中国修复重建外科杂志

中国修复重建外科杂志

脊柱机器人与透视辅助下经皮植钉治疗腰椎滑脱症中植钉精度的对比研究

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目的 探讨脊柱机器人辅助手术系统在轻中度腰椎滑脱症中临床应用价值,评估其植钉准确性。 方法 回顾性分析 2017 年 1 月—12 月采用微创经椎间孔椎间融合术(minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF)治疗的 56 例轻中度(Meyerding Ⅰ、Ⅱ度)腰椎滑脱症患者临床资料。其中 28 例利用机器人进行术前规划,安放机器人机械臂,按照术前规划经皮植入椎弓根螺钉(A 组);余 28 例在透视辅助下经皮植入椎弓根螺钉(B 组)。两组患者性别、年龄、体质量指数、滑脱类型、Meyerding 分度及手术节段分布等一般资料比较差异均无统计学意义(P>0.05),具有可比性。术后通过 CT 测量椎弓根螺钉外展角,参考 Neo 等的标准评估植钉准确性,采用 Babu 等的方法评判螺钉对上关节突的侵犯情况。 结果 两组分别植入 112 枚螺钉,A、B 组分别有 5 枚(4.5%)和 26 枚(23.2%)螺钉穿破椎弓根侧壁,差异有统计学意义(χ2=9.157,P=0.002);参考 Neo 等的标准评估植钉准确性,A 组 0 度 107 枚、1 度 3 枚、2 度 2 枚,B 组 0 度 86 枚、1 度 16 枚、2 度 6 枚、3 度 4 枚,差异有统计学意义(Z=4.915,P=0.031)。B 组有 20 枚(17.9%)螺钉穿过上关节突;A 组由于减压侧部分截取关节突关节,共计 80 枚螺钉关节突关节完好,仅有 3 枚(3.8%)螺钉穿过上关节突。根据 Babu 等的方法评估螺钉侵入上关节突关节的程度,A 组 0 级 77 枚、1 级 2 枚、2 级 1 枚,B 组 0 级 92 枚、1 级 13 枚、2 级 4 枚、3 级 3 枚,差异有统计学意义(Z=7.814,P=0.029)。A、B 组螺钉外展角分别为(23.5±6.6)°和(18.1±7.5)°,比较差异有统计学意义(t=3.100,P=0.003)。 结论 与传统透视经皮植钉相比,脊柱机器人辅助经皮植钉精确度高,螺钉穿破椎弓根侧壁及侵入关节突关节的发生率更低,并具有更大的螺钉外展角,与 MIS-TLIF 术式相结合,可用于腰椎滑脱症的微创治疗。

Objective To explore the clinical application value of the spinal robot-assisted surgical system in mild to moderate lumbar spondylolisthesis and evaluate the accuracy of its implantation. Methods The clinical data of 56 patients with Meyerding grade Ⅰ or Ⅱ lumbar spondylolisthesis who underwent minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) between January 2017 and December 2017 were retrospectively analysed. Among them, 28 cases were preoperatively planned with robotic arm and percutaneous pedicle screw placement according to preoperative planning (group A); the other 28 cases underwent fluoroscopy-guided percutaneous pedicle screw placement (group B). There was no significant difference in gender, age, body mass index, slippage type, Meyerding grade, and surgical segmental distribution between the two groups (P>0.05). The screw insertion angle was measured by CT, the accuracy of screw implantation was evaluated by Neo’s criteria, and the invasion of superior articular process was evaluated by Babu’s method. Results One hundred and twelve screws were implanted in the two groups respectively, 5 screws (4.5%) in group A and 26 screws (23.2%) in group B penetrated the lateral wall of pedicle, and the difference was significant (χ2=9.157, P=0.002); the accuracy of nail implantation was assessed according to Neo’s criteria, the results were 107 screws of degree 0, 3 of degree 1, 2 of degree 2 in group A, and 86 screws of degree 0, 16 of degree 1, 6 of degree 2, 4 of degree 3 in group B, showing significant difference between the two groups (Z=4.915, P=0.031). In group B, 20 (17.9%) screws penetrated the superior articular process, while in group A, 80 screws were removed from the decompression side, and only 3 (3.8%) screws penetrated the superior articular process. According to Babu’s method, the degree of screw penetration into the facet joint was assessed. The results were 77 screws of grade 0, 2 of grade 1, 1 of grade 2 in group A, and 92 screws of grade 0, 13 of grade 1, 4 of grade 2, 3 of grade 3 in group B, showing significant difference between the two groups (Z=7.814, P=0.029). The screw insertion angles of groups A and B were (23.5±6.6)° and (18.1±7.5)° respectively, showing significant difference (t=3.100, P=0.003). Conclusion Compared to fluoroscopy-guided percutaneous pedicle screw placement, robot-assisted percutaneous pedicle screw placement has the advantages such as greater accuracy, lower incidence of screw penetration of the pedicle wall and invasion of the facet joints, and has a better screw insertion angle. Combined with MIS-TLIF, robot-assisted percutaneous pedicle screw placement is an effective minimally invasive treatment for lumbar spondylolisthesis.

关键词: 腰椎滑脱症; 脊柱机器人辅助手术系统; 经椎间孔椎间融合术; 椎弓根螺钉; 微创

Key words: Lumbar spondylolisthesis; spinal robot-assisted surgical system; transforaminal lumbar interbody fusion; pedicle screw; minimally invasive

引用本文: 杨俊松, 郝定均, 刘团江, 刘鹏, 贺宝荣, 许晓舟, 拓源, 章雪芳, 李辉. 脊柱机器人与透视辅助下经皮植钉治疗腰椎滑脱症中植钉精度的对比研究. 中国修复重建外科杂志, 2018, 32(11): 1371-1376. doi: 10.7507/1002-1892.201804049 复制

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