中国组织工程研究 ›› 2023, Vol. 27 ›› Issue (18): 2884-2891.doi: 10.12307/2023.346

• 骨与关节图像与影像 bone and joint imaging • 上一篇    下一篇

三维CT评估单孔分体内镜治疗L4/5滑脱症椎间融合术的安全性

刘昌震1,孙  宁1,朱  锴1,刘  鑫1,窦永峰1,王建业1,毕经纬1,朱腾月2,孙兆忠1   

  1. 1滨州医学院附属医院脊柱外科,山东省滨州市   256603;2中国人民解放军总医院第六医学中心中医医学部骨伤科,北京市   100048
  • 收稿日期:2022-05-05 接受日期:2022-06-17 出版日期:2023-06-28 发布日期:2022-09-17
  • 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:刘昌震,男,1997年生,山东省烟台市人,汉族,滨州医学院在读硕士,主要从事微创脊柱外科的研究。
  • 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

Safety of interbody fusion with one-hole split endoscope for L4/5 spondylolisthesis evaluated by three-dimensional CT

Liu Changzhen1, Sun Ning1, Zhu Kai1, Liu Xin1, Dou Yongfeng1, Wang Jianye1, Bi Jingwei1, Zhu Tengyue2, Sun Zhaozhong1   

  1. 1Department of Spine Surgery, Affiliated Hospital of Binzhou Medical College, Binzhou 256603, Shandong Province, China; 2Department of Orthopedics, Department of Traditional Chinese Medicine, The Sixth Medical Center of PLA General Hospital, Beijing 100048, China
  • Received:2022-05-05 Accepted:2022-06-17 Online:2023-06-28 Published:2022-09-17
  • Contact: Sun Zhaozhong, Chief physician, Department of Spine Surgery, Affiliated Hospital of Binzhou Medical College, Binzhou 256603, Shandong Province, China
  • About author:Liu Changzhen, 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, No. 2R2017LH021 (to SZZ); “Clinical + X” Project of Binzhou Medical College, No. BY2021LCX17 (to SZZ); Science and Technology Project of Binzhou Medical College, No. BY2018KJ03 (to LX)

摘要:

文题释义:
单孔分体内镜(One-hole Split Endoscope,OSE):朱腾月教授于2019年以新的理念首先提出并应用于临床的一种新型内镜术式,是将同轴内镜技术的工作通道与镜体分离、单侧双通道内镜技术的单边双通道合为一个手术通道,其突出特征是无固定通道限制,既有同轴内镜自由操作的便利,也有单侧双通道内镜的广阔视野。 
椎体间植骨融合术:去除椎间盘、椎体间放置融合器支撑、植入同种异体骨或自体骨以便椎体间融合,辅助内固定装置,既能稳定疼痛运动节段,也可间接减压神经结构,恢复腰椎前凸,改善患者临床症状。目前已熟悉的脊柱内镜下腰椎体间融合技术能有效解决Ⅱ度以内腰椎滑脱症。

背景:新型的单孔分体内镜技术已用于治疗腰椎滑脱症,但尚无该技术安全性、可行性、有效性的文献。
目的:通过腰椎CT三维重建,观测骨性标志点与L4、L5神经及椎间隙位置关系,评估单孔分体内镜L4/5滑脱症椎体间融合术的安全性。
方法:26例Ⅰ度L4/5滑脱症患者(滑脱组)和26例志愿者(正常组),均行腰椎CT扫描,导入Mimics 17.0软件,测量参数:①测量垂直距离。a,b:L5上终板与L5上关节突冠状位关节面内侧缘交点(N)分别至乳突后缘最高点(R)和L5上关节突尖部(S);c:L4下关节突尖部(X)至N所在矢状面与L4下终板交点(M)。②测量水平距离。d:R至N所在横断面与L4出口神经根下缘交点(N1);e:R至M所在横断面与L4出口神经根下缘交点(M1);f:N至N所在横断面与神经组织外侧缘交点(N2);g:N1至N2;h:M1至M2;i:N2至M1;j:M1至L5上关节突矢状位关节面后缘(R1)。③9例患者行单孔分体内镜椎体间植骨融合术,采用腰腿痛目测类比评分、日本骨科协会评估治疗分数(JOA)、Oswestry功能障碍指数(ODI)、36条目简明量表(Short-form 36,SF-36)评估疗效。
结果与结论:①滑脱组b,c之间差异无显著性意义(P > 0.05),表明显露L4/5椎间盘只需去除等量的上、下关节突和/或椎板骨质。②两组d,e差异均有显著性意义(P < 0.05),应根据病理变化数据规划手术。③两组f,g,i差异均无显著性意义(P > 0.05),表明退行性滑脱未改变行走与出口神经的位置关系,在两者恒定不变的横向工作区置入融合器是安全的。④9例腰椎滑脱症患者末次随访的目测类比评分、JOA、ODI及SF-36评分均较术前、术后6个月明显改善(P < 0.05)。⑤安全开窗范围:S向下(11.78±2.34) mm至N、X向上达L4下终板分别显露椎间盘上、下缘;向外开窗至M1不会伤及L4神经;向内减压谨防损伤N及其附近的L5神经。了解新型的单孔分体内镜技术特点有助于提高手术的安全性和疗效。  

https://orcid.org/0000-0003-2361-3187 (刘昌震) 

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: 腰椎滑脱症, 单孔分体内镜, 椎体间植骨融合术, mimics, 腰椎CT三维重建

Abstract: BACKGROUND: A novel one-hole split endoscope technique has been used in the treatment of lumbar spondylolisthesis, but there is no literature on the safety, feasibility and effectiveness of this technique.
OBJECTIVE: The relationship between bone markers and L4, L5 nerves and intervertebral space position is observed by lumbar CT three-dimensional reconstruction to evaluate the safety of intervertebral fusion with one-hole split endoscopic L4/5 spondylolisthesis. 
METHODS:  Totally 26 patients with grade I L4/5 spondylolisthesis (spondylolisthesis group) and 26 volunteers (normal group) underwent lumbar CT scanning. Data were input into Mimics 17.0 software to measure the following parameters: (1) vertical distance. a, b: The intersection of the medial edge of the articular surface at the coronal position of the upper endplate of L5 and the upper articular process of L5 (N) to the highest point of the posterior edge of the mastoid process (R) and the tip of the superior articular process of L5 (S); c: point of intersection between L4 inferior articular process tip (X) and N on sagittal plane and L4 inferior endplate (M). (2) Horizontal distance. d: intersection point between R and N and lower edge of  L4 outlet nerve root (N1); e: intersection point of transverse section from R to M with lower edge of L4 outlet nerve root (M1); f: intersection point of N to N cross section and lateral edge of nerve tissue (N2); g: N1 to N2; h: M1 to M2; i: N2 to M1; j: Posterior edge of articular surface (R1) in sagittal position of superior articular process from M1 to L5. (3) Nine patients underwent a one-hole split splinterbody endoscopic interbody fusion with bone grafting. The outcomes were evaluated by visual analogue scale for lumbar and leg pain, Japanese Orthopaedic Association Evaluation score, Oswestry Disability Index, and 36-item Short-Form scale.
RESULTS AND CONCLUSION: (1) There was no significant difference between b and c in the spondylolission group (P > 0.05), indicating that only equal amounts of upper and lower articular processes and/or laminae were removed to expose the L4/5 disc. (2) There were statistically significant differences in d and e between the two groups (P < 0.05), so surgery should be planned according to pathological changes. (3) There were no significant differences in f, g and i between the two groups (P > 0.05), indicating that the degenerative spondylolisthesis did not change the position relationship between walking and outlet nerve, and it was safe to implant the fusion device in the constant transverse workspace of both groups. (4) Visual analogue scale score, Japanese Orthopaedic Association Evaluation score, Oswestry Disability Index and 36-item Short-Form scale score of nine patients with lumbar spondylolisthesis were significantly improved at the last follow-up compared with the data before operation and 6 months after operation (P < 0.05). (5) Safe fenestrating range: S down (11.78±2.34) mm to N, X up to L4 lower endplate to expose the upper and lower margins of the intervertebral disc. Opening the window outward to M1 would not damage L4 nerve; decompress inwards to prevent damage to N and its adjacent L5 nerves. Understanding the technical features of the novel one-hole split endoscope technique can help improve surgical safety and efficacy.

Key words: lumbar spondylolisthesis, one-hole split endoscope, interbody bone graft fusion, mimics, lumbar CT three-dimensional reconstruction

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