中国组织工程研究

中国组织工程研究 ›› 2023, Vol. 27 ›› Issue (4): 539-546.doi: 10.12307/2023.251

• 数字化骨科 digital orthopedics • 上一篇    下一篇

构建腰椎三维模型测量腰椎管减压术区神经组织及骨性结构的位置关系

王建业，刘  鑫，田  霖，孙  宁，李岳飞，毕经纬，刘昌震，孙兆忠   

  1. 滨州医学院附属医院脊柱外科，山东省滨州市   256603
  • 收稿日期:2022-02-19 接受日期:2022-04-18 出版日期:2023-02-08 发布日期:2022-06-22
  • 通讯作者: 孙兆忠，主任医师，滨州医学院附属医院脊柱外科，山东省滨州市 256603
  • 作者简介:王建业，男，1997年生，山东省聊城市人，汉族，滨州医学院在读硕士，主要从事微创脊柱外科方面的研究。
  • 基金资助:
    国家重点研发计划资助项目(2017YFC0114002)，子项目负责人：孙兆忠；山东省自然科学基金资助项目(2R2017LH021)，项目负责人：孙兆忠；滨州医学院“临床+X”项目(BY2021LCX17)，项目负责人：孙兆忠；滨州医学院科技计划项目(BY2018KJ03)，项目负责人：刘鑫

Measuring the position relation between nerve tissue and bony structure in lumbar spinal canal decompression area by constructing a three-dimensional model of the lumbar spine

Wang Jianye, Liu Xin, Tian Lin, Sun Ning, Li Yuefei, Bi Jingwei, Liu Changzhen, Sun Zhaozhong    

  1. Department of Spine Surgery, Affiliated Hospital of Binzhou Medical College, Binzhou 256603, Shandong Province, China
  • Received:2022-02-19 Accepted:2022-04-18 Online:2023-02-08 Published:2022-06-22
  • Contact: Sun Zhaozhong, Chief physician, Department of Spine Surgery, Affiliated Hospital of Binzhou Medical College, Binzhou 256603, Shandong Province, China
  • About author:Wang Jianye, Master candidate, Department of Spine Surgery, Affiliated Hospital of Binzhou Medical College, Binzhou 256603, Shandong Province, China
  • Supported by:
    the National Key Research and Development Program, No. 2017YFC0114002 (to SZZ); Shandong Natural Science Foundation of China, No. 2R2017LH021 (to SZZ); Binzhou Medical College “Clinical + X” Project, No. BY2021LCX17 (to SZZ); Science and Technology Project of Binzhou Medical College, No. BY2018KJ03 (to LX)

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摘要：

文题释义：
腰椎三维模型测量：将患者腰椎CT脊髓造影数据资料以DICOM格式导入Mimics 21.0软件构建腰椎三维模型，以单侧双通道对侧入路的视角观测腰椎侧隐窝、椎间孔、椎间隙、关节突、黄韧带附着处及神经根起点等重要结构的位置关系。
腰椎管减压术：在此文中主要是指在对侧入路中使用单侧双通道内镜技术治疗腰椎管狭窄症，能更好地显露对侧的侧隐窝、椎间孔区域，减压更彻底；能较好地保留关节突关节及腰椎峡部，避免腰椎融合手术。

背景：单侧双通道内镜对侧入路治疗腰椎管狭窄症的文献较少，目前尚无该入路镜下定位、减压范围、各结构毗邻关系等深入分析的资料。
目的：通过三维CT重建，观测侧隐窝、椎间孔区域的骨性结构、神经组织、椎间隙、黄韧带附着处及腰椎峡部的位置关系，指导单侧双通道内镜技术在腰椎管狭窄症对侧入路治疗中的合理应用。
方法：纳入2019年6月至2021年7月滨州医学院附属医院收治的34例腰椎管狭窄症患者，术前行腰椎CT脊髓造影检查，将影像资料导入Mimics 21.0软件重建腰椎三维CT图像。测量L4/5和L5S1节段相关参数：①腰椎棘突侧方与椎板下缘交点(Q)分别至同序数腰椎对侧椎弓根下缘(a)、下位腰椎对侧椎弓根上缘(b)、同序数腰椎下终板(c)、下位腰椎上终板(d)垂直距离；②上关节突尖部至同序数椎弓根上缘(e)、上位腰椎下终板(f)垂直距离；③腰椎下终板至同序数椎弓根下缘(g)垂直距离；④腰椎上终板至同序数椎弓根上缘垂直距离(h)；⑤神经根起点下缘分别至上位腰椎椎弓根下缘(i)、下位腰椎椎弓根上缘(j)垂直距离；⑥经Q(头倾或尾倾)与同序数腰椎对侧椎弓根下缘建立直径3 mm导棒，测量其外展角度(k)。7例患者根据上述测量结果完成单侧双通道内镜对侧入路腰椎管减压术，分别用疼痛目测类比评分、Oswestry功能障碍指数、36条目简明量表综合评估患者情况以验证手术疗效。
结果与结论：①Q点、黄韧带上缘可作为镜下重要定位标志；黄韧带上缘压迹线对应的黄韧带上缘可作为内镜下定位标志，以此确定出口神经根、椎间孔上缘及腰椎峡部、下关节突；内镜下经Q点、以垂直于棘突后正中线、无头尾倾方向即可达L4/5对侧椎间孔中1/3水平及L4下终板附近，向下完成椎间盘水平的侧隐窝减压；②L5神经根起点下缘大多投影于对侧L4/5椎间孔下1/3水平，这与L4/5椎间隙投影相一致，说明L5行走神经根多在L4/5椎间盘水平附近受压；③Q点、S1神经根起点下缘、L5出口神经根均对应L5S1椎间孔上1/3水平，应对该区域对应的、神经组织密集的侧隐窝谨慎减压；④ L4/5 、L5S1椎间隙位置均投影于椎间孔下1/3水平附近、均位于Q点以下，手术通道应经Q点水平适度尾倾对椎间隙水平减压；⑤去除L4/5、L5S1增生上关节突骨赘时，应保留近似正常高度上关节突、避免影响腰椎稳定性；⑥7例对侧入路手术患者均顺利完成手术，随访时间6-12个月；随着术后康复时间延长，目测类比评分、Oswestry功能障碍指数较术前显著降低，36条目简明量表评分较术前显著改善；⑦提示研究结果可指导单侧双通道内镜对侧入路手术治疗腰椎管狭窄症。
缩略语：单侧双通道内镜：unilateral biportal endoscopic，UBE

https://orcid.org/0000-0002-8838-0022 (王建业)

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

关键词: 腰椎管狭窄症, 单侧双通道内镜技术, 三维CT, 对侧入路, Mimics, 腰椎管减压

Abstract: BACKGROUND: There are few articles on the treatment of lumbar spinal stenosis by unilateral two-channel endoscopic contralateral approach, and there is no in-depth analysis of the endoscopic location, decompression scope and adjacent relationship of various structures of this approach.  
OBJECTIVE: To observe the bony structure, nerve tissue, intervertebral space, attachment of ligamentum flavum and position of lumbar isthmus in lateral recess and foraminal area through three-dimensional CT imaging.
METHODS:  Totally 34 patients with lumbar spinal stenosis admitted to the Affiliated Hospital of Binzhou Medical College from June 2019 to July 2021 were enrolled. Lumbar CT myelography was performed before surgery, and the images were imported into Mimics 21.0 software to reconstruct lumbar three-dimensional CT model. Relevant parameters of L4/5 and L5S1 segments were measured: (1) The vertical distance from the intersection of the lumbar spinous process and the lower edge of the lamina (Q) to the lower edge of the contralateral same lumbar pedicle (a), the upper edge of the contralateral pedicle of the lower lumbar spine (b), the lower endplate of same lumbar (c), the upper endplate of lower lumbar vertebrae (d); (2) The vertical distance from superior articular process to the upper edge of same lumbar pedicle (e), the lower endplate of upper lumbar vertebrae (f); (3) The vertical distance from the lower endplate of lumbar vertebrae to the lower edge of the contralateral lumbar pedicle (g); (4) The vertical distance from the upper endplate of lumbar vertebrae to the upper edge of the same lumbar pedicle (h); (5) The vertical distance from the lower edge of the nerve root origin to the lower edge of the upper lumbar pedicle (i), the upper edge of the lower lumbar spine pedicle (j); (6) A 3 mm diameter guide rod was established through point Q and the lower edge of the contralateral same lumbar pedicle to measure the abduction angle of guide rod (k). Seven patients underwent unilateral biportal endoscopic lumbar decompression through the contralateral approach. The effect of surgery was verified by visual analog scale score, Oswestry disability index, and short form-36 health survey.  
RESULTS AND CONCLUSION: (1) The Q points and the upper margin of ligamentum flavum could be used as important localization markers under the endoscopy. The upper margin of the ligamentum flavum was used to locate the exiting nerve root, the upper edge of the foramina, the lumbar isthmus and the inferior articular process. The level of 1/3 of the contralateral foramen of L4/5 and the vicinity of L4 inferior endplate could be reached by Q point perpendicular to the posterior midline of spinous process, and then decompress the lateral recess at the level of the disc. (2) The lower edge of L5 nerve root origin was mostly projected at the level of L4/5 lower 1/3 of the foramen, and it was consistent with the L4/5 intervertebral projection, suggesting that the L5 walking nerve roots were mostly compressed near the level of the L4/5 disc. (3) The Q point, the lower edge of S1 nerve root origin and the L5 the exiting nerve root all corresponded to the level of the upper 1/3 of the L5S1 intervertebral foramen, and the corresponding lateral recess with dense nerve tissue in this area should be prudently decompressed. (4) The intervertebral spaces of L4/5 and L5S1 were projected near the level of the lower 1/3 of the same segment intervertebral foramen and under the Q point. The operation channel should be decompressed through Q point level with moderate tail tilt.  (5) When removing the hyperplastic superior facet osteophytes of L4/5 and L5S1, the superior facet should be retained at approximately normal height to avoid affecting the stability of lumbar spine. (6) All seven patients with contralateral approach surgery successfully completed the operation, and the follow-up time was 6-12 months. With the prolongation of postoperative rehabilitation time, the visual analog scale score and Oswestry disability index were significantly lower than those before surgery, and the score of short form-36 health survey was significantly improved than that before surgery. (7) It is suggested that the results of this study can guide unilateral biportal endoscopy for lumbar spinal stenosis through contralateral approach.

Key words: lumbar spinal stenosis, unilateral biportal endoscopy, three-dimensional CT, contralateral approach, mimics, lumber spinal canal decompression

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