三维可视化技术在胸椎黄韧带骨化症手术治疗中的应用

Application of three-dimensional visualization technology in surgical resection of thoracic ossification of ligamentum flavum

目的探讨三维可视化技术辅助设计手术治疗胸椎黄韧带骨化症的临床应用价值。方法回顾性分析2013年11月—2016年12月郑州市骨科医院脊柱一科采用椎板切除治疗的44例胸椎黄韧带骨化症的临床资料。其中,男25例、女19例,年龄40~76岁。术前均采用Mimics软件对胸椎CT扫描的DICOM数据进行三维重建,在胸椎椎板和骨化黄韧带的三维可视化模型上观察骨化灶的立体结构以及与椎弓根、关节突、椎板的位置关系,计算数字模拟骨化灶体积;按照"分区椎板切除"的方式在三维可视化数字模型上进行骨化黄韧带的模拟切除;按照术前模拟切除步骤,实施手术操作。观察手术时间、术中出血量及并发症发生情况。术后12个月采用日本骨科协会(JOA)评分评估神经功能,根据术前和术后JOA评分计算JOA改良率,评估手术疗效。结果三维重建模型44个,重建骨化灶103个,骨化灶体积为(1831±443)mm3。44例患者均顺利完成手术,手术时间65~180(96.7±19.6)min;术中出血量230~1350(432±83.5)mL。患者术后无脊髓神经损害症状加重者,术后神经症状均逐步好转。44例患者均获随访,随访时间13~46(25±10.3)个月。随访期间无迟发性感染、神经症状加重、内固定失败等并发症发生。术后12个月JOA评分(8.8±1.8)分,明显高于术前的(5.3±2.0)分,差异有统计学意义(t=11.566,P<0.01);JOA评分改善率为64.2%±21.7%,疗效评价优13例、良21例、可10例,优良率77.3%(34/44)。结论应用三维可视化技术进行术前评估,能够立体、全面了解骨化黄韧带的形态,通过模拟手术,设计手术切除范围,可以提高手术精准度、安全性和有效性,为胸椎黄韧带骨化症的诊疗提供了一种新的术前影像学辅助方法。

Objective To evaluate the laminectomy for thoracic ossification of the ligamentum flavum(OLF)by preoperative planning of preoperative three-dimensional visualization.Methods From November 2013 to December 2016,forty-four patients(25 males,19 females,40-76 years old)with thoracic OLF underwent preoperative three-dimensional(3D)visualization surgery planning.The three-dimensional structure of OLF were reconstructed with digital imaging,and the positional relationship with pedicle,articular process and lamina were displayed.The numerical simulation of osseointegration volume were calculated.We performed a simulated resection of the OLF on a 3D visualization digital model by"Zoning laminectomy".Duration of operation,volume of bleeding,complication were recorded.The neurological function of the patients was evaluated by the Japan Orthopaedic Association(JOA)spinal function scale and calculated the improvement rate.Results The 44 preoperative three-dimensional reconstruction models were used to simulate surgical resection.The volume of digital simulation single OLF was(1831±443)mm3.The average operating duration was 65-180(96.7±19.6)min,the average bleeding was 230-1350(432±83.5)mL.The symptoms of spinal cord nerve injury did not increase after operation.The neurological symptoms of the patients were gradually improved after surgery.Forty-four patients were followed up after surgery.Follow-up time was 13-46(25±10.3)months.No complications,such as delayed infection,aggravation of neurological symptoms and failure of internal fixation,occurred during follow-up.JOA score was 8.8±1.8 at 12 months after surgery,which was significantly higher than that before surgery 5.3±2.0,and the difference was statistically significant(t=11.566,P<0.01).JOA score improvement rate was 64.2%±21.7%.The curative effect evaluation was excellent in 13 cases,good in 21 cases,and fair in 10 cases,with the excellent and good rate of 77.3%(34/44).Conclusions The preoperative evaluation is performed using 3d visualization technology,and the morphology of ossified ligament flavum can be understood stereoscopic and comprehensively.The surgical resection area is designed by simulating the operation.It can improve surgical accuracy,safety and effectiveness.It provides a new preoperative imaging assistant method for the diagnosis and treatment of ossification of thoracic vertebra ligament yellow.