脊柱侧凸手术中徒手置钉、3D打印导板和导航技术辅助置钉的准确性对比

A comparative research on the accuracy of pedicle screw implantation in corrective surgery for scoliosis patient with freehand, drill guide template and three-dimensional image navigation

中文关键词:  脊柱侧凸  椎弓根螺钉  徒手法  3D打印导板  计算机导航

英文关键词:Scoliosis  Pedicle screws  Freehand  Guide template  Computer navigation

中文摘要:

  【摘要】 目的：比较脊柱侧凸手术中徒手置钉、3D打印导板及计算机导航辅助三种椎弓根螺钉置入技术的准确性。方法：2014年2月～2019年12月，32例于我院骨科行后路矫形椎弓根螺钉内固定手术的脊柱侧凸患者纳入本研究，男6例，女26例；年龄11~68岁（32.8±20.5岁），共置入530枚螺钉。术前均完善全脊柱正侧位X线片、CT和MRI检查，根据术中置钉方法分为三组：A组，徒手置钉（10例，163枚）；B组，术前根据CT薄层扫描数据制备3D打印导板辅助术中置钉（11例，176枚）；C组，术中采用计算机导航辅助置钉（11例，191枚）。术后均行全脊柱正侧位X线片及CT扫描检查。在手术前后影像学图片上测量术前、术后侧凸Cobb角，术前顶椎旋转度和椎弓根横径，根据Gertzbein法测量螺钉置钉准确度并计算置钉满意率，分析影响置准确率的因素。结果：32例患者术前Cobb角69.4°±21.3°（35.0°～115.0°），术后Cobb角23.0°±12.9°（2.4°～47.5°），矫正率（68.8±12.0）%（46.2％～95.0%）。A组术前顶椎旋转角为25.5°±8.9°（9.5°～39.0°），B组为31.3°±11.6°（9.9°～50.0°），C组为30.7°±17.0°（11.2°～60.0°）（P=0.556）；椎弓根畸形比例A组为31.9%，B组为33.0%，C组为39.3%（P=0.281）；畸形椎弓根胸/腰椎比A组为31/21，B组为47/11，C组为64/11，A组与B、C组比较有显著性差异（P<0.05）。根据术后CT评价椎弓根置钉准确性，A组置钉满意率92.8%，B组为89.4%，C组为92.6%，三组间无显著性差异（P＞0.05）；B组胸椎置钉满意率低于C组（P=0.042）；置钉椎体位置与置钉满意率呈正比（P=0.029，OR=1.086，95%CI：1.008-1.169），术前Cobb角与置钉满意程度呈负相关关系（P=0.005，OR=0.964，95%CI：0.939-0.989），手术时间A组为350±114min，B组为447±133min，C组为414±128min，三组间比较无统计学差异（P=0.219）。A组1例患者出现伤口血肿；B组1例患者因置钉位置偏内出现神经功能受损，1例非螺钉相关的神经功能损害，1例脑脊液漏，1例下肢静脉血栓合并肺部感染、肋间神经痛；C组1例患者出现迟发性胸腔内出血，1例患者出现伤口感染。结论：采用徒手置钉法、3D打印导板和计算机导航辅助置钉技术在脊柱侧凸患者矫形术中的置钉准确性一致；计算机导航辅助技术在胸椎畸形椎弓根的置钉准确性具有优势。

英文摘要:

  【Abstract】 Objectives: To compare the accuracy of free-hand implantation, drill guide template and 3D image navigation implantation for pedicle screw in corrective surgery for scoliosis. Methods: This study included 32 patients(mean age 32.8±21.0 years) with scoliosis who underwent corrective surgery in Peking University Third Hospital from February 2014 to December 2019. The patients were divided into three groups according to the pedicle screw implantation technique: group A using free-hand(10 patients with 163 pedicle screws), group B using drill guide template(11 patients with 176 pedicle screws), and group C using three-dimensional image navigation(11 patients with 191 pedicle screws). Total spine X-ray and CT were routinely performed before and after surgery, and the drill guide template was built according to thin-slice CT in group B. In group C, the real time 3D image navigation was applied in assistant to pedicle screw implantation. The Cobb angle before and after surgery, apex rotation and transverse diameter of pedicle before surgery were measured. The accuracy rate of screws were measured by Gertzbein′s method and satisfactory rate was calculated. Results: The Cobb angle of 32 patients was 69.4°±21.3°(35.0°-115.0°) before surgery, 23.0°±12.9°(2.4°-47.5°) after surgery, and the correction rate was (68.8±12.0)%(46.2％-95.0％). The rotation angle of the apex vertebral was 25.5°±8.9°(9.5°-39.0°) in group A, 31.3°±11.6°(9.9°-50.0°) in group B, and 30.7°±17.0°(11.2°-60.0°) in group C(P=0.556). The proportion of abnormal pedicle was 31.9% in group A, 33.0% in group B and 39.3% in group C(P=0.281). According to the postoperative CT evaluation of the accuracy of pedicle screw placement, the satisfaction rate of pedicle screw placement was 92.8% in group A, 89.4% in group B and 92.6% in group C(P=0.629), and there was no significant difference between the satisfaction rates of screw placement(P>0.05). The satisfaction rate in thoracic spine in group B was lower than that in groups A and C(P=0.042). There was a positive correlation between segment of spine and satisfaction rate(P=0.029, OR=1.086, 95%CI: 1.008-1.169), but a negative correlation between the Cobb angle before surgery and satisfaction rate(P=0.005, OR=0.964, 95%CI: 0.939-0.989). The operative time of group A, B, C was 350±114min， 447±133min， 414±128min, respectively, with no significance among three groups(P=0.219). In group A, a patient suffered from wound hematoma. In group B, a patient had neurological deterioration due to the screw misplacement and a patient suffered from cerebrospinal fluid leakage, and one patient suffered from non-screw-related neurological deterioration. One patient suffered from deep venous thrombosis with pulmonary infection, and intercostal neuralgia. In group C, a patient suffered from delayed intrapleural hemorrhage, and another patient suffered from surgical site infection. Conclusions: Free-hand technique, drill guide template and intraoperative navigation have similar accuracy in pedical screw implantation in scoliosis surgery. Intraoperative navigation may have advantages in abnormal thoracic pedicle screws.