O-arm导航、3D打印导板及C型臂X线机辅助下寰枢椎螺钉置入的准确性比较

Comparison of the accuracies of atlantoaxial screw placement assisted by O-arm navigation,3D printed guide plate,and C-arm

目的:对比分析O-arm导航、个体化3D打印导板、C型臂X线机辅助下置入寰椎侧块螺钉和枢椎椎弓根螺钉的准确性和安全性.方法:回顾性分析2015年1月~2020年12月在我院行寰枢椎内固定术患者的临床资料,根据纳入和排除标准,共纳入47例患者,男28例,女19例;年龄15~59岁(46.2±10.0岁).根据置入寰枢椎螺钉方式的不同,分为导航组(应用O-arm导航辅助下置钉,11例)、导板组(应用3D打印导板指导下置钉,15例)、透视组(依据解剖标志在C型臂X线机透视辅助下徒手置钉,21例).统计三组的手术时间、置钉时间、术中出血量、一次性置钉成功率、螺钉置入精准性及并发症.结果:导航组手术时间、置钉时间和出血量分别为120.7±11.1min、20.0±1.1min和225.8±25.6ml;导板组分别为97.5±9.0min、15.8±1.9min和162.7±18.5ml;透视组分别为121.0±12.8min、19.4±2.1min和239.0±24.5ml,导板组手术时间、置钉时间、出血量少于其他两组(P<0.05).共置入寰枢椎螺钉188枚,导航组44枚、导板组60枚、透视组84枚.导航组一次性置钉成功率为100%(44/44),导板组为93.3%(56/60)、透视组为80.9%(68/84),导航组一次性置钉成功率高于其他两组(P<0.05).导航组0、1、2、3级置钉分别44、0、0、0枚,置钉准确率为100%;导板组分别为59、1、0、0枚,准确率为98.3%;透视组分别72、6、3、3枚,准确率为85.7%,透视组置钉准确率低于其他两组(P<0.05).透视组有3枚螺钉进入椎动脉孔,但术后均无脑缺血等相关表现.透视组术后2例患者出现枕颈部疼痛,分析原因为术中刺激C2神经根,给予糖皮质激素及脱水剂治疗后症状缓解;导航组与导板组均未出现术后枕颈部疼痛.三组患者手术切口均一期愈合,无切口或深部感染.结论:O-arm导航及个体化3D打印导板辅助下置入寰枢椎螺钉均能取得较高的准确率,优于传统的C型臂X线机辅助下徒手置钉技术;O-arm导航技术在寰枢椎的一次性置钉成功率方面具有优势;个体化3D导板能够在精确置入寰枢椎螺钉的情况下,节省手术时间、减少出血量.

Objectives:To compare and analyze the accuracy and safety of O-arm navigation,individualized 3D printed guide plate,and C-arm X-ray machine assisted atlantal lateral mass screw placement and axial pedicle screw placement.Methods:The clinical data of patients who underwent atlantoaxial internal fixation in our hospital from January 2015 to December 2020 were analyzed retrospectively.According to the inclusion and exclusion criteria,a total of 47 patients were enrolled,including 28 males and 19 females.The age ranged from 15 to 59 years,with an average of 46.2±10.0 years.The patients were divided into navigation group(O-arm navigation assissted,11 cases),guide plate group(3D printed guide plate assissted,15 cases),fluoroscopy group(freehand underC-arm fluoroscopy combined with anatomical signs,21 cases)according to different atlantoaxial screw placement methods.The operative time,screw placement time,intraoperative blood loss,one-time success rate,screw accuracy,and complications were collected and compared between the three groups.Results:The guide plate group was less in operative time(97.5±9.0min),screw placement time(15.8±1.9min),and the intraoperative blood loss(162.7±18.5ml)than those of the navigation group(120.7±11.1min,20.0±1.1min,and 225.8±25.6ml)and the fluoroscopy group(121.0±2.8min,19.4±2.1min,and 239.0±24.5ml)(P<0.05).A total of 188 atlantoaxial screws were inserted,and the one-time success rate of screw placement was 100%(44/44)in the navigation group,93.3%(56/60)in the guide plate group,and 80.9%(68/84)in the fluoroscopy group,which was higher in the navigation group than the other two groups(P<0.05).According to the grades of screw placement of 0,1,2,and 3,the accuracy of screw placement was 100%(44/0/0/0)in the navigation group,98.3%(59/1/0/0)in the guide plate group,and 85.7%(72/6/3/3)in the fluoroscopy group,which was lower in the fluoroscopy group than that in the other two groups(P<0.05).In the fluoroscopy group,three screws were inserted into the vertebral artery foramen,and no cerebral ischemia or other related manifestations were found.Two patients experienced postoperative occipitocervical pain in the fluoroscopy group due to stimulation of C2 nerve root during operation,which was relieved after treatment with glucocorticoid and dehydrating agent.No patients of the other two groups experienced postoperative occipitocervical pain.The incision of the three groups of patients all healed in one stage without incision or deep infection.Conclusions:Both O-arm navigation system and individualized 3D printed guide plate assisted atlantoaxial screw placement can achieve high accuracy,which are beter than the traditional freehand screw placement technique under C-arm fluoroscopy;O-arm navigation technology superiors in the one-time success rate of atlantoaxial screw placement;Individualized 3D printed guide plate can save operative time and reduce bleeding while accurately placing atlantoaxial screws.