3D打印及导航技术辅助腰椎皮质骨轨迹螺钉置入的准确性及疗效分析

Accuracy and clinical efficacy of three-dimensional printing and navigation technology assisted lumbar cortical bone trajectory screw placement

背景:腰椎皮质骨螺钉轨迹螺钉技术适用于骨质疏松患者及肥胖患者,但凭借经验徒手置钉失败率高,风险大,学习曲线长,不易掌握。目的:对比3D打印及术中导航技术辅助腰椎皮质骨轨迹螺钉置钉与徒手置钉的准确性,探讨3D打印技术及术中导航技术在腰椎手术中应用的优势。方法:纳入西安空军军医大学唐都医院2017年1月至2018年1月采用腰椎皮质骨轨迹螺钉内固定治疗伴有骨质疏松的腰椎退行性变患者32例,随机分为3组。3D打印组10例术中利用术前打印的置钉导板置入腰椎皮质骨轨迹螺钉;术中导航组12例术中在导航辅助下置入腰椎皮质骨轨迹螺钉;徒手置钉组10例术前完善常规检查,术中采用徒手置钉。所有患者术后均行CT平扫,根据螺钉穿破皮质的程度将置钉精确性分为4级,评估置钉的准确性并对3组患者围术期情况进行统计学分析。结果与结论:(1)3D打印组共置入皮质骨轨迹螺钉44枚(L_3 2枚,L_4 18枚,L_(5 )24枚),其中0级38枚,1级6枚,无2级或3级不良置钉;术中导航组共置入皮质骨轨迹螺钉52枚(L_3 6枚,L_4 20枚,L_5 26枚),其中0级47枚,1级5枚,无2级或3级不良置钉;徒手置钉组共置入皮质骨轨迹螺钉40枚(L_3 4枚,L_416枚,L_5 20枚),其中0级27枚,1级8枚,2级3枚,3级2枚;(2)3组间置钉精确性分级差异有显著性意义(P=0.010);3D打印组和导航组组间差异无显著性意义(P=0.540),2组均优于徒手置钉组(P=0.034;P=0.005);(3)3组患者相比,术中导航组平均住院日少于3D打印组和徒手置钉组(P=0.001;P=0.009),3D打印组术中出血量少于徒手置钉组(P=0.005),术中导航组的手术时间长于其他2组(P=0.004;P=0.026);(4)徒手置钉组1例患者出现脑脊液漏,其余患者均未出现置钉相关的血管、神经并发症;3组所有患者术后随访均未出现螺钉松动移位及断裂情况;(5)提示利用3D打印及术中导航技术辅助皮质骨轨迹螺钉治疗伴骨质疏松腰椎退行性变,螺钉置入准确性高,可有效降低不良置钉率,防止置钉相关并发症;且3D打印技术在减少术中出血量方面、导航技术在缩短平均住院日方面有一定的优势。

BACKGROUND:Lumbar cortical bone trajectory screw is available for the osteoporotic and obese patients,but un-armed placement exhibits high failure rate and risk,long learning duration and difficulty in grasping.OBJECTIVE:To compare the accuracy of three-dimensional printing and intraoperative navigation technology assisted lumbar cortical bone trajectory screw placement and unarmed placement,and to explore the advantages of three-dimensional printing technology and intraoperative navigation technology in lumbar surgery.METHODS:Thirty-two patients with lumbar degenerative diseases and osteoporosis who treated with lumbar cortical bone trajectory screw fixation at Tangdu Hospital,The Military Medical University of Air Forces from January 2017 to January 2018 were enrolled and randomized into three groups.The patients in the three-dimensional printing group(n=10)were placed the lumbar cortical bone trajectory screws by intraoperative pre-printed nail guide.The patients in the navigation group(n=12)were placed the lumbar cortical bone trajectory screws under the aid of navigation.The patients in the unarmed group(n=10)completed the routine examination before surgery and the nails were placed by experience.All patients undertook postoperative CT scans.The accuracy of the nails was divided into four grades according to the degree of screw penetration to assess the accuracy of placement.The perioperative status of the patients in each group was statistically analyzed.RESULTS AND CONCLUSION:(1)The three-dimensional printing group had 44 cortical bone trajectory screws being inserted(2 L3 screws,18 L4 screws and 24 L5 screws),38 of them were classified as grade 0,6 were grade 1,and no grade 2 or grade 3 was identified.A total of 52 cortical bone trajectory screws were placed in the navigation group(6 L3 screws,20 L4 screws and 26 L5 screws),47 of them were classified as grade 0,5 as grade 1,and no grade 2 or grade 3 was identified.The unarmed group had 40 cortical bone trajectory screws being inserted(4 L3 screws,16 L4 screws and 20 L5 screws),27 of them were classified as grade 0,8 as grade 1,3 as grade 2,and 2 as grade 3.(2)There were significant differences in the accuracy of nail placement among groups(P=0.010).There was no significant difference between three-dimensional printing and navigation groups(P=0.540),and both groups were better than the unarmed group(P=0.034;P=0.005).(3)The average hospitalization time in the navigation group was less than that in the three-dimensional printing and unarmed groups(P=0.001;P=0.009).The three-dimensional printing group had less intraoperative blood loss than that in the unarmed group(P=0.005),while the operation time was longer than that in the other two groups(P=0.004;P=0.026).(4)One patient in the unarmed group occurred with cerebrospinal fluid leakage,and the other patients had no vascular or neurological complications associated with nail placement.All patients in the three groups did not have displacement loosening or fracture after operation.(5)Our findings suggest that using three-dimensional printing technology and intraoperative navigation can help lumbar cortical bone trajectory screw placement in the treatment of lumbar degenerative disease with osteoporosis.The accuracy of screw placement is high,which can effectively reduce the rate of poor nail placement and prevent postoperative complications.Three-dimensional printing technology can reduce the amount of intraoperative blood loss,and the navigation technology has the advantage in shortening average hospitalization time.