3D打印导板导航技术在一期后路治疗颈胸段结核伴后凸畸形的疗效分析

Efficacy of 3D print guide technique in one stage posterior approach for the treatment of cervical andthoracic tuberculosis with kyphosis

目的探讨3D打印技术在一期后路病灶清除植骨融合椎弓根钉固定治疗不同发病节段的颈胸段结核性后凸畸形并截瘫中个性化应用的疗效。方法回顾性分析2008年1月至2017年1月新疆维吾尔自治区人民医院骨一科收治的31例颈胸段结核患者的病例资料。其中病变节段位于胸椎移行区（T1～T4）8例，颈椎移行区（c5～C7）10例，颈胸段交界区13例，累及2个椎体7例，3个椎体14例，4个椎体10例。3D打印组（A组）12例，非3D打印组（B组）19例。所有病例均选择一期经后路环脊髓周围结核病灶清除钛网支撑植骨融合并椎弓根钉固定术。术后正规服用抗结核药物6．12个月，随访观察后凸畸形矫正度和截瘫恢复情况，红细胞沉降率（ESR）、C一反应蛋白（CRP）变化情况。结果所有病例得到随访6个月。12例患者术前利用3D打印技术进行了术前规划，术中均按术前方案进行手术。术中发现采用3D打印技术术前设计的椎弓根螺钉的直径和长度、进钉方向以及进钉点与后正中线的距离等指标与术中实际使用情况一致。术后第3天复查x线片，可见骨折复位效果满意，椎弓根钉位置良好。术后6个月随访复查X线片显示椎弓根钉位置良好、无松动断裂，所有患者均骨性愈合，未见骨折内固定节段性不稳。3D打印组手术的术中出血、手术时间、术后引流量，与非3D打印组的手术结果相比，3D打印组手术的创伤明显减少[手术时间：（131±18）rain比（162±23）min，P〈0．01；术中出血量：（528±34）ml比（615±41）ml，P〈0．01；术后引流量：（257±46）ml比（327±56）ml，P〈0．01；两组ESR：术前为（64±42）mm／1h，术后为（6±7）mm／1h，P〈0．01；两组CRP：术前（72±41）μg／L，术后（13±6）μg／L，P〈0．01]。3D打印组患者的术后1、2周，1、3个月JOA评分均优于非3D打印组，术后6个月两组间差异无统计学意义。两组患者术前、术后Cobb角纠正均得到满意结果，两组术后Cobb角矫正度差异有统计学意义，术后6个月随访两组间差异无统计学意义，Cobb矫正角度丢失平均为1°。本组脊柱结核均治愈，无严重手术并发症。结论根据颈胸椎结核性后凸畸形和截瘫严重程度，选择一期经后路手术治疗方式能获得有效的根治，可行彻底的病灶清除、植骨融合并畸形矫正后内固定获得脊柱前后方的稳定性，3D导板导航技术增加手术的精确性、安全性，并可以提供术前更加详细、直观、立体、现实个性化手术方案，术后可以快速康复。

Objective To investigate the application of 3D printing technology in the treatment of patients with cervical kyphosis and paraplegia in different segments of the cervical spine after one-stage debridement, bone graft fusion and pedicle screw fixation. Methods From January 2008 to January 2017, a total of 31 patients with thoracolumbar tuberculosis were treated in the Department of Orthopaedics, the Xinjiang Uygur Autonomous Region people＇s Hospital. Lesions of the thoracic spine （T1 -T4 ） in 8 cases, （C5 -C7） in 10 cases, cervical and thoracic segment in 13 cases, involving a total of 2 cases of vertebral body in 7 cases, 3 cases of vertebral body in 14 cases, 4 cases of vertebral body. 3D printing group （ groupA） 12 cases, non 3D printing group （group B） of 19 cases. All cases were treated with a posterior approach to the treatment of the cervical spinal cord around the spinal cord. After taking regular anti tuberculosis drugs in 6 - 12 months, follow-up observation of correction of kyphosis and paraplegia recovery, blood sedimentation rate （ESR） , C-reactive protein （CRP） changes. Results All cases were followed up for at least 6 months. Twelve patients were treated with 3 D printing technique before operation, and the operation was performed according to the preoperative plan. The diameter and length of pediele screws, the direction of insertion, and the distance between the insertion point and the posterior midline of the pedicle screw were similar to those in the 3D. Three days after the operation, the effect of fracture reduction was satisfactory, and the position of pedicle screws was good. After 6 months of follow-up, the X-ray showed that the pedicle screws were in good position, and there was no loosening and fracture. All the patients were healed, and there was no segmental instability. 3D printing group during surgery bleeding, operation time, postoperative drainage volume, compared with the non 3D print group of surgical results, 3D printing group significantly reduce the surgical trauma [ （ 131± l 8 ） min vs （ 162 ± 23 ）, P 〈 0. 01 ; （ 528 ± 34 ） ml vs （ 615 ±41 ） ml, P 〈0. 01 ; （257±46） vs （327 ±56） , P 〈0. 01 ; （not grouping,before after operation） , （64 ±42） ram/1 h vs （6±7） mm/1 h,P〈0.01; CRP （not packet） ：（72 ±41） μg/L, （13 ±6） mm/1 h,P〈0.01]. There was significant difference between two groups. The JOA scores of patients in the 3D group were better than those in the non 3D group after the operation in 1,2 week and in 1,3, and month. There was no significant difference between the two groups after the operation. Two groups of patients before and after correction of Cobb angle were satisfied, and no significant difference between the two groups. Cobb lost an average of 1 degrees angle correction. The spinal tuberculosis in this group were cured without serious complications. Conehlsions According to the cervical and thoracic tuberculous kyphosis and paraplegia severity, choose a posterior surgery can achieve effective cure, feasible thorough debridement with fixed spinal stability before and after the party obtained bone fusion and deformity correction in 3D technology to increase the accuracy and safety of operation, and can be provide more detailed preoperative, intuitive, three-dimensional, realistic personalized operation scheme. It can reduce the operation trauma, and achieve ranid reeover after ooeration.