徒手置钉技术在脊柱畸形矫正中的准确性与安全性研究

Accuracy and safety of pedicle screw placement in spinal deformity correction with free hand technique

目的 探究徒手置钉技术在脊柱畸形矫正中的准确性与安全性.方法 回顾性分析本院2012年4月-2012年8月所有因脊柱畸形而接受脊柱后路三维矫形椎弓根内固定手术的36名病例.所有病例术中仅采用徒手置钉技术,均不使用C形臂X线机透视或导航系统等计算机辅助设备,较严重病例或重度后凸需要截骨者使用神经电生理监测.术后行脊柱全长正侧位X线片及CT扫描,通过影像归档和通信系统（picture archiving and communication systems,PACS）查看影像资料,记录皮质穿破的类型及距离.术后密切观察有无血管及神经源性并发症直至出院.结果 36名患者置入螺钉总数为550枚.其中210枚螺钉发生误置,总发生率为38.18%（210/550）.内侧皮质穿破（medial cortical perforation,MCP）的发生率为5.27%（29/550）;外侧皮质穿破（lateral cortical perforation,LCP）的发生率为27.09%（149/550）;椎体前壁穿破（anterior cortical perforation,ACP）的发生率为6.55%（36/550）;上终板穿破（endplate perforation,EPP）的发生率为0.55%（3/550）;椎间孔穿破（foramen perforation,FP）的发生率为0.91%（5/550）.上、中、下胸椎及腰椎的MCP发生率分别为3.39%（2/59）、3.90%（51/128）、5.81%（10/172）、6.28%（12/191）,LCP发生率分别为44.07%（26/59）、50.78%（65/128）、25.00%（43/172）、7.85%（15/191）.MCP在胸椎及腰椎的发生率相近,分别为4.7%（17/359）、6.3%（12/191）,差异无统计义意义（P＞0.05）,而胸椎较腰椎更易发生LCP,发生率分别为 37.3%（134/359）、7.9%（15/191）,差异有统计学意义（P＜0.01）.所有病例术后均无神经、血管及内脏相关并发症出现.结论 徒手置钉技术在脊柱畸形矫正中的应用是安全的,可以避免使用术中透视、计算机导航等带来的不利影响.LCP是最常见的穿破类型,在胸椎的发生率比在腰椎高,因而在胸椎使用计算机图像系统等协助置钉可能更有应用价值.

Objective To explore the accuracy and safety of pedicle screw placement in spinal deformity correction with free-hand technique. Methods Posterior spinal instrumentation was performed with free-hand technique in 36 patents with spinal deformity from April 2012 to August 2012. In all cases, the screw applications were performed by free hand technique, and neurophysiologie monitoring was used only in serious cases or severe kyphosis which needed osteotomy. Radiological inves- tigation with computed tomography（CT） scans and X-ray films were performed once the patients become in stable condition. Postoperative analyses were performed through the picture archiving and communication systems （PACS） to evaluate whether the 550 screws during posterior instrumentation in a total of 36 patients with spinal deformity were positioned correctly, and the incidence and extent of cortical breach by misplaced pedicle screws was determined and recorded. Close observation of the presence or absence of vascular and neuropathic complications was conducted until discharge. Results From April 2012 to August 2012, a total of 36 patients with spinal deformity underwent posterior spinal instrumentation surgery, a total of 550 screws were inserted, of which 210 screws were considered to be misplaced, the total malposition rate was 38.18% （210/ 550）. The rate of medial cortical perforation （MCP） was 5.27% （29/550） ; the rate of lateral cortical perforation （LCP） was 27.09% （149/550）; the rate of anterior cortical perforation （ACP） was 6. 55% （36/550）; the rate of the endplate perforation （EPP） was 0.55% （3/550） ; the rate of foramen perforation （FP） was 0. 91% （5/550）. According to their loca-tions, the rate of MCP in upper （ T1-4 ） , middle （ T 5-8 ） and lower （ T9-12 ） thoracic： and lumhar （ L1-5 ） were 3.39% （ 2/59 ）, 3.90% （51/128）, 5.81% （10/172） , 6.28% （ 12/191 ）, respectively; the rate of LCP in the 4 regions were 44.07% （26/ 59） , 50.78% （65/128）, 25.00% （43/172）, 7.85% （ 15/191 ）, respectively. The rate of MCP in thoracic and lumbar spine were 4.7% （ 17/359 ）, 6.3% （ 12/191 ）, respectively, with no statistic signific.ant （ P 〉0. 5 ）, but the LCP was more likely to occur in thoracic area than in the lumbar spine, with the rate to be 37.3% （ 134/359）, 7.9% （ 15/191 ）, respectively （ P 〈 0.01 ）. No vascular and neuropathic complications were observed during the experiment. Conclusion Ped- icle screw fixation with free-hand technique in patients with spinal deformity appears to be safe, and because of the reduction of surgery time, the absence of exposure to radiation, as well as the very low rate of infection, it seems to be the best way for well trained doctor to plaee pedicle screws by using free-hand technique. LCP is the most common type, especially in the tho- racic spine, so using the computer image system to assist screws insertion may contribute more than in the lumbar spine.