术中即时三维导航辅助与徒手置入枢椎椎弓根螺钉固定治疗Hangman骨折的治疗结果比较

Axis pedicle screwing assisted by intraoperative 3-D navigation versus freehand axis pedicle screwing in treatment of Hangman fracture

目的比较术中即时三维导航辅助与徒手置入枢椎椎弓根螺钉固定治疗Hangman骨折的治疗结果。方法回顾性分析2014年5月至2019年12月宁波市第六医院脊柱外科行后路枢椎椎弓根螺钉治疗的64例Hangman骨折患者资料。根据枢椎椎弓根螺钉置入方式的不同分为导航组(采用术中即时三维导航辅助下置入枢椎椎弓根螺钉,n=34)和徒手组(徒手置入枢椎椎弓根螺钉,n=30)。记录并比较两组患者枢椎椎弓根螺钉置钉时间、手术时间、术中出血量、透视时间、住院时间、住院总费用、并发症发生情况。根据术后颈椎CT并按照Park等提出的螺钉分级标准评估枢椎椎弓根螺钉置入准确率。在术前、术后3个月、末次随访时,应用改良日本骨科协会腰痛评分表(mJOA)评估手术前、后患者的神经功能,应用视觉模拟评分(VAS)评估颈部疼痛程度,测量C2,3椎体成角和C2椎体前移距离。末次随访时应用Moon分级评估疗效。结果导航组和徒手组患者术前一般资料比较差异均无统计学意义(P>0.05),具有可比性。导航组置钉准确率(98.2%,54/55)显著优于徒手组(85.2%,46/54),差异有统计学意义(P<0.05)。导航组置钉时间、手术时间、透视时间、住院总费用均高于徒手组,差异均有统计学意义(P<0.05)。徒手组中3例患者发生椎动脉损伤。两组所有患者术后均未发生螺钉松动、断钉和断棒。两组患者术中出血量、住院时间、随访时间差异均无统计学意义(P>0.05)。两组患者术后3个月、末次随访时VAS评分、mJOA评分、C2,3成角、C2前移距离均较术前显著改善,差异均有统计学意义(P<0.05),但同期两组间比较差异均无统计学意义(P>0.05)。末次随访时导航组Moon分级优于徒手组,差异有统计学意义(P<0.05)。结论相比于徒手置钉技术,术中即时三维导航技术辅助置入枢椎椎弓根螺钉治疗Hangman骨折,能提高置钉的准确性和安全性,减少术后并发症,获得更好的疗效。

Objective Tocompare the therapeutic results between axis pediclescrewing assisted by intraoperative 3-D navigation and freehand axis pedicle screwing in the treatment of Hangman fracture.Methods A retrospective analysis was performed of the 64 patients with Hangman fracture who had received posterior axis pedicle screwing at Department of Spinal Surgery,The Sixth Hospital of Ningbo from May 2014 to December 2019.According to the placement methods of axis pedicle screws,they were divided into a navigation group(n=34,subjected to axis pedicle screwing assisted by intraoperative 3-D navigation)and a freehand group(n=30,subjected to freehand axis pedicle screwing).Pedicle screw placement time,operation time,intraoperative bleeding,fluoroscopy time,hospital stay,total hospitalization cost and complications were recorded and compared between the 2 groups.The accuracy of axis pedicle screw placement was evaluated according to the postoperative cervical CT and screw grading criteria proposed by Park et al.At admission,3 months postoperation,and the last follow-up,neurological function of the patients was evaluated by modified Japanese Orthopedic Association(mJOA)score,neck painwas evaluatedbyvisual analogue scale(VAS),and C2/3vertebral body angulation and C2 forward displacement were measured.The clinical efficacy was evaluated by Moon grading at the lastfollow-up.Results The navigation group and thefreehandgroupwere comparabledue to insignificant differences between them in the preoperative general data(P>0.05).The accuracy of screw placement in the navigation group(98.2%,54/55)was significantly higher than that in the freehand group(85.2%,46/54)(P<0.05).The screw placement time,operation time,fluoroscopytime and total hospitalization cost in the navigation group were significantly more than those in the freehand group(P<0.05).Vertebral artery injury occurred in 3 cases in the freehand group.Screw loosening,screw breakage or rod breakage occurred in none of the patients after operation.There was no significant difference between the 2 groups in the intraoperative bleeding,hospital stay or follow-up time(P>0.05).In both groups,the VAS score,mJOA score,C2/3 vertebral body angulation and C2 forward displacement were significantly improved at 3months postoperation and the last follow-up compared with those at admission(P<0.05),but there was no significant difference between the 2groups in the contemporary comparisons(P>0.05).At the last follow-up,Moon grading in the navigation group was significantly better than that in the freehand group(P<0.05).ConclusionIn the treatment of Hangman fracture,compared with freehand screw placement,axis pedicle screwing assisted by intraoperative 3-D navigation can improve accuracy and safety of screw placement and reduce postoperative complications,leading to better clinical efficacy.