摘要
研究背景：Paul Harrington1962年发明了棒-钩装置，对提高脊柱稳定性做出重大贡献，通过后路钩的连接行撑开和压缩，将畸形不愈合率从30％-40％减少到低于15％-20％，但其仅可在冠状面上提供良好的矫形，在提供旋转稳定性方面或有效控制矢状面对线方面是不充分的。Eduardo Luque等联合使用棒及椎板下钢丝技术，通过节段性连接，提高了矢状面上的控制，进一步减少脊柱假关节的发生率，但椎板下钢丝可发生神经损伤，以及光滑棒上钢丝无法对抗轴向力量。内固定系统随后的发展主要集中于保留节段性固定的优点。椎弓根螺钉是近年来后路脊柱内固定方法最显著的发展，在40年代最早报告使用椎弓根螺钉，1959年Boucher将其用于后路腰椎融合稳定手术，1969年Harrington和Tullos使用椎弓根螺钉联合Harrington棒结构行L_1-S_1滑脱的复位治疗，法国的Roy-Steffee等人随后发展了椎弓根固定系统，进一步改进内植物的设计，并在多节段固定中与固定孔钢板联合使用。
椎弓根是椎体的最坚强部分，被认为是椎体的“力量核心”，正确放置的椎弓根螺钉对所有平面上的负荷具有动力性抵抗力，并且为矫正各个椎体的旋转和矢状面矫形提供支点。在获得多平面矫形和稳定的同时，融合节段的数日最少，更重要的是，内植物牢固固定时，并不需要撑开和完整的椎板。椎弓根螺钉无须进入椎管，因此减少神经损伤的危险性。通过联合使用棒系统和其他脊柱内固定，椎弓根系统能提供不同的力量，包括加压、冠状面和矢状面的移位和旋转。从80年代以来，出现许多基于椎弓根螺钉的脊柱固定系统。临床上后路椎弓根钉技术应用日益增加，出现许多类型的椎弓根钉系统供临床医生选择。由于植入过程中存在损伤脊髓、神
郑州大学2004届硕士学位论文
胸腰段椎弓根钉道侧壁的临床研究
经、血管的潜在危险，直到1999年美国FDA才正式批准该项技术为脊柱后路固定
的.级装置，可以治疗除重度椎体滑脱以外的病例，而.级装置被认为可以用于
脊柱固定的实验性治疗，但是还未被FDA证实其安全性和有效性。
近十几年来，国内外椎弓根应用解剖得到迅速发展。既有从形态学方面进行
观察研究，又有从量化角度，对进钉点与周围标志及相关参数进行研究。从临床
角度分析，椎弓根在植钉过程中的完整性甚为重要。临床上判断椎弓根钉穿破的
方法和手段较少。一般仅应用X线来判断椎弓根的完整性，其准确性较差。而椎
弓根完整性的判断又依赖于对钉道侧壁完整性的认识和分析。从目前文献看，对
临床真实钉道侧壁的研究较少，进行计算机X摄像(CR照相)技术，SCr和实体
标本之间的对比分析的研究更少，利用CR技术，螺旋CT(S CT)及实体标本对
不同进钉方法的临床真实钉道侧壁间的对比研究尚未见报道。本项实验在这方面
进行了研究。
国内外在椎弓根应用解剖方面的研究进展为本项实验奠定了理论基础;
MoranIZI等1989年应用切割工具处理椎弓根，获取并测量松质骨的相关参数，研
究其和椎弓根高度和宽度的变化规律，该研究为本项实验提供了方法学基础。
目的:为临床量化的“人”字靖法和“Magerl”法的胸腰段椎弓根钉道侧壁厚
度，探讨计算机x摄像，(简称CR)和螺旋cT(简称scI’)在评价椎弓根钉安全
性方面的临床意义，寻找一种判断胸腰段椎弓根钉安全性的客观依据。
材料与方法:(1) 20具成人胸n到腰2(T 11一L:)的干燥脊柱标本，标本
来至郑州大学医学院和平顶山卫生学校。(2)将标本按进钉方法不同分为“人”
字峭法和“Magerl”法两纵组，按处理方法不同分为cR、scT和实体标本三横
组。将标本固定在自制的脊柱标本固定器上，左、右侧椎弓根分别利用“人”字
晴法和“Magerl”法植入临床应用的椎弓根钉，(T;，、1:螺钉直径:5.omm，长度:
35.0m试L，、:螺钉直径:5.omm，长度:40.0mm)，制造钉道。对标本行cR技术、
螺旋Cl，照像，于椎弓根最窄处应用厚度为0.smm的锯于额状面离断椎弓根，获
得CR，SCI，和实体标本三组关于钉道侧壁的数据，并记录三组内、外、上、下
壁的穿破情况。(3)数据应用sPss10.0进行统计学分析，统计方法采用配对资
料的t检验、完全随机设计资料的方差分析、最小显著差的t检验和行X列表资
料的x“检验，p<0.05为差异有显著性标准。
结果:(1)CR、SCT和实体标本组内，内侧壁和外侧壁间进行统计学分析，
郑州大学2()O4届硕士学位论文
胸腰段椎弓根钉道侧壁的临床研究
内侧壁和外侧壁问有显著统计学意义，p<0.01;一[、下侧壁的厚度间有显著统计学
意义，p<。.01。(2)CR和SCT、CR和实体标本组间的内侧壁厚度间、外侧壁厚
度问进行统计学分析，有显著统计学意义，p<0.01。(3) scT和实体标本组的内、
外侧壁厚度数据问有差异，p>.()5但无统计学意义。(4) CR组中，两种进钉方法
的内、外侧壁的穿破情况进行统计学分析，除在Ll一2段了值为1.85，p值为0.173
外，p仃L均小J几0.01，具有显著统计学意义。SCT及实体间，两种进钉方法的内、
外侧壁的穿破均具有显著统计学意义，承()，()5;cR组的总穿破率与scT组的总
穿破率问的统计学分析，二者有显著统计学意义，x“=10.14，p<0.()5。而一卜、下侧
壁则无穿破
Background: The pedicle screw technique is used by orthopaedic surgeon now. There are many styles of the pedicle screw systems to choice for the orthopaedic surgeon. Because there is much potential trauma to spinal cord, nerve or blood vessel during operation. FDA of America authorized this technique as one of standard methods until 1999. The clinical anatomy and techniques were studied during 1990s,Many experts studied the morphologic characters and the relations between the inserting screw point and the surrounding organs or tissues ,which were the theoretic foundation as our study .Moran used the saw dissect the pedicle and obtained the parameters about the pedicle ,which was the method ' s foundation as our study. We investigated many up-to-the-minute literatures ,The studies about the pedicle screw wall was rare by Computed Radiography(CR) Spiral CT(SCT) and true vertebrae .Moreover the comparing studies was much rare by different inserting screw methods .We tried to do study at our department.
Objectives : To quantify the pedicle screw path wall for clinical surgeon on T 11-L2 with the" Magerl "technique and the "A" shape crest technique ; To evaluate clinical significance of Computed Radiography (CR) Spiral CT(SCT) and true vertebrae about pedicle screw's safety ; To look for a objective foundation to determine about pedicle screw's safety of thoracolumbar segment.
Material and Methods: In this study, the data were presented that provide the surgeon with information about the sereve wall ,which were especially useful for pedicle screw fixation. By the different inserting screw methods ,We divided the specimens as
two longitudinal groups :thc " Magcrl " technique group and the "A" shape crest technique group ; By the different managing methods , We divided the specimens as three transverse groups :CR group > SCT group and true vertebrae specimen group .We used the" Magcrl" technique and the" A "shape crest technique to insert the pedicle screws with the truely clinical screw in every pedicle of T11 -L2 of twenties adult vertebras. (2) We drew off the screw from the pedicle ,thcn got the image by CR and Spiral-CT. finally ,wc dissected the pedicle at the narrowwest position , measured the superior, inferior, medial and lateral wall and observed the penetration about the pedicle .(3) The data were analyzed by software SPSS10.0, t-test,F-test LSD t-test and X2 -test were used to compare difference between groups ,A difference was considerred significant if the p value was below 0.05.
Results: (1) There were significant differences (p <0.01) about the medial and lateral wall among CR group, S-CT group and true pedicle group ,So the inferior and superior wall were . (2) There was significant differcnccs( p <0.001)about the medial walls between CR group and S-CT group ,between the CR group and the true vertebrae group.So the lateral walls were. (3) There was no significant difference about the medial wall between SCT group and truly vertebrae group ,Neither the lateral wall was (p >0.05). (4) As far as it was the violation ratio about the CR group ,S-CT group and true pedicle wall group , the penetration's ratio of the CR group was compared with the ratio of SCT group and the truly vertebrae group .there were significant difference .(p <0.01). At L1 -L2 ,the violation ratio of CR group between the "A" shape crest technique and The "Magerl" technique has not difference ,p =0.173. the violation of superior and inferior didn't happen. (5) At T11-12 ,Thc medial wall of "Mageral" technique was thicker than its of the " A " shape crest technique , The lateral wall of "Magerl" technique was thinner than its of the "A" shape crest technique ;Al L1-2.Thc medial wall of "Magcrl" technique was thinner than its of the " A "shape crest technique , The lateral wall of "Magerl" technique was thicker than its of the " A " shape
crest.
Conclusions :
(1) The medial and lateral wall have the important significance for the pedicle' s
safely;
(2) S-CT is more reliable than Computed Radiography about evaluating th
引文
1. Michele AA, Krueger FJ, Surgical approach to the vertebral body. [J]. J Bone Joint Surg(Am),1949,31:873-874.
2. Moran JM, Berg WS,. Berry JL ,et, al. Transpedicular screw fixation .[J]. J Orthop Rcs ,1989,7:107-114.
3．杜心如，赵玲秀，张一模等．腰椎“人”字嵴项点毗邻结构观察及临床意义．[J]．中国脊柱脊髓杂志，2001，11(2)，89-91．
4. [4] Magerl FP. Stabilization of the lower thoracic and lumbar spine with exteral skeletal fixation. [J]. Clin Orthop,1984,189:125.
5. Zindrick MR, Wiltse LL, Doornik A, et al. Analysis of the morphometric characteristice of the thoracic and lumbar pedicles. [J]. Spine, 1987,12:160-166。
6. Panjabi MM, Takatak, Geol V, et al. Thoracic human vertebrae:Quantitative three-dimensional anatomy. [J]. Spine 1991;16:888-901.
7. Panjabi MM, Oxland TR, Parks EH. Quantitative anatomy of cervical spine ligaments. Part Ⅱ .middle and lower cervical spine .[J]. J Sinai Dis.1991;4;277-285.
8. Ebraheim NA, Xu R, Ahmad M. Yeasting RA.. Projection of the thoracic pedicle and its morphometric analysis. [J] .Spine 1997.22:233-238.
9. Ebraheim NA, .Rollins JR, Xu R ,Yeasting RA .Projection of the lumbar pedicle and its morphometric analysis. [J] .Spine 1996.21;1296-1300.
10. Krag MH, Beynnon BD, Pope MH, et al .An internal fixator for posterior application to short segmentals the thoracic lumbar or lumbosacar spine:design and testing. [J]. Clin Orthop, 1986,203:75-97.
11. Dai L, Mechanism of thoracolumbar burst fractures: a biomechanical study. [J] .Chin Med J (Engl) 2002,115(3):336-8.
12. Saillant G, Anatomical study of vertebral pedicles surgical application, [J]. Riv Chirurg Orthop, 1976,62(2):151-157.
13．候树勋，史亚民，国人下胸椎及腰椎椎弓根形态学特点及临床意义，[J]．中华骨科杂志，1994，14(4)：222-225．
14．史亚民，柴伟，候树勋等，胸椎椎弓根形态测量研究，[J]．中国脊柱脊髓杂
志，2002，12(3)：191-193．
15. Ralph Kothe, MD, James D, O'Holleran, BS, Wen liu, et al. Internal architecture of the thoracic pedicle. An anatomic study. [J]. Spine 1996,21(3):264-270。
16. Banta, CJ 2nd, King AG, Dabezies EJ, et al. Measurement of effective Pedicle diameter in the human Soine. [J]. Orthooedics 1989,12(7):939-942.
17．杜心如，赵玲秀，张一模，叶启彬．胸腰椎椎弓根内径的测量及其临床意义，[J]．中国脊柱脊髓杂志，2001，11(3)：162-164．
18．熊传芝，郝敬明，唐天驷．椎弓根钉道参数的变异性及其相关因素的研究．[J]．中华骨科杂志，2002，22(1)，31-35．
19．吕厚山，刘海鹰，陈坚等，脊柱内固定学(译)，第二版，中国医药科技出版社，2001：262．
20．方先来，张德，孟志华等．螺旋CT三维测量在腰椎弓根植钉中的应用研究．[J]．中国脊柱脊髓杂志，2004，14(2)，96-98．
21．吕厚山，刘海鹰，陈坚等，脊柱内固定学(译)，第二版，中国医药科技出版社，2001：101
22. Misenhimer GR, Peek RD, Wiltse LL, et al. Anatomic analysis of pedicle cortical and cancellous diameter as related to screw size [J]. Spine,1989,14:367-372.
23. Gianluca Cinotti MD, Stefano Gumina MD, Maurizio Ripani MD, et al.Pedicle instrumentation in the thoracic spine,Amorphometric and cadaveric study for placement of screws, [J]. Spine,1999,24(2):114-119.
24. Sjostrom L, Jacobsson O, Karlstrom G, et al . CT analysis of peclicles and screw tracts after implant removal in thoracolumbar fractures. [J]. J Spinal Disord, 1993,6:225-231.
25．杜心如，叶启彬，赵玲秀等．腰椎“人”字嵴顶点椎弓根螺钉进钉方法的解剖学研究．[J]．中国临床解剖学杂志，2002，20(2)，86-88．
26. Xu R, Ebraheim NA, Ou Y, et al. Anataomic considerations of pedicle screw placement in the thoracic spine ,Roy-Camille technique versus open-lamina technique. [J]. Spine ,1998,23(9):1065-1068.
27．张永刚，王岩主译．脊柱， 第1版，辽宁科学技术出版社，2003：451．
28. Castro WH, Halm H, Jerosch J, et al. Accuracy of pedicle screw placement in lumbar vertebrae. [J]. Spine,1996,21(ll):1320-1324.
29. Cotani Y, Cunninghag BW, Abumi, K, et al. Biomechanic analysis of cervical stabilization systems:an assessment transpediclar screw fixation in the cervical spine. [J]. Spine,1994,19:2529-2532.
30. Bhler DW, Berlemann U, Oxland TR, et al. Moments and forces during pedicle screw insertion: in Vitro and in Vivo measurements, [J]. Spine, 1998,23(11):1220-1228.