虚拟仿真技术构建三维模型在腰椎转移性肿瘤中的应用

doi:10.3969/j.issn.2095-4344.2014.48.024

摘要/Abstract

摘要：

背景：脊柱转移瘤往往破坏椎体和附件，患者会患有严重的疼痛，并发症发生率较高，例如截瘫和脊柱后凸畸形等。脊柱转移瘤治疗原则是早期诊断，手术完全切除，术后化疗。影像学技术如CT可判断脊柱转移瘤的转移情况，进行准确的术前定位。目前可视化仿真手术及虚拟现实技术已经逐渐应用于整形外科领域。
目的：通过探索虚拟现实技术来寻找一种实行经前后路联合治疗腰椎转移性肿瘤的途径。
方法：基于腰椎的64排螺旋CT连续薄层二维图像，Mimics软件分别重建正常腰椎、破坏病椎、腹主动脉及双侧肾脏的三维可视化结构，在三维模型拟行经前路病灶清除、钛网骨水泥支撑、后路椎弓根螺钉内固定。
结果与结论：基于Dicom格式数据进行三维重建图像结构清晰，可真实再现腰椎病椎和邻近脏器的结构，整个虚拟仿真手术真实直观。虚拟仿真手术准确重建腰椎恶性肿瘤及邻近结构的三维立体结构，明确病椎清除范围，经后路重建脊柱序列，此方法可为个体化的治疗方案提供了客观的依据。

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

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关键词: 植入物, 数字化骨科, 脊柱转移瘤, 腰椎, Mimics软件, 腹主动脉, 肾脏, 仿真手术, 虚拟现实技术, 三维重建

Abstract:

BACKGROUND: Vertebral metastatic tumor often damages vertebral body and the appendix, and causes severe pain in patients and high incidence of complications, such as paraplegia and spinal kyphosis. The principle of metastatic tumor treatment is early diagnosis, complete surgical resection, and postoperative chemotherapy. Imaging techniques such as CT can detect spinal metastases and accurately position the tumor before surgery. Currently visualized simulation and virtual reality techniques have been increasingly used in the field of orthopedics.
OBJECTIVE: To find an anterior-posterior approach for the treatment of vertebral metastases using visual reality technique.
METHODS: Based on the 64-layer spiral CT two-dimensional images of lumbar vertebra, we reconstructed the structure of normal vertebrae, affected vertebrae, abdominal aorta and bilateral kidney three-dimensionally using Mimics software. Then anterior debridement, titanium bone cement supporting, and posterior pedicle screw fixation were performed on three-dimensional models.
RESULTS AND CONCLUSION: Three-dimensionally reconstructed models were clearly visible in Dicom format, and can reproduce the structure of affected vertebrae and adjacent organs. The virtual stimulation operation provided clarity with strong relief perception. Virtual simulation surgery accurately visualize three-dimensional structure of malignant tumor and adjacent structure, position the lesion site, and reconstruct spinal sequence via the posterior approach. This method provides an objective evidence for individualized treatment programs.

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

全文链接：

Key words: tissue engineering, lumbar vertebrae, malignant tumor, vertebral column

中图分类号:

R318

刘登均，贺小兵，王明贵，李争艳，李奇，林荔军 . 虚拟仿真技术构建三维模型在腰椎转移性肿瘤中的应用[J]. 中国组织工程研究, 2014, 18(48): 7844-7848.

Liu Deng-jun, He Xiao-bing, Wang Ming-gui, Li Zheng-yan, Li Qi, Lin Li-jun. Application of three-dimensional models constructed using virtual simulation
technique in the vertebral metastatic tumor[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(48): 7844-7848.

图/表（结果） 2

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引言

材料方法

SUBJECTS AND METHODS

Design

An imaging experiment.

Time and setting

Experiments were performed in Department of Orthopedics, Chongqing Fuling Central Hospital in China from January to August in 2013.

Subjects

An 8-year-old male patient with vertebral metastases who were hospitalized in Department of Orthopedics, Chongqing Fuling Central Hospital in China was included in this study. This patient was diagnosed L₄ lumbar metastatic poorly differentiated adenocarcinoma with the biopsy guided by CT.

The present study was approved by the Ethical Committee of Chongqing Fuling Central Hospital.

Methods

Clinical material and CT scanning

Radiographic data were collected by 64-slice helical CT (Philips Brilliance 64; Philips Mecial Systems, Eindhoven, The Netherlands; Figure 1A). The CT technique involved scanner settings of 300 mA and 120 kV, thickness 5 mm, interval 5 mm, 0.984 pitch, and rotation speed 0.5 s/cycle.

Three-dimensional reconstruction of the vertebrae and adjacent organs

The involved patient was scanned with Philip 64-layer CT at the internal of 0.5 mm and matrix of 1 024 × 1 024. Totally 374 pictures were acquired, and primitive data of CT picture were stored in Dicom format and input to Mimics 12.1 software (Materialise, Leuven, Belgium). Each deck contour line was extracted automatically after defining bone tissue threshold. Every layer of picture would be processed by parting edge, editing selectively, repairing the hole and removing the redundant data, then we got the mask of skeleton three-dimensional, the mask of adjacent organs would be acquired by region growing and dynamic region growing. These masks were carried out three-dimensional calculation (Figure 1B). After smoothing with the free-form modeling system, its structure became clearer.

Visible simulation surgery for vertebral metastases

We finished visible simulation surgery in the MedCAD menu of Mimic software. Firstly, vertebral metastases was complete removed via the anterior approach (Figure 2A), according to the measured three-dimensional distance (Figure 2B), we chose suitable titanium mesh filled with PMMA to reset intervertebral space (Figure 2C). Secondly, based on anatomical parameter, the posterior pedicle screw fixations provided spinal stability by reinforcing the posterior tension band pedicle screw (Figure 2D). Finally, the simulated operation helped us predict the difficulties that may be encountered in the real operation process and what precautions to take, which contribute to determine the optimal operation planning.

Main outcome measures

Three-dimensional reconstruction images in Dicom format were observed

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

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讨论

Thoracic vertebra and lumbar vertebra are the common area for spinal tumor, especially thoracic vertebra, tumor destroy most part of the front column. The most frequent presentation is axial spinal pain^[6]. Management is guided by three key issues: neurologic compromise, spinal instability, and individual patient factors. In the management of spinal metastases bringing about neurological symptoms and signs, palliative surgical treatment plays an important role. The goals of surgery are preservation of neurological function especially that of the mobility, pain relief and local tumor control. No treatment has been proven to increase the life expectancy of patients with spinal metastasis^[5-6]. The goals of therapy are pain control and functional preservation. The main goal in the management of spinal metastatic deposits is always palliative rather than curative, with the primary aim being pain relief and improved. In our study, lower back pain of patient last for more than a month, without neurologic presentation. Recently, with the development of spinal surgery, surgical intervention includes excision of tumor by anterior approach, transpedicle fixation by posterior approach.

During transpedicle fixation, correct implantation of the screws without perforation of the pedicle is difficult and requires detailed anatomic knowledge and good surgical skills^[7-10]. The identification of the correct entry point for the pedicle screw and the angle of inclination in the sagittal and transverse planes are crucial^[11-12]. In the past, we got the medical information from X-ray, CT and MRI, which is not actual or intact^[13]. With the rapid development of computer technology, virtual reality technology plays an important role in medicine. In clinical practice, in order to avoid direct human surgical strategy, the best solution is to set up a virtual simulation system^[14-15]. Using virtual simulation system based on three-dimensional medical visual model, we can get all the anatomic parameter of tumor and pedicle, with these help, transpedicle screw implantation was accurate. Moreover, according to the three-dimensional measurement, distance between abdominal aorta and tumour is 21.87 mm, so we must be careful to disposal lumbar artery during removal of the tumor by anterior approach^[16-18].

In a word, utilizing virtual imaging technology with the aid of Mimics which generates virtual images, a three-dimensional model was produced with the CT images. A preoperative planning for excision of vertebral Virtual reality has brought new proportions in three-dimensional planning and management of various complex problems that are faced during various operations. Integration of three-dimensional imaging with virtual reality makes understanding the complex anatomy easier and helps improve decision making in patient management^[19-45]. Virtual simulation surgery of vertebral metastases provides surgeon more objective information, to help them adopt the individual strategy for every patient.

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
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