下胸椎侧前方椎体钉内固定置入点的相关解剖学测量

doi:10.3969/j.issn.2095-4344.2015.17.011

摘要/Abstract

摘要：

背景：有关成人下胸椎侧前方椎体钉进钉点位置的报道较多，由于种族、地域等差异及椎体形态变异较大，其置钉点的选择也不尽相同。

目的：为临床下胸椎侧前方固定以肋凹为参照物置钉提供解剖学参考。

方法：用游标卡尺测量20具成人尸体脊柱标本进行观察和肋凹解剖数据。

结果与结论：随着椎序的增加，脊柱标本椎体横径逐渐增大，肋凹上、下缘与上终板的距离逐渐增大，肋凹上、下缘与下终板的距离逐渐减小，肋凹前缘与椎管前缘的距离逐渐减小。结果证实，下胸椎肋凹的解剖位置是有规律可循的，肋凹是下胸椎侧前方内固定置钉简单、恒定、可靠的置钉点参照物。

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, 脊柱植入物, 下段胸椎, 椎体钉, 侧前方固定, 置钉点, 解剖学

Abstract:

BACKGROUND: There are many reports on the entrance point of adult inferior thoracic spinal latero-anterior screw. Because of the differences in race, districts and the shape of vertebral body are various, and the choice of screw placement position is also varied.

OBJECTIVE: To provide an anatomical reference for the implantation of clinical screws for inferior thoracic spinal latero-anterior fixation with the concave rib set as a reference.

METHODS: Spinal specimens from 20 adult cadavers were observed, and anatomical data were collected from the concave ribs. One vernier caliper was used for the measurements.

RESULTS AND CONCLUSION: The thoracic transverse diameters and the distance between the upper and the inferior edge of the concave rib and upper endplate increased gradually as the vertebral number increased, whereas the distances between the upper and the inferior edge of the concave rib and inferior endplate and between the anterior edge of the concave rib and anterior edge of the vertebral canal decreased gradually. Above findings suggested that the anatomical positions of the inferior thoracic concave ribs followed a set of rules. The concave rib could be used as a simple, constant, and reliable reference point for inferior thoracic spinal latero-anterior fixation screw placement.

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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Key words: Tissue Engineering, Thoracic Vertebrae, Prostheses and Implants, Anatomy

中图分类号:

R318

孙向新，王志杰. 下胸椎侧前方椎体钉内固定置入点的相关解剖学测量[J]. 中国组织工程研究, 2015, 19(17): 2683-2687.

Sun Xiang-xin, Wang Zhi-jie. Anatomic measurements of internal fixation-related implantation points of inferior thoracic spinal latero-anterior vertebral screws[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(17): 2683-2687.

图/表（结果） 2

Measurement results of anatomical data

Vertical distance from the leading edge tangent of the concave rib to the leading edge tangent of the vertebral canal and vertebral transverse diameter of the concave rib leading edge plane was measured (Figure 1).

The distance between the anterior edge of the concave rib and anterior edge of the vertebral canal (the value of a) decreased from T₉ (4.50±0.16) mm to T₁₂ (2.07±0.97) mm. The vertebral transverse diameter of the concave rib leading edge plane (the value of AB) increased from T₉ (32.53±0.56) mm to T₁₂ (46.96±0.37) mm. There was no significant difference between the left and right sides (Table 1).

Vertical distance from the upper and inferior edge tangent of the concave rib to the upper and inferior edge tangent of the upper and inferior end plate

The distance of the left side between the upper edge tangent of the concave rib and the upper edge tangent of the upper end plate increased from T₉ (0.67±0.40) mm to T₁₂ (9.04±0.17) mm and the right side increased from T₉ (0.54±0.34) mm to T₁₂ (9.05±0.23) mm (the value of Figure 1b).

The distance of the left side between the upper edge tangent of the concave rib and the inferior edge tangent of the inferior end plate decreased from T₉ (21.92±1.23) mm to T₁₂ (18.68±0.26) and the right side decreased from T₉ (21.35±1.60) mm to T₁₂ (18.63±0.38) mm (the value of Figure 1c).

The distance of the left side between the inferior edge tangent of the concave rib and the upper edge tangent of the upper end plate increased from T₉ (7.23±0.42) mm to T₁₂ (17.02±0.24) mm and the right side increased from T₉ (7.13±0.45) mm to T₁₂ (17.04±0.33) mm (the value of Figure 1d).

The distance of the left side between the inferior edge tangent of the concave rib and the inferior edge tangent of the inferior end plate decreased from T₉ (15.09±0.34) to T₁₂ (8.95±0.18) and the right side decreased from T₉ (14.94±0.45) to T₁₂(8.89±0.26) (the value of Figure 1e). P more than 0.05, it was no significant difference between the left and right sides (Table 2).

参考文献

[1]Liu J, Xiang BL, Wang Q, et al. Posterior screw-rod system fixation combined with anterolateral decompression and bone graft for severe thoracolumbar burst fracture in 12 cases. Zhongguo Zuzhi Gongcheng Yanjiu yu Linchuang Kangfu. 2011;15(35):6536-6539.
[2]Hei L, Yuan HF, Zhao HN, et al. Removal of intraosseous cartilaginous node originated from thoracic vertebrae via anterolateral extrapleural approach. Zhongguo Jizhui Jisui Zazhi. 2014;24(7):616-620.
[3]Wang YP, Wang XC, Xiong CL, et al. One stage posterior transpedicle fixation and debridement with bone graft to treat thoracic spinal tuberculosis. Linchuang Guke Zazhi. 2014; 17(1):8-10.
[4]Herring JA, Bradford DS. The Spine. American: Mc-Graw-HillInc. 2001:353-354.
[5]Ghanayem AJ. Anterior instrumentation in the management of thoracolumbar burst fractures. Clin Orthop Res.1997;33(5): 89-100.
[6]Sucato DJ, Flohr R. Accurate preoperative rod length measurement for thoracoscopic anterior instrumentation and fusion for idiopathic scoliosis. J Spinal Disord Tech. 2005; Suppl:S96-S100.
[7]Qiu Y, Rui BY, Zhu ZZ, et al. Nutrient artery entrance on the posterolateral wall of thoracic vertebral bodies: another potential landmark for vertebral screw insertion. Zhonghua Waike Zazhi. 2007;45(16):1105-1107.
[8]Jin DD, Zeng DB, Chen JT, et al. Analysis of failures in thoracic waist spinal injury surgery. Zhongguo Jiaoxing Waike Zazhi. 2003;11(14):952-954.
[9]Li ZJ, Li XH, Cai YQ, et al. Anatomy of costal fovea for costal head on vertebrae and its clinical significance. Jeipouxue Zazhi. 2006;29(3):351-354.
[10]Zhu HT, Zhu YL, Zhang F, et al. Anatomic and radiographic study of the rib head associated with spinal canal and Vertebral body in adult. Zhongguo Jizhui Jisui Zazhi. 2011; 21(9):774-777.
[11]Jin DD. Primary report of Z plate inner fixation system towards anterior approach of thoracic waist. Zhonghua Guke Zazhi. 1999;19(4):201-204.
[12]Zhang H, Sucato DJ. Regional differences in anatomical landmarks for placing anterior instrumentation of the thoracic spine in both normal patients and patients with adolescent idiopathic scoliosis. Spine. 2006;31(2):183-189.
[13]Li XH, Xu DC, Li ZJ, et al. An anatomical study in a Chinese population of the position of the rib head for placing anterior vertebral body screws. Morphol (Wamz). 2010;69(4): 232-240.
[14]Li XH, Xu DC, Li ZJ, et al. Anatomical study of position of the rib head for placing anterior vertebral body screws in a Chinese population. Orthopedics. 2010;33(12);884-894.
[15]Zhao TB, Fan QY, Li YQ, et al. Measurement of Chinese vertebrae in skeleton and X-ray photograph and its clinical significance. Zhongguo Linchuang Jiepouxue Zazhi. 2001; 19(4):302-304.
[16]Li ZJ, Li Y, Shi CD, et al. Measurement on vertebral body morphology of adults in north. Zhongguo Zuzhi Gongcheng Yanjiu yu Linchuang Kangfu. 2008;12(28):5531-5540.
[17]Beisse R. Endoscopic surgery on the thoracolumbar junction of the spine. Eur Spine J. 2006;15(6):687-704.
[18]Newton PO. Thoracoscopic anterior instrumentation for idiopathic scoliosis. Spine J. 2009;9(7):595-598.
[19]Lonner BS, Auerbach JD, Levin R, et al. Thoracoscopic anterior instrumented fusion for adolescent idiopathic scoliosis with emphasis on the sagittal plane. Spine J. 2009; 9(7):523-529.
[20]Bis?evi? M, Bis?evi? S, Ljuca F, et al. The radiological estimation of vertebral body volumes on the thoracic and lumbal spine. Coll Antropol. 2014;38(2):505-509.
[21]Oon Tan C, Botha C, Weinberg L, et al. Computerized tomographic anatomic relationships of the thoracic paravertebral space. J Cardiothorac Vasc Anesth. 2013; 27(6):1315-1320.
[22]Ali AH, Cowan AB, Gregory JS, et al. The accuracy of active shape modelling and end-plate measurements for characterising the shape of the lumbar spine in the sagittal plane. Comput Methods Biomech Biomed Engin. 2012; 15(2):167-172.
[23]Abuzayed B, Tutunculer B, Kucukyuruk B, et al. Anatomic basis of anterior and posterior instrumentation of the spine: morphometric study. Surg Radiol Anat. 2010;32(1):75-85.
[24]Lonner BS, Auerbach JD, Levin R, et al. Thoracoscopic anterior instrumented fusion for adolescent idiopathic scoliosis with emphasis on the sagittal plane. Spine J. 2009; 9(7):523-529.
[25]Sucato DJ, Kassab F, Dempsey M. et al. Analyis of screw placement relative to the aorta and spinal canal following anterior instrumentation for thoracic idiopathic scoliosis. Spine. 2004;29(5):554-559.
[26]Li XH, Li ZJ, Wang HY, et al. Digital measurement of the vertebral body during lateral anterior internal fixation of middle and lower thoracic vertebrae. Zhongguo Zuzhi Gongcheng Yanjiu. 2013;17(22):4042-4046.
[27]Bullmann V, Fallenberg EM, Meier N, et al. Anterior dual rod instrumentation in idiopathic thoracic scoliosis: a computed tomography analysis of screw placement relative to the aorta and the spinal canal. Spine. 2005;30(18):2078-2083.
[28]D’Aliberti G, Talamonti G, Villa F, et al. Anterior approach to thoracic and lumbar spine lesions: results in 145 consecutive cases. J Neurosurg Spine. 2008;9(5):466-482.
[29]Dai LY, Jiang LS, Jiang SD. Anterior-only stabilization using plating with bone structural autograft versus titanium mesh cages for two- or three-column thoracolumbar burst fractures: a prospective randomized study. Spine. 2009;34(14): 1429-1435.
[30]Wu Y, Hou SX, Wu WW, et al. Studying the influence of age and short or long segments of pedicle screw instrumentation to the clinical efficacy of early single thoracolumbar fracture. Zhonghua Wai Ke Za Zhi. 2009;47(23):1790-1793.
[31]Hu X, Siemionow KB, Lieberman IH. Thoracic and lumbar vertebrae morphology in Lenke type 1 female adolescent idiopathic scoliosis patients. Int J Spine Surg. 2014;8. doi: 10.14444/1030.
[32]Cho W, Le JT, Shimer AL, et al. The insertion technique of translaminar screws in the thoracic spine: computed tomography and cadaveric validation. Spine J. 2015;15(2): 309-313.
[33]Matsukawa K, Yato Y, Hynes RA, et al. Cortical bone trajectory for thoracic pedicle screws: a Technical note. J Spinal Disord Tech. 2014.
[34]Qiu XS, Jiang H, Qian BP, et al. Influence of prone positioning on potential risk of aorta injury from pedicle screw misplacement in adolescent idiopathic scoliosis patients. J Spinal Disord Tech. 2014;27(5):E162-E167.
[35]Vallefuoco R, Bedu AS, Manassero M, et al. Computed tomographic study of the optimal safe implantation corridors in feline thoraco-lumbar vertebrae. Vet Comp Orthop Traumatol. 2013;26(5):372-378.
[36]Weaver J, Seipel S, Eubanks J. T1 intralaminar screws: an anatomic, morphologic study.Orthopedics. 2013; 36(4): e473-e477.
[37]Cho W, Le JT, Shimer AL, Werner BC, et al. The insertion technique of translaminar screws in the thoracic spine: computed tomography and cadaveric validation. Spine J. 2015;15(2):309-313.
[38]Qiu XS, Jiang H, Qian BP, et al. Influence of prone positioning on potential risk of aorta injury from pedicle screw misplacement in adolescent idiopathic scoliosis patients. J Spinal Disord Tech. 2014;27(5):E162-E167.
[39]Cho W, Le JT, Shimer AL, et al. The insertion technique of translaminar screws in the thoracic spine: computed tomography and cadaveric validation. Spine J. 2015; 15(2): 309-313.
[40]Qiu XS, Jiang H, Qian BP, et al. Influence of prone positioning on potential risk of aorta injury from pedicle screw misplacement in adolescent idiopathic scoliosis patients. J Spinal Disord Tech. 2014;27(5):E162-E167.
[41]Shaikh KA, Bennett GM, White IK, et al. Computed-tomography-based anatomical study to assess feasibility of pedicle screw placement in the lumbar and lower thoracic pediatric spine. Childs Nerv Syst. 2012;28(10): 1743-1754.
[42]Zhuang Z, Xie Z, Ding S, et al. Evaluation of thoracic pedicle morphometry in a Chinese population using 3D reformatted CT. Clin Anat. 2012;25(4):461-467.

引言

材料方法

讨论

Given its abilities to remove damaged segments under direct vision, relieve spinal compression, and perform strong fixation after bone grafting, latero-anterior fixation technology has been used widely to treat spinal disorders such as ITS bursting fractures, tuberculosis, and tumor, which might lead to spinal oppression.

Previous literature review and disadvantages

At present, many reports of screwing position selection for the ITSLAIF surgery have been published. Jin^[11] thought that the thoracic vertebral screwing positions should be located at an intersection located 4-5 mm parallel to the posterior, upper, and inferior edges of the vertebral body. In fact, it would be highly difficult for clinical surgical procedures according to the criteria mentioned above.

Some scholars used the rib head as a screwing point, but it was often needed to be removed intraoperatively, which brought difficulty to determine the screw position^[12-14]. In addition, many scholars discovered that there were large variations in vertebral shapes^[15-24].

Therefore, the determination of a tangible and constant screwing reference would be of great importance.

Significance of anatomic measurements of the rib head of lower thoracic vertebrae

Through the specimen measurements obtained in this study, we found that the minimum value of vertebral transverse diameter of the concave rib leading edge plane was T₉ (32.53±0.56) mm, and the maximum value was T₁₂ (46.96±0.37) mm.

The measured results prompted that the thoracic transverse diameters increased gradually as the vertebral number increased, which was similar to results of Sucato et al ^[25] and Li et al ^[26]. It also suggested that the vertebral screw selection had certain regularity when placing in the lower thoracic vertebrae and provided the anatomical basis for choosing the length of the screw^[27-42]. We also found that the minimum value of distance between the anterior edge of the concave rib and anterior edge of the vertebral canal was T₉ (4.50±0.16) mm, and the maximum value was T₁₂ (2.07±0.97) mm. The minimum value of the left side between the upper edge tangent of the concave rib and the upper edge tangent of the upper end plate was T₉ (0.67±0.40) mm and the right side was T₉ (0.54±0.34). The maximum value of the left side was T₁₂ (9.04±0.17) mm and the right side was T₁₂ (9.05±0.23) mm. The minimum value of the left side between the inferior edge tangent of the concave rib to the upper edge tangent of the upper end plate was T₉ (7.23±0.42) mm and the right side was T₉ (7.13±0.45) mm. The maximum value of the left side was T₁₂ (17.02±0.24) mm and the right side was T₁₂ (17.04±0.33) mm. The maximum value of the left side between the upper edge tangent of the concave rib and the inferior edge tangent of the inferior end plate was T₉ (21.92±1.23) mm and the right side was T₉ (21.35±1.60) mm. The minimum value of the left side was T₁₂ (18.68±0.26) mm and the right side was T₁₂ (18.63±0.38) mm. The maximum value of the left side between the inferior edge tangent of the concave rib and the inferior edge tangent of the inferior end plate was T₉ (15.09±0.34) mm and the right side was T₉ (14.94±0.45) mm. The minimum value of the left side was T₁₂ (8.95±0.18) mm and the right side was T₁₂ (8.89±0.26) mm. It was no significant difference between the left and right sides.

These data suggested the distance between the upper and inferior edges of the concave rib and upper endplate increased gradually as the vertebral number increased, whereas the distances between the upper and inferior edge of the concave rib and inferior endplate and between the anterior edge of the concave rib and anterior edge of the vertebral canal decreased gradually; in particular, for T₁₁ and T₁₂, part of the data appeared negative. These results indicated that the partial concave rib was located on the vertebral arch pedicle, and the anterior edge of the vertebral canal was directed forward to protrude into the anterior edge of the concave rib. These data were combined with increase in vertebral sequence number, the positions of the thoracic concave ribs gradually migrated towards the vertebral middle body and vertebral arch pedicle.

The above data confirmed that the lower thoracic concave ribs had relatively constant anatomical relationship. The concave ribs thus can be used as a simple and reliable screwing point during ITSLAIF surgery.

Conclusions

The concave rib is relatively constant, tangible anatomical marks in the inferior thoracic spine; this structure provides a particular set of rules that can be followed and thus can be used as a simple and reliable screwing point reference during ITSLAIF surgery.

T₁₁ and T₁₂should be given special attention because here, the partial concave rib is located on the vertebral arch pedicle and the anterior vertebral canal edge is directed forward to protrude into the anterior edge line of the concave rib.

Accordingly, the screw should be placed at a slightly forward angle in the anterior edge of the concave rib in order to avoid spinal canal penetration and spinal cord injury.

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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