3D打印导板辅助椎动脉高跨患者C2椎弓根螺钉置入的临床研究

Clinical study of C2 pedicle screw placement in patients with high-riding vertebral artery assisted by 3D-printed navigation template

目的:探讨在椎动脉高跨患者中3D打印导板辅助置入C2椎弓根螺钉的准确性和安全性。方法:回顾性分析2018年1月~2018年12月在我院行上颈椎后路内固定术的72例C2椎动脉高跨患者。根据辅助C2椎弓根螺钉置入方式的不同分为导板组(n=36例)和徒手组(n=36例)。两组患者年龄、性别、体重指数(BMI)、疾病类型等一般资料比较差异均无统计学意义(P>0.05)。记录并比较两组患者C2椎弓根螺钉置钉时间、手术时间、术中出血量、透视时间、术中出血量、置钉相关并发症、手术技术费用、住院时间以及术前、术后3d、术后6个月VAS评分、JOA评分。根据术后颈椎CT并按照Kawaguchi等提出的螺钉分级标准评估C2椎弓根螺钉置入准确率,并计算术前模拟置钉与术后实际置钉进钉角度在矢状面与横断面上的偏差。结果:导板组置钉时间、手术时间、透视时间明显优于徒手组(P<0.05),手术技术费用徒手组明显低于导板组(P<0.05)。两组术中出血量、住院时间无明显统计学差异(P>0.05),两组术后3d、术后6个月的VAS评分和JOA评分均较术前明显改善(P<0.05),组间比较无统计学差异(P>0.05)。导板组和徒手组分别置入C2椎弓根螺钉42枚、43枚;置钉准确率(0级+1级)分别为95.2%、72.1%。两组螺钉矢状面偏离角度分别为0.52°±0.42°、2.21°±0.69°,横断面偏离角度分别为0.51°±0.36°、2.16°±0.77°。导板组在置钉准确率、螺钉偏差角度均优于徒手组(P<0.05)。并发症情况:两组患者中共发生椎动脉损伤4例,其中导板组0例,徒手组4例,差异有统计学意义(P<0.05),所有患者术后均未发生螺钉松动、断钉断棒。结论:在椎动脉高跨患者中,3D打印导板和徒手技术辅助置钉可达到相似的临床疗效,但在置钉准确性和安全性方面,导板技术更占优势,同时它能显著缩短置钉时间、透视时间,降低手术并发症。

Objectives:To investigate the accuracy and safety of 3D-printed navigation template-assisted C2 pedicle screw(C2PS)placement in patients with high-riding vertebral artery.Methods:A retrospective study was performed on 72 patients with high-riding vertebral artery who underwent posterior internal fixation of upper cervical spine in our hospital from January 2018 to December 2018.According to the different placement methods of C2PS,they were divided into two groups:navigation template group(n=36),and freehand group(n=36).There were no significant difference in age,gender,body mass index(BMI)and disease type between the two groups(P>0.05).The single C2PS placement time,operation time,fluoroscopy time,intraoperative blood loss,operation-related complications,operation cost,hospitalization time,VAS scores and cervical JOA scores preoperatively and at 3 and 6 months postoperatively in the two groups were recorded and compared.The accuracy of C2PS placement was evaluated according to the screw classification standard proposed by Kawaguchi et al.And the deviation angles of C2PS in sagittal plane and cross section were recorded.Results:The C2PS placement time,operation time and fluoroscopy time in navigation template group were significantly better than those in freehand group(P<0.05),and the technical cost in freehand group was significantly lower than that in navigation template group(P<0.05).There were no significant difference in intraoperative blood loss and hospitalization time between the two groups(P>0.05),the VAS and JOA scores at 3 days and 6 months postoperatively were significantly improved compared with the preoperative scores(P<0.05)but did not differ significantly between the 2 groups(P>0.05).42 and 43 C2 pedicle screws were placed in navigation template group and freehand group,respectively,The accuracy(grade 0+grade 1)was 95.2%and 72.1%,respectively.Deviation sagittal in the two groups were 0.52°±0.42°,2.21°±0.69°,respectively.And deviation transversal were 0.51°±0.36°,2.16°±0.77°,respectively.The accuracy,screw deviation angle of navigation template group were better than those of freehand group(P<0.05).Complications:four vertebral artery injuries(0 in navigation template group,4 in freehand group).There were no screw loosening,broken screw or broken rod in all patients after surgery.Conclusions:In patients with HRVA,3D-printed navigation template and freehand technology-assisted C2PS placement can provide similar clinical efficacy,but in terms of the accuracy of screw placement,navigation template technology is more dominant,and it can significantly shorten the time of screw placement,fluoroscopy time and reduce the complications of operation.