侧卧位和俯卧位下置入椎弓根螺钉对老年患者脊柱后路手术的影响

Comparison of the clinical outcome between the prone and lateral position for the lumbar pedicle screw placement in elderly patients

目的在60岁以上老年患者的脊柱后路手术中,比较侧卧位和俯卧位下置入椎弓根螺钉的精确性及安全性,同时比较两种体位对老年患者手术过程中耐受能力的影响。方法总结2007年10月～2010年10月进行后路椎弓根螺钉固定的42例老年腰椎疾病患者的临床资料。其中男性26例,女性16例;年龄60～82岁,平均68.3岁;腰椎管狭窄25例,腰椎滑脱8例,腰椎间盘突出节段失稳9例。术中全身麻醉条件下根据解剖标志徒手置入椎弓根螺钉。所有患者术后均行CT检查。其中21例患者采取侧卧位后路椎弓根螺钉置入,21例患者采取俯卧位后路椎弓根螺钉置入。术中观察两组患者的肺通气功能和耐受能力,并比较分析其差异。术后在工作站系统上分析两组患者椎弓根螺钉破壁率的差别。结果与俯卧位相比,侧卧位患者术中的二氧化碳分压较低,耐受能力较强(P<0.05)。侧卧位病例共置入98枚椎弓根螺钉,平均每例患者置入4.7枚螺钉。螺钉完全在椎弓根内89枚,占90.8%。破壁9枚,占9.2%。俯卧位病例共置入88枚椎弓根螺钉,平均每例患者置入4.2枚螺钉。螺钉完全在椎弓根内81枚,占92.0%。破壁7枚,占8.0%。两组患者椎弓根螺钉破壁率没有差异(P>0.05)。结论全身麻醉条件下与俯卧位相比,60岁以上的老年患者在侧卧位下行椎弓根螺钉的徒手置入同样有较高的精确性和安全性,同时可以降低体位对肺通气功能的影响,提高老年患者的手术耐受能力。

【Objective】 To compare the accuracy of pedicle screw placement and the operating tolerance between the prone and lateral position in elderly patients.【Methods】 Forty two consecutive cases treated with posterior spinal instrumentation with pedicle screws were investigated from Oct.2007 to Oct.2010.The patients included 26 boys and 16 girls,with a mean age of 68.3 years at surgery（range 60 ～ 82 years）.The diagnoses were lumbar stenosis（n =25）,spondylolisthesis（n =8）,Lumbar disc herniation combined with instability（n =9）.Pedicle screws were inserted according to the anatomic landmark with free hand technique.Postoperative CT scans were performed in all cases.These patients were divided into two groups with 21 patients treated in the prone position and 21 patients treated in the lateral position.The PaCO2 and operating tolerance were recorded during the operation.The perforation of pedicle screws was measured using Pacs Client software（PACS）.【Results】 Compared with the prone position,the patients in the lateral position underwent with the lower PaCO2 and better tolerance.There were 98 pedicle screws inserted in the lateral position,with each patient of average 4.7 screws.89 screws were well contained in pedicle,with the percentageof 90.8%.There were 9 screw malpositioned with the percentage of 9.2%.There were 88 pedicle screws inserted in the lateral position,with each patient of average 4.2 screws.81 screws were well contained in pedicle,with the percentage of 92.0%.There were 7 screw malpositioned with the percentage of 8.0%.There was no significant difference for the accuracy of pedicle screw placement between the two operating positions.【Conclusions】The safety and accuracy of pedicle screw placement for the lateral position were similar to the prone position in the elderly patients.And the pulmonary function and surgical tolerance of elderly patients could be improved in lateral position.