于奇 趙紅宇 劉云會(huì)^*

(中國(guó)醫(yī)科大學(xué)附屬盛京醫(yī)院神經(jīng)外科，沈陽(yáng) 110004)

[摘要]目的 探討應(yīng)用神經(jīng)導(dǎo)航系統(tǒng)進(jìn)行椎弓根螺釘植入的優(yōu)越性及近期療效。方法 在神經(jīng)導(dǎo)航輔助下, 對(duì)17例患者植入76枚椎弓根螺釘，記錄患者的單個(gè)椎體注冊(cè)時(shí)間、釘?shù)罍?zhǔn)備時(shí)間、術(shù)中出血量、術(shù)中“C”型臂照射次數(shù)、導(dǎo)航精度、術(shù)中螺釘重植次數(shù)以及術(shù)后并發(fā)癥；術(shù)后行CT評(píng)價(jià)椎弓根螺釘位置。結(jié)果 平均單個(gè)椎體注冊(cè)約6.3±2.1min；平均釘?shù)罍?zhǔn)備時(shí)間約2.6±1.3min；平均術(shù)中出血量約253±70ml；平均 “C”型臂照射約3.5±0.5次；平均導(dǎo)航精度約0.9±0.1mm。根據(jù)Richter法評(píng)估，其中優(yōu)70枚，良5枚，差1枚，優(yōu)良率98.68%；術(shù)中重植螺釘4枚，重植率5.26%。共隨訪到患者10例（3-7月），均無明顯神經(jīng)系統(tǒng)陽(yáng)性體征。結(jié)論 在神經(jīng)導(dǎo)航輔助下, 術(shù)者可以實(shí)時(shí)監(jiān)測(cè)植入過程，前瞻性地判斷植入椎弓根釘?shù)拇笮?、位?/span>, 使椎弓根螺釘植入有較高的準(zhǔn)確性和安全性。

[關(guān)鍵詞] 神經(jīng)導(dǎo)航 椎弓根螺釘 脊柱 內(nèi)固定手術(shù)

Clinical application of a neuronavigation system in the spinal fixation surgery

Yu qi, Zhao hong-yu, Liu yun-hui

The Department of Neurosurgery of Shengjing Hospital Affiliated to China Medical University, Shenyang 110004,China.

[Abstract]Objective To explore the accuracy and short term effect of the pedicle screws placement assisted by a neuronavigation system in the spinal surgery. Methods 76 pedicle screws insertion were accomplished in 17 cases assisted by a neuronavigation system. The single vertebral registration time, screw channel preperation time, intraoperative blood loss, uses of "C"-arm, accuracy of the neuronavigation, times of pedicle screws re-implanted and the complications were recorded. The locations of pedicle screws were evaluated by postoperative CT scan. Results Average single vertebral registration time was about 6.3±2.1min; Averagescrew channel preperation time wasabout 2.6±1.3min; Average intraoperative blood loss was about 253±70ml; Average uses of "C"-arm was about 3.5±0.5 times; Average accuracy of the neuronavigation was about 0.9±0.1mm. The assessment of pedicle screws were carried out according to Richter et al. In all the pedicle screws inserted, 70 were excellent, 5 were good, and only 1 was bad, theexcellent and good rate was 98.68%. There were 4 pedicle screws(5.26%) re-implanted in the operation. 10 patients werefollowed up for 3-7 months, and there were no positive neurological signs. Conclusions With the help of neuronavigation, the procedure of the insertion were real-time monitored, and the size, location of the pedicle screws were evaluated prospectively, which will improves theaccuracy and security.

[Key words] Neuronavigation; Pedicle screws; Spine; Internal fixation

神經(jīng)導(dǎo)航外科是微侵襲神經(jīng)外科重要組成部分，近十年來在脊髓脊柱神經(jīng)外科領(lǐng)域發(fā)展迅速，其直觀、客觀、精準(zhǔn)的優(yōu)勢(shì)日益被廣大醫(yī)師認(rèn)可。我科自2012年5月至2013年8月在神經(jīng)導(dǎo)航輔助下完成脊柱固定手術(shù)17例, 取得了滿意的效果, 特報(bào)道如下。

1.對(duì)象與方法

1.1一般資料

本組男性11例, 女性6例, 年齡31~ 62歲, 平均48.4±12.3歲。術(shù)后病理顯示12例為神經(jīng)鞘瘤患者（C₃~C₇者1例，T₅~T₁₂者5例，L₁~L₄者6例），其中2例腫瘤呈啞鈴型; 1例為脊膜瘤（C₇~T₁）；1例為室管膜瘤（L₁~L₂）；2例為腰椎退行性變患者（L₃~L₅）；1例為脊髓腹側(cè)海綿狀血管瘤患者（C₁~C₂）。

1.2 術(shù)前準(zhǔn)備及導(dǎo)航計(jì)劃

導(dǎo)航設(shè)備為德國(guó)BrainLAB Kolibri導(dǎo)航系統(tǒng)，軟件版本為VV Spine 5.6。術(shù)前將脊柱平掃CT（層高1-2mm，格式為DICOM）通過光盤或網(wǎng)絡(luò)傳送至導(dǎo)航工作站，完成三維圖像重建及導(dǎo)航計(jì)劃并保存至工作站硬盤。

1.3 神經(jīng)導(dǎo)航實(shí)時(shí)引導(dǎo)下手術(shù)及內(nèi)固定

手術(shù)當(dāng)日患者全麻后取俯臥位，依據(jù)術(shù)前定位片或“C”型臂確定病變節(jié)段。將紅外線機(jī)臂置于患者頭側(cè)，調(diào)整至合適距離（1.5～2m），注意與參考球架之間避免遮擋。暴露預(yù)定節(jié)段棘突，將參考球架固定在棘突上，注意與棘突方向平行。依次完成20個(gè)點(diǎn)的匹配注冊(cè)(圖1)，導(dǎo)航系統(tǒng)會(huì)自動(dòng)計(jì)算導(dǎo)航精度，誤差<2.0mm< span="">時(shí)認(rèn)為注冊(cè)成功，誤差越小，匹配越準(zhǔn)。以探針棒分別指示棘突、上下椎關(guān)節(jié)、橫突等結(jié)構(gòu)檢驗(yàn)導(dǎo)航系統(tǒng)準(zhǔn)確性。注冊(cè)完成后即可在神經(jīng)導(dǎo)航指引下選擇椎弓根螺釘?shù)娜朦c(diǎn)和方向、模擬選擇椎弓根螺釘?shù)闹睆胶烷L(zhǎng)度, 模擬螺釘?shù)耐泛蜕疃?/span>, 實(shí)時(shí)監(jiān)測(cè)螺釘?shù)倪M(jìn)入位置和方向（圖2，圖3）。待所有螺釘植入后，切除棘突及后椎板等結(jié)構(gòu)，切開硬脊膜并處理病變，嚴(yán)密縫合硬膜，最后安裝內(nèi)固定附屬器。

1.4 術(shù)后處理

術(shù)后持續(xù)切口引流，待引流量< 50 mL/d 后拔除引流管。術(shù)后24 h 常規(guī)給予抗生素預(yù)防切口感染。術(shù)后臥床4周，之后戴支具逐漸坐起。

1.5 療效評(píng)價(jià)指標(biāo)

評(píng)估所有患者的單個(gè)椎體注冊(cè)時(shí)間、釘?shù)罍?zhǔn)備時(shí)間、術(shù)中出血量、術(shù)中“C”型臂照射次數(shù)、導(dǎo)航精度、術(shù)中椎弓根螺釘重植次數(shù)及術(shù)后并發(fā)癥。術(shù)后行CT檢查，采用Richter法^[1]對(duì)椎弓根螺釘位置進(jìn)行評(píng)估：優(yōu)，螺釘完全位于椎弓根內(nèi)；良，僅有螺釘穿出椎弓根峽部皮質(zhì)（不超過螺釘直徑的1/4）；差，螺釘明顯穿出椎弓根峽部（超過螺釘直徑的1/4）。

1.6 統(tǒng)計(jì)學(xué)方法

采用SPSS19.0統(tǒng)計(jì)軟件進(jìn)行分析，計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差表示。

2.結(jié)果

本研究17例患者均成功完成手術(shù)，無神經(jīng)、血管損傷等嚴(yán)重并發(fā)癥發(fā)生。共植入螺釘76枚（頸椎12枚、胸椎20枚、腰椎44枚），平均單個(gè)椎體注冊(cè)用時(shí)約6.3±2.1min（自導(dǎo)航參考架固定起計(jì)時(shí)）；平均釘?shù)罍?zhǔn)備時(shí)間約2.6±1.3min；平均術(shù)中出血量約253±70ml；平均術(shù)中“C”型臂照射次數(shù)3.5±0.5次；平均導(dǎo)航精度0.9±0.1mm。根據(jù)Richter法評(píng)估螺釘植入位置，其中優(yōu)70枚，良5枚，差1枚，優(yōu)良率98.68%；術(shù)中重植螺釘4枚，重植率5.26%。共隨訪到患者10例，隨訪時(shí)間3~7個(gè)月，均無明顯神經(jīng)系統(tǒng)陽(yáng)性體征。經(jīng)X線或CT檢查無脫釘、斷釘情況。2例患者術(shù)后出現(xiàn)一過性發(fā)熱，經(jīng)對(duì)癥治療后好轉(zhuǎn)。

3.討論

脊髓脊柱手術(shù)會(huì)醫(yī)源性地造成脊柱穩(wěn)定性的破壞，患者術(shù)后可能出現(xiàn)脊柱畸形、脊髓受壓、神經(jīng)功能障礙等不良并發(fā)癥。近年來，已有部分神經(jīng)外科醫(yī)師將椎弓根螺釘內(nèi)固定技術(shù)應(yīng)用于脊髓手術(shù)后的脊柱內(nèi)固定手術(shù)。由于螺釘?shù)闹踩氪嬖谝欢ǖ氖д`率，其結(jié)果可導(dǎo)致固定系統(tǒng)強(qiáng)度下降甚至失效，以及神經(jīng)、血管、內(nèi)臟的損傷^[2-3]。神經(jīng)導(dǎo)航的出現(xiàn)很好的解決了這個(gè)技術(shù)難題，其精準(zhǔn)定位的特點(diǎn)能夠?qū)崿F(xiàn)計(jì)算機(jī)實(shí)時(shí)控制狀態(tài)下的椎弓根螺釘植入，確保手術(shù)安全^[4]。

3.1 神經(jīng)導(dǎo)航能夠提高椎弓根螺釘植入的準(zhǔn)確性及安全性

本研究中植入螺釘?shù)臏?zhǔn)確率可以達(dá)到98.68%，與文獻(xiàn)報(bào)道相當(dāng)^[5-7]。本組研究雖未設(shè)立同期對(duì)照組，但通過回顧性分析類似研究的文獻(xiàn)表明，傳統(tǒng)徒手植入螺釘?shù)臏?zhǔn)確率約68.1%~83.8%^[8-10]，神經(jīng)導(dǎo)航引導(dǎo)下植入螺釘?shù)臏?zhǔn)確率遠(yuǎn)高于徒手植入螺釘。本研究中所有患者術(shù)后均未出現(xiàn)明顯神經(jīng)系統(tǒng)損傷，僅有2例病人術(shù)后出現(xiàn)一過性發(fā)熱，但無神經(jīng)系統(tǒng)感染。考慮由于神經(jīng)外科手術(shù)常需要打開硬脊膜，少量的腦脊液滲漏及植入物均是造成發(fā)熱原因。因此，嚴(yán)密縫合硬脊膜是避免術(shù)后出現(xiàn)神經(jīng)系統(tǒng)感染及植入螺釘失敗的關(guān)鍵所在。

3.2 神經(jīng)導(dǎo)航能夠縮短手術(shù)時(shí)間，減少放射線輻射

與傳統(tǒng)方法中置釘?shù)母鱾€(gè)環(huán)節(jié)需要在“C”型臂下反復(fù)定位、確認(rèn)相比，神經(jīng)導(dǎo)航可以實(shí)時(shí)顯示椎弓根釘?shù)闹萌脒^程， 包括開口、攻絲、上螺釘，尤其對(duì)于發(fā)育細(xì)小、形態(tài)不規(guī)則的椎弓根，更能夠準(zhǔn)確快速置釘。Shin ^[11]等報(bào)道，傳統(tǒng)方法釘?shù)罍?zhǔn)備時(shí)間約3.7min，本研究中平均釘?shù)罍?zhǔn)備時(shí)間約2.6±1.3min，可在一定程度上縮短手術(shù)時(shí)間。在實(shí)際手術(shù)操作中，筆者體會(huì)到，對(duì)于頸段（C₃~C₆）、下胸段（T₁₀~T₁₂）、腰段（L₁~L₅），由于椎體形態(tài)變化較小，相對(duì)位置較固定，在某一椎體注冊(cè)完成后，相鄰椎體仍有較高的導(dǎo)航精度，而不需要重復(fù)注冊(cè)，這為節(jié)省手術(shù)時(shí)間創(chuàng)造了很大便利。此外，由于神經(jīng)導(dǎo)航能夠減少“C”型臂的使用次數(shù)，降低了術(shù)中放射線輻射，對(duì)醫(yī)護(hù)人員以及患者都有很好的保護(hù)作用^[12-13]。

3.3 應(yīng)用神經(jīng)導(dǎo)航的注意事項(xiàng)

①導(dǎo)航注冊(cè)過程使用表面匹配的注冊(cè)方式，三維重建時(shí)需要注意調(diào)整閾值，使脊柱骨質(zhì)完全在三維影像中呈現(xiàn)，閾值多選120-180。②在導(dǎo)航注冊(cè)過程中要保證棘突完整，注冊(cè)過程中需使用尖頭探針，使所獲取的點(diǎn)在脊柱骨質(zhì)表面而非在肌肉和筋腱組織上，并保證取點(diǎn)時(shí)不會(huì)產(chǎn)生滑動(dòng)。③導(dǎo)航注冊(cè)過程中獲取匹配注冊(cè)點(diǎn)時(shí)，需注意一定要在同一椎體上。④導(dǎo)航注冊(cè)一旦開始，參考球架不能發(fā)生任何位移，如產(chǎn)生位移則需要重新注冊(cè)。⑤驗(yàn)證導(dǎo)航注冊(cè)精度需多點(diǎn)驗(yàn)證，并輔以實(shí)時(shí)跟蹤尖頭探針的滑動(dòng)來驗(yàn)證導(dǎo)航的準(zhǔn)確性。⑥在注冊(cè)和導(dǎo)航使用過程中參考球架需保持小角度傾斜朝向?qū)Ш綑C(jī)臂。

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