Morphological analysis of optimal selection of lumbar pedicle
screws in adolescents aged 12-15 years

doi:10.3969/j.issn.2095-4344.2652

Chinese Journal of Tissue Engineering Research ›› 2020, Vol. 24 ›› Issue (21): 3321-3328.doi: 10.3969/j.issn.2095-4344.2652

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Morphological analysis of optimal selection of lumbar pedicle screws in adolescents aged 12-15 years

Xu Yangyang¹, Zhang Kai², Li Zhijun³, Zhang Yunfeng⁴, Su Baoke¹, Wang Xing³, Wang Lidong⁵, Wang Yidan¹, He Yujie³, Li Kun³, Wang Haiyan³, Li Xiaohe³

¹Graduate School of Inner Mongolia Medical University; ²Department of Orthopedics, Ulanqab Second Hospital; ³Department of Anatomy, School of Basic Medicine, Inner Mongolia Medical University; ⁴Department of Radiology, the Second Affiliated Hospital of Inner Mongolia Medical University;⁵Deoartment of Radiology, Inner Mongolia International Mongolian Hospital

Received:2019-10-21 Revised:2019-10-25 Accepted:2019-11-29 Online:2020-07-28 Published:2020-04-16
Contact: Wang Haiyan, Master, Associate professor, Master’s supervisor, Department of Anatomy, School of Basic Medicine, Inner Mongolia Medical University, Hohhot 010110, Inner Mongolia Autonomous Region, China Li Xiaohe, MD, Professor, Master’s supervisor, Department of Anatomy, School of Basic Medicine, Inner Mongolia Medical University, Hohhot 010110, Inner Mongolia Autonomous Region, China
About author:Xu Yangyang, Master candidate, Graduate School of Inner Mongolia Medical University, Hohhot 010110, Inner Mongolia Autonomous Region, China Zhang Kai, Doctoral candidate, Attending physician, Department of Orthopedics, Ulanqab Second Hospital, Ulanqab 012000, Inner Mongolia Autonomous Region, China Xu Yangyang and Zhang Kai contributed equally to this work.
Supported by:
the National Natural Science Foundation of China, No. 81460330, 81560348, and 81860383; the Youth Science and Technology Talent Project of Inner Mongolia Education Department, No. njyt-15-b05; Science and Technology Program of Inner Mongolia Autonomous Region, No. 2016; the Science and Technology Innovation Guide Project of Inner Mongolia Autonomous Region, No. 2017; the Natural Science Foundation of Inner Mongolia Autonomous Region, No. 2016ms08131; the Returned Scholar Foundation of Human Resources and Social Security Department of Inner Mongolia Autonomous Region, No. TKD2017KJBW012; the Science and Technology Million Program of Inner Mongolia Medical University, No. YKD2017KJBW012

Abstract

Abstract:

BACKGROUND: A large amount of literature has been published on the vertebral pedicle morphology at thoracolumbar segments in adults, but little is known about the morphology of pedicles in adolescents, especially in Asian populations. Adolescent spine disorders are increasing and there are few precise morphological studies.

OBJECTIVE: To investigate the anatomy of lumbar vertebrae of adolescents aged 12-15 years in Inner Mongolia, provide detailed information for pedicle screw placement, determine the safe and appropriate screw size, and provide data reference for screw size design.

METHODS: The normal chest and lumbar CT data of 65 adolescents aged 12-15 years in Inner Mongolia were collected and divided into two groups, 31 cases of 12-13 years old, and 34 cases of 14-15 years old. The raw data of the thoracic and lumbar vertebrae images scanned continuously were imported into Mimics 21.0 for analysis and measurement in DICOM format. Pedicle width, pedicle height, transverse diameter, longitudinal diameter, pedicle length, pedicle outer declination, pedicle maximum external angle, pedicle head inclination, and pedicle area were measured.

RESULTS AND CONCLUSION: (1) The L₁-L₄ pedicle width in the two groups was less than pedicle height, and pedicle width and pedicle height at L₅ were similar. The pedicle width determined the screw diameter, which was larger in males than in females. (2) In 12-13 years old, the screw length at L₁-L₅ was between 40-45 mm. In 14-15 years old, the screw length was between 40-45 mm at L₁-L₄, and 45-50 mm at L₅. (3) The laws of the two groups were the same. The transverse diameter of spinal canal was significantly larger than longitudinal diameter of spinal canal (P < 0.05), and there was no significant difference between men and women. (4) The transverse pedicle angle: In 12-13 years old, L₁-L₂ had small change, L₂-L₅ gradually increased; in 14-15 years old, L₁-L₅ gradually increased; it is larger in males than in females in both groups. (5) Maximum transverse pedicle angle: The two groups had the same law. L₁-L₅ gradually increased, and decreased with age. There was no significant difference between left and right sides and sexes. There was significant difference among different ages (P < 0.05). (6) The sagittal pedicle angle: The in 12-13 years old, 3°-8°; in 14-15 years old, 0°-5°. The value decreased with age, and there was significant difference between men and women in L₃-L₄(P < 0.05). (7) Pedicle area: The two groups had the same rules. L₁-L₅ gradually increased, and L₄-L₅ had a clear trend of change. (8) Analysis of pedicle parameters showed that the size of the screws in the lumbar vertebrae of normal adolescents was suitable for the clinician to grasp the anatomy of the lumbar spine and improve the accuracy of clinical operation.

Key words: adolescents, lumbar vertebrae, pedicle screw, morphological characteristics, three-dimensional reconstruction measurement, the National Natural Science Foundation of China

CLC Number:

Xu Yangyang, Zhang Kai, Li Zhijun, Zhang Yunfeng, Su Baoke, Wang Xing, Wang Lidong, Wang Yidan, He Yujie, Li Kun, Wang Haiyan, Li Xiaohe. Morphological analysis of optimal selection of lumbar pedicle screws in adolescents aged 12-15 years[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(21): 3321-3328.

Figures/Tables 3

2.1.1 椎弓根宽 12-13岁，L1-L5逐渐增大，L1-L5最小值分别为(5.11±1.64)，(5.38±1.38)，(6.48±1.62)，(8.41±1.81)及(11.9±2.19) mm，男性大于女性，左右侧差异无显著性意义，L2-L4男女之间差异有显著性意义，L1-L5节段差异有显著性意义。 14-15岁，椎弓根宽变化趋势同12-13岁，L1-L5逐渐增大，L1-L5最小值分别为(5.59±0.82)，(6.33±0.89)，(6.32± 1.35)，(9.45±1.47)及(12.03±0.83)mm，男性小于女性，左右侧差异无显著性意义，L1-L5节段差异有显著性意义。 2.1.2 椎弓根高 12-13岁，L1-L5逐渐减小，L1-L5最小值分别为(12.70±1.82)，(11.78±1.49)，(11.71±1.70)，(11.19± 1.59)及(10.66±1.88) mm，L4，L5节段差异有显著性意义。 14-15岁，此次研究中变化趋势不确定，L1-L5最小值分别为(12.42±0.90)，(11.65±1.32)，(11.38±0.62)，(11.11± 1.90) 及(10.17±1.39) mm；左右侧与性别间均差异无显著性意义，L4，L5节段差异有显著性意义。 2.1.3 模拟椎弓根长 12-13岁，L1-L5变化范围不大，均为40-45 mm，左右侧与性别间差异均有显著性意义，L1节段差异有显著性意义。 14-15岁，L1-L4变化范围不大，均为40-45 mm；L5在45-50 mm之间，L1，L3左右之间差异有显著性意义，L1节段差异有显著性意义。 2.1.4 椎管横径与椎管纵径 2组规律相同，椎管橫径L1-L5逐渐增大；椎管纵径L1-L4先轻微减小，L4-L5增大。椎管橫径均大于椎管纵径，椎管呈现椭圆-倒三角的形态变化，椎管橫径、椎管纵径之间差异均有显著性意义，男女之间差异无显著性意义。 2.1.5 椎弓根外偏角(α) 12-13岁，L1-L2变化不大，L2-L5逐渐增大，男(8.23±3.27)°至(30.41±6.33)°，女(6.40±2.32)°至(26.98±5.51)°，男性大于女性，L3-L4男女之间差异有显著性意义，L4，L5节段差异有显著性意义。 14-15岁，L1-L5逐渐增大，男(9.32±2.63)°至(29.75± 2.45)°，女(4.84±2.32)°至(18.37±2.11)°，男性大于女性，L1男女之间差异有显著性意义，L1-L5节段差异有显著性意义。 2.1.6 椎弓根最大外偏角(β) 12-13岁，L1-L5逐渐增大，男(21.58±7.02)°至(54.81±6.39)°，女(16.70±6.53)°至(51.79±6.44)°，男性大于女性。 14-15岁，L1-L5逐渐增大,男(20.76±2.63)°至(50.73± 3.66)°，女(16.04±4.65)°至(31.95±4.07)°；β值随年龄增长而减小，左右侧与性别间均差异无显著性意义，不同年龄间差异有显著性意义，2组L1-L5节段差异有显著性意义。 2.1.7 椎弓根头倾角(θ) 腰椎不同于胸椎，腰椎椎弓根宽且θ较小，胸椎头倾角明显，螺钉置入时要指向下终板方向，但腰椎指向上终板。12-13岁，L1-L5有一个3°-8°的角度指向上终板，男(3.80±2.84)°至(7.39±3.51)°，女(3.87±2.60)°至(5.62±3.30)°；L4-L5男女之间差异有显著性意义。 14-15岁，L1-L5有一个0°-5°的角度指向上终板，男(2.47±0.26)°-(3.56±0.97)°，女(3.89±1.06)°-(4.86±1.49)°；θ值随年龄增长而减小，L3-L4男女之间差异有显著性意义，2组L1节段差异有显著性意义。 2.1.8 椎弓根面积 12-13岁，L1-L5逐渐增大，L4-L5有一个明显的变化趋势，L1-L5为(92.45±20.22) mm2至(214.62± 18.66)mm2。 14-15岁，L1-L5逐渐增大，L4-L5有一个明显的变化趋势，L1-L5为(96.37±28.73) mm2至(237.52±21.29) mm2，L1左右间差异有显著性意义，L3，L5男女之间差异有显著性意义，2组L1-L5节段差异有显著性意义。 2.2 与国内外文献比较 2.2.1 椎弓根宽此次研究中12-15岁青少年腰椎L1-L5，椎弓根宽逐渐增加(5.11-12.03 mm)，与DZIER?ANOWSKI等[5]、MOHAMED等[6]、MOHANTY等[7]、LOTFINIA等[8]、SANI等[9]得出的规律相同，男性大于女性，均大于此次研究测量值。MUGHIR等[10]对马来西亚17岁以下青少年研究得出，椎弓根宽男性明显大于女性，上腰椎建议使用3.5 mm直径的螺钉，下腰椎使用5.0-6.5mm直径的螺钉；18岁以上L1-L5椎弓根宽，男7.3-16.2 mm，女5.8-13.9 mm。成年日本人L1-L5的椎弓根宽，男7.4-11.1 mm，女6.9-10.6 mm[11]。在成年印度人中L1-L5椎弓根宽，男7.1-16.2 mm，女5.9- 12.8 mm[12]。Kim等[13]报道成年朝鲜族人L1-L5椎弓根宽，男7.0-18.9 mm，女6.6-17.6 mm。 2.2.2 椎弓根高 12-13岁L1-L5逐渐减小(12.70- 10.17 mm)；而14-15岁，L1-L4减小，L4-L5增大，L4最小。DZIER?ANOWSKI等[5]对27-75岁白人CT资料研究得出，椎弓根高值L1-L4减小，L4-L5增大，L4节段最小，与此次实验结果相似。戚力升等[14]通过对100例成人腰椎CT资料研究得出L1-L5逐渐减小(15.1-10.4 mm)，变化趋势与此次研究相似，但测量值大于此次研究结果。WANG等[15]对6-11岁儿童影像学资料进行研究，椎弓根宽，L1-L5逐渐增大；椎弓根高，6-8岁L1-L5逐渐增大，9-11岁L1-L4减小，L4-L5增大；椎管橫径与椎管纵径，L1-L5逐渐增大，与此次研究变化趋势一致，但椎弓根尺寸小于此次实验数据。SANI等[10]对南非人群进行研究，椎弓根高L1-L5逐渐下降，与此次实验结果相似。L1-L4节段椎弓根宽小于椎弓根高，所以L1-L4的螺钉尺寸取决于椎弓根宽，L5节段椎弓根高小于椎弓根宽，所以L5的螺钉尺寸取决于椎弓根高。 2.2.3 椎弓根长此次研究中12-15岁青少年腰椎L1-L5椎弓根长值变化范围较小(40-45 mm)。DZIER?ANOWSKI等[5]对27-75岁白人CT资料研究得出，椎弓根长值为50-52 mm，大于此次研究结果。GRIVAS 等[16]对100例33-87岁希腊成人CT资料进行研究，发现L4处最长(55.31±4.52)mm，比此次研究测量值大，变化趋势与此次研究12-13岁相似。戚力升等[14]通过对100例成人腰椎CT资料研究得出L1-L5逐渐增大(48.6-52.7 mm)，变化趋势与此次研究相似，但测量值大于此次研究结果。SANI等[10]对南非人群研究，椎弓根长L1-L5略有下降，与此次研究14-15岁组结果相似。MUGHIR等[11]对马来西亚17岁以下青少年研究得出，椎弓根长从L1-L3逐渐增加，L3-L4逐渐减少，L3最长，L5最短，并且提倡在青少年人群中使用更短的椎弓根螺钉，在所有的腰椎水平上，选择30-35 mm的螺钉长度。KADIOGLU等[17]发现土耳其成人椎弓根轴长在L1最长(42.7 mm)，L5最短(40.8 mm)，土耳其成人与国内青少年尺寸相似。 2.2.4 椎管橫径和椎管纵径椎管橫径，L1-L5逐渐增大(21.07-27.80 mm)；椎管纵径，L1-L4先轻微减小，L4-L5增大(14.49-16.72 mm)。 2.2.5 外偏角α和最大外偏角β L1-L5均逐渐增大趋势，α角男为8.23°-30.41°，女为6.40°-26.98°；β角男为21.58°-54.81°，女为16.70°-51.79°。张军等[18]通过对300份椎弓根CT资料研究得出相似的结论，外偏角α为13.04°-33.07°。DZIER?ANOWSKI等[5]对27-75岁白人CT资料研究得出，α角为20°-32°，大于此次研究结果。CACCIOLA等[19]通过对意大利325名健康人(平均年龄62岁)L4，L5的CT资料研究得出，90%外偏角>30°，10%外偏角<30°。?APAR等[20]使用CT测量测量α角，L1为10.9°，L2为12°，L3为14.4°，L4为17.7°，L5为29.8°，与此次研究有差别。MOHANTY等[7]、SANI等[10]研究得出外偏角α的变化趋势与此次研究大体一致。AZAR等[21]对50例印度人群的CT研究发现，L1为(10.90±3.13)°，L5为(24.75±3.83)°，与西方人群相似。 2.2.6 头倾角θ L1-L5与上终板有小于8°的θ角，角度较小。DZIER?ANOWSKI等[5]对27-75岁白人CT资料研究得出，θ为10°-12°，大于此次研究结果。SANI等[10]对南非人群研究得出θ角为4.43°-4.88°，L1-L5略有增加，与此次研究结果相似。 2.2.7 椎弓根面积 L1-L5逐渐增大，为92.45- 237.52 mm2。DZIER?ANOWSKI等[5]研究得出，L1-L5逐渐增大，为62-140 mm2，与此次实验差别较大。分析得出中国青少年椎弓根外偏角较大，与冠状面成角，测得椎弓根面积值在冠状面投影的椎弓根轴面面积会变大。 LOTFINIA等[8]对50例伊朗人(男25例，女25例)的研究中发现，椎弓根宽值男性大于女性。ALAM等[22]分析了49例巴基斯坦人的220块腰椎CT图像，发现男性直径较大，女性角度更大。GüLE?等[23]研究了土耳其人群的腰椎结果，发现椎弓根宽、椎弓根高和椎弓根长随性别、年龄和身高而变化；外偏角α随年龄变化，不随性别或身高变化，没有发现α值在不同性别上的差异。美国人群的503具尸体测量结果表明，椎弓根宽、椎弓根高男性均大于女性，男性身高较高、体质量较大则具有较大的腰椎椎弓根[24]。椎弓根的大小随着年龄的增长而增加；在女性则相反[25]，此次研究却发现2组结果中女性发育快于男性，尤其是椎弓根宽。选择合适的椎弓根螺钉时应考虑到这些差异，年龄和性别是正确选择合适椎弓根螺钉的特殊变量。椎弓根尺寸受到遗传和种族的差异[26]。ALBAN等[27]研究发现，椎弓根宽，L1黑人最大(7.73 mm)，亚洲人最小 (5.98 mm)；L2，黑人、亚洲人最大(7.90 mm和7.32 mm)；L3-L5，白种人最大(9.42 mm，11.32 mm，14.73 mm)，亚洲人最小(8.79 mm，10.5 mm，14.05 mm)。STOCKTON等[28]报道，α角在L2中，白种人>黄种人>黑人和西班牙人。在L3，黄种人>黑人和西班牙人。亚洲人的腰椎椎弓根明显小于黑人或白人，与TSE等[29]的研究一致。 KIM等[13]和TAN等[30]报道韩国人和华裔新加坡人的椎弓根尺寸小于欧洲人。CHADHA等[31]和ACHARYA等[32]报道白人的椎弓根尺寸明显大于印度人。CHARLES等[33]得出结论，椎弓根的总体尺寸随着年龄增长。MCLAIN等[34]发现，椎弓根的大小受性别或种族影响，椎弓根的大小与个体的身高成比例。这可以解释为什么在目前的研究中，东方人椎弓根的尺寸比西方人群要小。CACCIOLA等[21]指出，椎弓根尺寸小，神经根结构更接近椎弓根，这也可能是腰椎稳定手术中椎弓根螺钉错位的一个重要危险因素。 "

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Morphological analysis of optimal selection of lumbar pedicle screws in adolescents aged 12-15 years

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