摘要
目的评估导航辅助下内侧"in-out-in"技术在枢椎椎弓根螺钉固定中的安全性和临床效果。方法本研究为回顾性队列研究。回顾性分析2020年8月至2023年7月于河南省人民医院脊柱脊髓外科采用内侧"in-out-in"技术植入枢椎椎弓根螺钉治疗的68例枢椎椎动脉高跨患者的临床和影像学资料。男性32例,女性36例,年龄(56.9±10.2)岁(范围:35~78岁)。其中36例患者行导航辅助下内侧"in-out-in"技术植入枢椎椎弓根螺钉,纳入导航组;32例采用徒手置钉方法,纳入徒手组。记录并比较两组手术时间、术中出血量,手术前后脊髓横截面积(SSC)、寰齿前间隙(ADI)、斜坡-椎管角(CCA)、术后椎弓根-螺钉最大间距(PSDmax)、植骨融合时间、融合率及内固定相关并发症发生情况,并评估日本骨科学会(JOA)评分。数据比较采用独立样本t检验、重复测量方差分析、配对样本t检验、χ^(2)检验或Fisher确切概率法。结果6例寰齿间骨赘阻挡复位的患者先行颈前路寰齿关节成形,再行俯卧位后路手术,其余62例均行后路复位内固定手术。导航组36例患者均完成枢椎内侧"in out in"螺钉植入,34例为单侧内侧"in out in"螺钉植入,2例为双侧内侧"in out in"螺钉植入。徒手组28例完成内侧"in out in"螺钉植入,4例(12.5%)植入失败,导航组置钉失败率低于徒手组(χ^(2)=5.027,P=0.025)。导航组后路手术时间小于徒手组[(158.1±25.7)min比(176.4±27.6)min,t=2.829,P=0.006],两组后路手术出血量的差异无统计学意义[(217.5±62.2)ml比(212.7±53.2)ml,t=0.340,P=0.735]。两组手术前后SSC均无明显变化(P值均>0.05)。导航组与徒手组术后JOA评分、ADI和CCA均较术前明显改善(P值均<0.01),组间比较均无差异(P值均>0.05)。导航组术后PSDmax为(4.7±0.9)mm,植骨融合时间为(4.9±1.3)个月,徒手组术后PSDmax为(4.8±0.5)mm,植骨融合时间为(4.9±1.7)个月,组间差异均无统计学意义(P值均>0.05)。在钉道制备过程中,导航组1例(2.8%),徒手组3例(9.4%)患者,因手钻刺破硬脊膜出现脑脊液漏;徒手组1例术后出现症状性脑梗死,表现为构音障碍,经内科治疗后恢复,两组脑脊液漏、椎动脉损伤发生率无差异。结论采用导航辅助内侧"in out in"技术能为枢椎椎动脉高跨患者安全、快速植入三柱固定螺钉,置钉准确性高,临床效果满意。
ObjectiveTo evaluate the safety and clinical efficacy of the navigation-assisted medial“in-out-in”technique in C_(2) pedicle screw fixation.MethodsThis study is a retrospective cohort study.The clinical data of 68 patients with high-riding vertebral arteries of the axis who underwent C_(2) pedicle screw implantation using the medial“in-out-in”technique in the Department of Spinal Surgery,Henan Provincial People′s Hospital from August 2020 to July 2023 were retrospectively analyzed.There were 32 males and 36 females,with an age of(56.9±10.2)years(range:35 to 78 years).Among them,36 patients underwent navigation-assisted medial“in-out-in”technique for C_(2) pedicle screw implantation and were included in the navigation group;32 patients received freehand screw placement and were included in the freehand group.The operative time,intraoperative blood loss,postoperative maximum pedicle-screw distance(PSD_(max)),bone graft fusion time,fusion rate,and occurrence of internal fixation-related complications were recorded and compared between the two groups.The spinal cord cross-sectional area(SSC)was measured before surgery and at 1 week after surgery.The atlanto-dental interval(ADI),clivus-canal angle(CCA),and Japanese Orthopaedic Association(JOA)score were evaluated before surgery,at 1 week,3 months,1 year after surgery,and at the final follow-up.Independent sample t-test,repeated measures analysis of variance,paired t-test,χ^(2) test,or Fisher′s exact test were used for data comparison.ResultsSix patients with reduction blocked by atlanto-dental osteophytes first underwent anterior cervical atlanto-dental arthroplasty,followed by posterior surgery in the prone position,while the remaining 62 patients underwent posterior reduction and internal fixation.All 36 patients in the navigation group successfully completed C_(2) medial“in-out-in”screw implantation,including 34 cases with unilateral medial”in-out-in”screw implantation and 2 cases with bilateral implantation.In the freehand group,28 cases completed medial“in-out-in”screw implantation,with 4 cases(12.5%)of implantation failure;the implantation failure rate in the navigation group was lower than that in the freehand group(χ^(2)=5.027,P=0.025).The posterior surgical time in the navigation group was shorter than that in the freehand group((158.1±25.7)minutes vs.(176.4±27.6)minutes,t=2.829,P=0.006),while there was no statistically significant difference in intraoperative blood loss during posterior surgery between the two groups((217.5±62.2)ml vs.(212.7±53.2)ml,t=0.340,P=0.735).There was no significant change in SSC before and after surgery in both groups(all P>0.05).The postoperative JOA scores,ADI,and CCA in both the navigation group and the freehand group were significantly improved compared with those before surgery(all P<0.01),and there were no differences between the two groups(all P>0.05).The postoperative PSD_(max) was(4.7±0.9)mm and the bone graft fusion time was(4.9±1.3)months in the navigation group,compared with(4.8±0.5)mm and(4.9±1.7)months in the freehand group,respectively;there were no statistically significant differences between the two groups(all P>0.05).During pedicle preparation,1 case(2.8%)in the navigation group and 3 cases(9.4%)in the freehand group developed cerebrospinal fluid leakage due to dural puncture by the hand drill.One patient in the freehand group developed symptomatic cerebral infarction postoperatively,presenting with dysarthria,which recovered after medical treatment.There was no significant difference in the incidence of cerebrospinal fluid leakage or vertebral artery injury between the two groups.ConclusionThe navigation-assisted medial“in-out-in”technique enables safe and rapid implantation of three-column fixation screws in patients with high-riding vertebral arteries of the axis,with high accuracy in screw placement and satisfactory clinical outcomes.
作者
邵佳
高延征
高坤
毛克政
张修儒
Shao Jia;Gao Yanzheng;Gao Kun;Mao Kezheng;Zhang Xiuru(Department of Spinal Surgery,Henan Provincial People′s Hospital,Zhengzhou 450003,China)
出处
《中华外科杂志》
北大核心
2025年第12期1146-1155,共10页
Chinese Journal of Surgery
基金
河南省医学科技攻关项目(LHGJ20230019)
河南省自然科学基金(202300410400)。
关键词
寰枢关节
内固定器
椎弓根螺钉
椎动脉高跨
导航
融合
Atlanto-axial joint
Internal fixators
Pedicle screw
High riding vertebral artery
Navigation
Fusion
