3D打印体外导板辅助经皮椎弓根螺钉固定术治疗胸腰椎骨折的临床疗效观察

Clinical observation of 3D printed external guide plate assisted percutaneous pedicle screw fixation in the treatment of thoracolumbar fractures

中文关键词:  胸腰椎骨折  3D打印体外导板  椎弓根螺钉  微创

英文关键词:Thoracolumbar fracture  3D printed external guide plate  Pedicle screw  Minimally invasive

中文摘要:

  【摘要】 目的：观察3D打印体外导板辅助经皮椎弓根螺钉固定术治疗胸腰椎骨折的临床疗效。方法：回顾性分析2017年8月~2020年8月行经皮椎弓根螺钉固定手术的47例胸腰椎骨折患者的临床资料，男13例，女34例；年龄21~69岁。均为单节段损伤，T12 11例，L1 26例，L2 7例，L3 2例，L4 1例。22例术前制作3D打印个体化体外导板，模拟置钉，术中辅助置钉（导板组）；25例采用X线透视辅助下徒手置钉（徒手组）。对比两组手术时间、置钉时间、术中X线透视次数、术中出血量、术后并发症；采用Neo分级标准评价两组手术置钉等级，计算置钉准确率；在术前、术后X线片上测量骨折椎体前缘高度和Cobb角，计算椎体矢状面指数，评价骨折复位及矫正情况；术前和术后1d、7d及1年时进行疼痛视觉模拟评分（visual analogue scale，VAS）评分、日本骨科协会（Japanese Orthopedics Association，JOA）评分和Oswestry功能障碍指数（Oswestry disability index，ODI）评定。结果：导板组手术时间、置钉时间、术中X线透视次数、术中出血量分别为63.57±12.18min、23.69±3.63min、15.26±4.15次、48.82±13.72ml；徒手组分别为85.56±16.27min、41.36±8.12min、26.93±6.93次和74.35±18.64ml；导板组均少于徒手组，差异有统计学意义（P<0.05）。导板组0级置钉119枚，1级置钉3枚，置钉准确率为97.54%；徒手组0级置钉128枚，1级置钉10枚，2级置钉1枚，置钉准确率为92.09%，导板组置钉准确率高于徒手组，差异有统计学意义（P<0.05）。术后两组的椎体前缘高度、椎体矢状面指数和Cobb角与术前相比均有显著性改善（P＜0.05）；两组同时间点比较均无统计学差异（P＞0.05）。两组术后VAS评分、JOA评分和ODI与术前比较均有显著性改善，差异有统计学意义（P<0.05），两组间同时间点比较均无统计学差异（P＞0.05）。两组患者术后伤椎均达到骨性愈合，均未出现术后并发症。结论：3D打印体外导板辅助经皮椎弓根螺钉固定术治疗单节段胸腰椎骨折可取得良好效果，与徒手经皮椎弓根螺钉固定术相比能够显著性提高置钉准确率，并缩短手术时间、减少术中辐射暴露。

英文摘要:

  【Abstract】 Objectives: To observe the clinical effect of 3D printed external guide plate assisted percutaneous pedicle screw fixation in the treatment of thoracolumbar fractures. Methods: A retrospective analysis was performed on 47 patients with thoracolumbar fractures who underwent percutaneous pedicle screw fixation from August 2017 to August 2020, including 13 males and 34 females, aged 21-69 years. The patients were all single-segment fractures, involving T12 in 11 cases, L1 in 26 cases, L2 in 7 cases, L3 in 2 cases, and L4 in 1 case. 22 cases were treated with 3D printed customized in vitro guide plates made before surgery in simulating screw placement and assisting placement during operation(guide plate group), and the other 25 cases were treated with freehand screw placement under X-ray fluoroscopy(freehand group). The operative time, screw placement time, intraoperative X-ray fluoroscopy times, intraoperative blood loss, and postoperative complications were compared between the two groups. The Neo classification was used to evaluate the grades of screw placement in the two groups, and the accuracy of screw placement was calculated. The anterior height of the fractured vertebral body and the Cobb angle were measured on the preoperative and postoperative X-ray images, and the sagittal plane index of the vertebral body was calculated to evaluate the reduction and correction of the fracture. The visual analogue scale(VAS) score, Japanese Orthopedics Association(JOA) score and Oswestry disability index(ODI) were recorded before operation and at 1 day, 7 days and 1 year after operation. Results: The operative time, screw placement time, intraoperative X-ray fluoroscopy times, and intraoperative blood loss of the guide plate group were all less than those of the freehand group, which were 63.57±12.18min vs 85.56±16.27min, 23.69±3.63min vs 41.36±8.12min, 15.26±4.15 vs 26.93±6.93, and 48.82±13.72ml vs 74.35±18.64ml, respectively, and the differences were with statistical significance(P<0.05). The accuracy of screw placement was 97.54% of the guide plate group with 119 screws of grade 0 and 3 screws of grade 1, which was higher than that of the freehand group of 92.09% with 128 screws of grade 0, 10 screws of grade 1, and 1 screw of grade 2, and the difference was statistically significant(P<0.05). The anterior height of the vertebral body, sagittal index of the vertebral body, and Cobb angle of the two groups after operation were improved significantly compared with those before operation(P<0.05), and no significant difference was found between the two groups at the same time points(P>0.05). The VAS score, JOA score and ODI of the two groups after operation were significantly improved compared with those before operation(P<0.05), and there was no statistical difference between the two groups at the same time points(P>0.05). The injured vertebrae in patients of both groups achieved bone healing after operation, and no postoperative complications occurred. Conclusions: 3D printed external guide plate assisted percutaneous pedicle screw fixation can achieve good results in the treatment of single-segment thoracolumbar fractures, which can improves the screw placement accuracy significantly, shortens the operative time, and reduces the intraoperative radiation exposures comparing with freehand percutaneous pedicle screw fixation.