后路鏡的進(jìn)入作業(yè)十分有效和幫助減少手術(shù)操作的困難。7.矢狀位下位椎體上關(guān)節(jié)突尖部和上位椎體后下緣距離,橫軸位下位椎體上關(guān)節(jié)突和上位椎體后下緣中點(diǎn)距離距離,測量表明:俯臥0度小于俯臥30度,差異顯著,這為我們在穿刺和置入工作套管時要十分注意進(jìn)入深度,防止過深進(jìn)入會導(dǎo)致穿刺針和套管進(jìn)入到椎體前方損傷椎體前方的血管,導(dǎo)致危險和意外的發(fā)生。說明脊柱微創(chuàng)手術(shù)椎間孔入路時,利用術(shù)前三維CT測量規(guī)劃,有利于指導(dǎo)椎間孔鏡入路操作(去除部分關(guān)節(jié)突和控制置管深度),防止出口神經(jīng)根和走行神經(jīng)根的損傷。根據(jù)測得的數(shù)據(jù),我們應(yīng)用椎間盤鏡手術(shù)不同體位下治療腰椎間盤突出癥患者并觀察手術(shù)療效,共觀察22例,結(jié)論:椎間盤鏡下治療腰間盤突出癥采用俯臥30度位對比采用俯臥0度位更有利于操作,安全,縮短置管進(jìn)入椎管內(nèi)時間,降低并發(fā)癥,手術(shù)切口小,出血量和術(shù)后第三天JOA評分沒有明顯差異。結(jié)論:測量結(jié)果表明:1.冠狀位椎板間最大距離,L34、L45、L5S1各部位俯臥位0度和30度有顯著性差異;2.矢狀位椎間孔長徑(縱徑),L34、L45、L5S1各部位俯臥位0度和30度亦有顯著性差異;3.矢狀位下位椎體的上關(guān)節(jié)突尖部和上位椎體后下緣距離,L34、L45、L5S1各部位俯臥位0度和30度存在顯著性差異;4.橫軸位下位椎體上關(guān)節(jié)突和上位椎體后下緣中點(diǎn)距離,L34、L45、L5S1各部位俯臥位0度和30度也有明顯的統(tǒng)計學(xué)差異;5.上述四個參數(shù)經(jīng)過分析,在性別(男女)組和癥狀組(腰痛和下肢痛組)無顯著性差異;6.應(yīng)用測得的數(shù)據(jù)進(jìn)一步行臨床觀察和驗(yàn)證,對22例采用椎間盤鏡手術(shù)治療腰椎間盤突出癥的患者,采用俯臥30度的患者在置管進(jìn)入椎管時間,手術(shù)切口大小,并發(fā)癥的發(fā)生率顯著低于俯臥0度位的患者。7.對于脊柱微創(chuàng)手術(shù),無論椎板間路還是椎間孔入路俯臥30度均有利于內(nèi)鏡套管的置入,減少神經(jīng)根和硬膜囊的損傷機(jī)會。8.脊柱微創(chuàng)手術(shù)椎間孔入路時,利用術(shù)前三維CT測量規(guī)劃,有利于指導(dǎo)椎間孔鏡入路操作(去除部分關(guān)節(jié)突和控制置管深度),防止出口神經(jīng)根和走行神經(jīng)根的損傷。
[Abstract]:Background: lumbar degenerative diseases often require surgery, surgical methods: open surgery or minimally invasive endoscopic treatment, endoscopic therapy has been widely used in lumbar degenerative diseases, complications: dural injury and nerve root injury, the reason is due to the complex irregular bony structures of lumbar vertebrae, natural orifice small, small space it is around the dural sac and spinal nerve injury in the process of placing channel equipment, dural sac and spinal nerve injury caused by the possibility of a larger, once the damage is huge and irreversible, so the technology is the difficulty of the operation, causing bottlenecks in the development of minimally invasive techniques, to firmly grasp the doctor in the anatomy and discuss the surgical experience, including the change of position is in practice we need to consider and explore. Objective: to simulate the surgery of lumbar degenerative disease prone, prone position and 0 degrees respectively in 3 CT 3D measurement for lumbar column structure after 0 degrees, were measured and the minimally invasive endoscopic surgery related data: the maximum distance between posterior coronal, sagittal intervertebral foramen diameter (longitudinal diameter), sagittal lower vertebral facet on the tip of the upper and lower edge after centrum distance under the distance from the middle and upper margin of articular posterior vertebral axial inferior vertebra, observation and study of lumbar spondylosis prone position 0 degrees and 30 degrees of lumbar posterior structure, especially the minimally invasive endoscopic surgery and related data, for different positions of lumbar lateral and posterior catheter approach for the objective basis for. Changes of different lumbar prone position after column structure position, can reasonable surgical options for clinical degenerative disorders of the lumbar minimally invasive endoscopic surgery, catheter into the right way, design new endoscopic equipment, provide anatomic basis of development and application, from To improve the safety and convenience of minimally invasive spine endoscopic surgery. Methods: 50 patients with degenerative lumbar spine (volunteer), according to the symptoms of lumbago and leg pain were divided into two groups, using SIEMENS 64 slice CT underwent L3-S1 scan, the first spiral CT scanning was performed in all CT patients, all the first 0 patients prone CT scan, then prone CT scans were performed in 30 degrees, the DICOM data into baohulu digital medical image acquisition workstation for 3D reconstruction, were measured: the maximum distance between posterior coronal, sagittal intervertebral foramen diameter, sagittal facet to the tip of the upper vertebral body after the lower edge of the lower edge of the distance from the midpoint of the lower edge of the facet and the posterior axial lower vertebra. The data are in table, statistics, lumbago and leg pain group were included in the group, the group of men and women, prone to 0 degrees 浣嶅拰淇崸30搴︿綅緗粍鍐嶅垎鍒粺璁＄浉鍏蟲暟鎹，

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