传统寰枢椎后路椎弓根螺钉置钉技术和个性化导向模板辅助置钉技术的临床对比研究

A comparative study on the safety of atlantoaxial pedicle screw placement between free-hand technique and personalized 3D template technique in patients with atlantoaxial instability

中文关键词:  个性化导向模板  3D打印  寰枢椎  椎弓根螺钉

英文关键词:Personalized  3D printing  Atlanto-axial  Pedicle screws

中文摘要:

  【摘要】 目的：比较传统置钉技术与个性化导向模板辅助置钉技术手术治疗寰枢椎不稳症的置钉准确性。方法：回顾性分析2011年6月~2017年7月我科收治的寰枢椎不稳症患者56例（男33例，女23例），男性年龄56.8±8.9岁（36~71岁），女性年龄54.5±10.8岁（33~72岁），其中30例行传统寰枢椎后路椎弓根螺钉内固定植骨融合术（对照组），26例行个性化定点-定向导向模板辅助寰枢椎椎弓根螺钉内固定植骨融合术（观察组）。寰椎和枢椎定点导板均有长条状扶手设计。术后3d复查CT评估寰椎和枢椎螺钉置入的安全性，并将螺钉位置分为4级：0级，螺钉完全位于骨性钉道内；1级，在横断面或矢状面上，螺钉直径穿破骨皮质≤50%；2级，在横断面或矢状面上，螺钉直径穿破骨皮质＞50%；3级，螺钉直径完全穿破骨皮质。比较两组螺钉安全率（0级设为安全，1~3级设为存在风险）、手术时间、术中透视次数以及术中出血量。结果：寰椎椎弓根螺钉对照组0级48枚、1级7枚、2级2枚、3级1枚，观察组0级49枚、1级2枚、2级1枚、3级0枚，各级组间比较均无明显差异。枢椎椎弓根螺钉对照组0级53枚、1级6枚、2级1枚、3级0枚，观察组0级48枚、1级2枚、2级0枚、3级0枚，各级组间比较均无明显差异（P＞0.05）。螺钉安全率对照组及观察组组间比较存在差异（P=0.019）；平均手术时间对照组109.2±17.1min，观察组115.2±16.6min，两组间比较存在差异（P=0.009）；平均透视次数对照组12.50±1.95次，观察组6.85±2.44次，两组间比较存在差异（P＜0.0001）；平均术中出血对照组198.1±108.3ml，双导板组160.3±135.4ml，两组间比较无明显差异（P=0.216）。患者术后随访时间14~26个月（19.4±4.1个月），所有病例行寰枢椎后路术后均获得融合。结论：改良个性化导向模板辅助寰枢椎椎弓根螺钉置钉技术比传统置钉技术更能有效减少术中X线透视次数并提高临床手术置钉的准确性。

英文摘要:

  【Abstract】 Objectives: To compare the accuracy of traditional screw placement technique and improved personalized template assisted screw placement technique in the treatment of atlantoaxial instability. Methods: From June 2011 to July 2017, 56 patients (male 33, female 23) with atlantoaxial instability were analyzed retrospectively. The average age was 56.8±8.9 years(36-71 years) for male and 54.5±10.8 years (33-72 years) for female. The follow-up time was 14-26 months(19.4±4.1 months). A total of 30 patients underwent traditional posterior atlantoaxial pedicle screw internal fixation and fusion(control group), while the other 26 patients underwent atlantoaxial pedicle screw internal fixation and bone fusion assisted by personalized pointing and drilling template(test group). The pointing template of atlas and axis are designed with handrails. Three days after operation, all patients underwent CT reexamination to evaluate the safety of screw placement in atlas and axis, and the screw position was categorized into four grades: grade 0, the screw was completely located in the pedicle; grade 1, in the cross section or sagittal plane, the screw penetrated the osseous cortex ≤50%; grade 2, in the cross section or sagittal plane, the screw penetrated the osseous cortex >50%; grade 3, the screw completely penetrated the osseous cortex. Grade 0 was set as safety, and grade 1-3 was set as risk. The safety rate of screws, operation time, the times of intraoperative fluoroscopy and the amount of intraoperative hemorrhage were compared between the two groups. Results: As for C1 screw, there were 48 screws of grade 0, 7 screws of grade 1, 2 screws of grade 2 and 1 screw of grade 3 in the control group, while 49 screws of grade 0, 2 screws of grade 1, 1 screw of grade 2 and 0 screw of grade 3 in the test group. There was no statistically significant difference(P＞0.05) in each grade of screw classification between the two groups at C1 level. As for C2 screw, 53 screws of grade 0, 6 screws of grade 1, 1 screw of grade 2 and 0 screw of grade 3 in the control group, while 48 screws of grade 0, 2 screws of grade 1, 0 screw of grade 2 and 0 screw of grade 3 in the test group. There was no statistically significant difference in each grade of screw classification between the two groups at C2 level(P＞0.05). Significant statistical difference between the two groups was found in the safety rate of screws(P=0.019). For the control group and the test group, the average operation time was 109.2±17.1min and 115.2±16.6min respectively, with significant differences(P=0.009), and the average number of fluoroscopy was 12.50±1.95 and 6.85±2.44 respectively, with significant differences(P<0.0001). The average intraoperative hemorrhage was 198.1±108.3ml in the control group and 160.3±135.4ml in the double guide plate group, with no significant difference between the two groups(P=0.216). All cases obtained fusion after posterior atlantoaxial approach operation at the last follow up. Conclusions: Improved personalized template assisted screw placement technique can effectively reduce the times of X-ray fluoroscopy, and it can be more accurate than free-hand technique in atlantoaxial pedicle screw placement in clinics.