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中华老年骨科与康复电子杂志

中华老年骨科与康复电子杂志 ›› 2019, Vol. 05 ›› Issue (03) : 123 -129. doi: 10.3877/cma.j.issn.2096-0263.2019.001

所属专题： 文献；

腰椎

皮质骨通道螺钉技术在腰椎退变性疾病中的临床应用
赵永辉1, 陆声1,†(), 马宇龙1, 施荣茂1, 王龙1, 梁金龙1, 陈太邦1, 罗浩天1, 徐永清1   
  1. 1. 650032　昆明，中国人民解放军联勤保障部队第九二〇医院创伤骨科研究所
  • 收稿日期:2018-10-04 出版日期:2019-06-05
  • 通信作者: 陆声
  • 基金资助:
    云南省重大科技专项计划-重大科技专项（生物医药）(2017ZF025)

Clinical application of cortical bone screw technique in elderly patients with lumbar degenerative diseases

Yonghui Zhao1, Sheng Lu1,†(), Yulong Ma1, Rongmao Shi1, Long Wang1, Jinlong Liang1, Taibang Chen1, Haotian Luo1, Yongqing Xu1   

  1. 1. Department of Orthopedic Surgery, The 920rd Hospital of Joint Logistics Support Force, Kunming 650032, China
  • Received:2018-10-04 Published:2019-06-05
  • Corresponding author: Sheng Lu
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引用本文：

赵永辉, 陆声, 马宇龙, 施荣茂, 王龙, 梁金龙, 陈太邦, 罗浩天, 徐永清. 皮质骨通道螺钉技术在腰椎退变性疾病中的临床应用[J]. 中华老年骨科与康复电子杂志, 2019, 05(03): 123-129.

Yonghui Zhao, Sheng Lu, Yulong Ma, Rongmao Shi, Long Wang, Jinlong Liang, Taibang Chen, Haotian Luo, Yongqing Xu. Clinical application of cortical bone screw technique in elderly patients with lumbar degenerative diseases[J]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2019, 05(03): 123-129.

目的

探讨经椎弓根皮质骨通道（CBT）螺钉内固定技术在腰椎退变性疾病中的临床疗效。

方法

回顾性收集中国人民解放军联勤保障部队第九二〇医院2016年8月~2018年5月间收治的腰椎退变性疾病患者53例，均行经后路椎管减压椎间植骨融合内固定手术治疗，其中23例应用CBT螺钉技术，30例应用传统椎弓根螺钉技术，分别观察两组患者手术时间、术中出血量、VAS评分、JOA评分和改善率以及术后恢复情况、有无并发症等，综合评价临床疗效。

结果

所有患者均获得随访，随访时间为3~18个月，平均（12±4）个月。手术置钉过程中均未出现螺钉把持力不足、峡部或椎弓根劈裂以及在置钉过程中引起的血管、神经损伤等情况。两组患者症状均得到不同程度改善，术后JOA评分[CBT组：（23.7±2.3）分，传统组：（23.9±2.0）分]和VAS评分[CBT组：（1.2±0.7）分，传统组：（1.3±0.8）分]均较术前降低[JOA评分：CBT组：（9.1±2.7）分，传统组：（10.3±2.0）分；VAS评分：CBT组：（5.3±1.2）分，传统组：（5.4±1.2）分；]，差异均具有统计学意义（均P<0.05）两组间比较手术时间[CBT组：单节段为（2.0±0.3）h，双节段为（2.8±0.4）h。传统组：单节段为（2.1±0.3）h，双节段为（3.0±0.2）h]、术后VAS评分[（CBT组：（1.2±0.7）分，传统组：（1.3±0.8）分]和JOA评分[（CBT组：（23.7±2.3）分，传统组：（23.9±2.0）分]无明显统计学差异，但CBT螺钉组的术中出血量[（单节段：（297±48）ml，双节段：（367±41）ml]少于传统椎弓根螺钉组[（单节段：（347±44）ml，双节段：（427±46）ml]（t=-3.209，t=-2.692，P<0.05）。术后影像学随访均未见螺钉松动、尾冒脱落、钉棒断裂、椎间隙高度丢失、椎间融合器位移等不良事件的发生。

结论

应用CBT螺钉内固定技术治疗腰椎退变性疾病是一种手术创伤更小、术后恢复更快且安全可靠、固定有效的置钉方法。

关键词: 椎弓根螺钉, 脊柱, 腰椎
Objective

To investigate the clinical outcome of application of transpedicular cortical bone trajectory (CBT) screw fixation in lumbar degenerative diseases.

Methods

A retrospective research based on the collection of 53 lumbar degenerative disease cases, who underwent posterior spinal canal decompression and interbody fusion since August 2016 to May 2018, in 920 hospital of the PLA Joint Logistic Unit. 23 cases were treated with CBT screw technique and 30 cases were treated with traditional pedicle screw technique. The operation time, intraoperative blood loss, VAS score, JOA score and improvement rate and postoperative functional restoration, clinical complications has been observed in the two groups for comprehensive evaluation of clinical efficacy.

Results

All patients received an average of (12±4) months (3-18 months) follows up. During the screw placement process, no insufficient holding of screws, isthmus or pedicle cleft palate occurred, blood vessel and nerve damage caused by the screw placement process as well. The symptoms of the two groups showed various degree of improvement. Postoperative JOA scores (CBT group: 23.7±2.3, pedicle screw group: 23.9±2.0) and VAS scores (CBT group: 1.2±0.7, pedicle screw group: 1.3±0.8) were improved compared with preoperative (CBT group: 5.3±1.2, pedicle screw group: 5.4±1.2). The operation time was compared between the two groups (CBT group: single segment was 2.0±0.3 h, double segment was 2.8±0.4 h. pedicle screw group: single segment 2.1±0.3 h, double segment 3.0±0.2 h), postoperative VAS score (CBT group: 1.2±0.7, pedicle screw group: 1.3±0.8) and JOA scores (CBT group: 23.7±2.3 points, pedicle screw group: 23.9±2.0 points) had no statistically significant difference, but the intraoperative blood loss of the CBT screw group (single segment: 297±48 ml, double segment: 367±41 ml) was less than the pedicle screw group (single segment: 347±44 ml, double segment: 427±46 ml)(t=-3.209, t=-2.692, P<0.05). No postoperative adverse events such as loose screws, tail screw detachment, broken screws loss of intervertebral space, and intervertebral cage displacement have been observed.

Conclusion

CBT screw for the treatment of lumbar degenerative disease is a less trauma, faster postoperative recovery, safe and reliable screw placement method.

Key words: Pedicle screws, Spine, Lumbar Vertebrae
表1 两组患者的年龄、性别、疾病名称及手术固定节段比较
组别 例数 性别（例） 年龄（岁，±s） 疾病类型（例） 手术节段（例）
男 女 腰椎管狭窄症 腰椎间盘突出症 腰椎滑脱症 单节段 双节段
CBT组 23 9 14 56±8 15 5 3 17 6
传统组 30 12 18 65±5 21 4 5 18 12
统计值   χ2=0.004 t=4.735 χ2=0.699 χ2=1.124
P值   0.949 0.785 0.705 0.289
图10~11 安装好内固定装置后术中再次透视确定螺钉和椎间融合器的位置
图18~30 男性，70岁，L3~L4椎管狭窄症伴L3~L5骨折。图18~19患者矢状位和横断面MRI，显示L3~L4节段明显狭窄且L3~L5椎体楔形变；图20~21腰椎CT正位和侧位片，可见L3~L4椎间隙狭窄、L3~L5椎体楔形变；结合患者症状及体征，选择L2~L4后路皮质骨螺钉固定，L3~L4节段减压椎间融合，L5椎体骨水泥强化；图22~23术后腰椎正位及侧位片，显示内固定位置良好；图24术后CT矢状位，可见螺钉的位置以及横断面螺钉的位置；图25 L2横断面；图26 L3横断面；图27 L4横断面；图28 L5横断面，可见骨水泥的弥散范围；图29~30术后3个月复查腰椎正侧位片，示内固定装置在位，螺钉无松动、拔钉，椎间融合器无移位
表2 传统螺钉和CBT螺钉两组间手术情况的比较
组别 例数 手术时间（h，±s） 出血量（ml，±s）
单节段 双节段 单节段 双节段
CBT螺钉组 23 2.0±0.3 2.8±0.4 297±48 367±41
传统螺钉组 30 2.1±0.3 3.0±0.2 347±44 427±46
统计值   t=-0.710 t=-0.767 t=-3.209 t=-2.692
P值   0.483 0.473 0.003 0.016
组别 例数 JOA评分（分，±s） t值 P值 VAS评分（分，±s） t值 P值
术前 术后 改善率% 术前 术后
CBT螺钉组 23 9.1±2.7 23.7±2.3 73.4% 19.669 <0.01 5.3±1.2 1.2±0.7 13.658 <0.01
传统螺钉组 30 10.3±2.0 23.9±2.0 72.8% 26.278 <0.01 5.4±1.2 1.3±0.8 15.608 <0.01
统计值   t=-1.805 t=-0.401 χ2=0.225     t=-0.517 t=-0.540    
P值   0.077 0.690 0.823     0.607 0.591    
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