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经口枢椎前移旋转截骨减压内固定技术的影像解剖学研究及临床应用

Imaging anatomical study and clinical application of transoral axis slide and rotation osteotomy technique

摘要:

目的:设计经口枢椎前移旋转截骨减压内固定术(axis slide and rotation osteotomy,ASRO),测量该术式截骨相关的影像解剖学参数,并探讨其临床应用价值。方法:选取90例颈椎CT数据,男54例,女36例;年龄26~72岁,平均48.7岁。基于Mimics软件进行CT三维重建,拟于枢椎椎体两侧行前后向截骨,测量最小截骨角度、最大截骨角度、截骨轨迹距关节面内侧最小距离、截骨轨迹距关节面内侧最大距离、枢椎侧块上关节面内外侧距离、枢椎截骨面上缘、下缘及最窄处截骨深度。收治1例56岁枕颈融合失败寰枢椎脱位的女性患者,症状为行走困难伴四肢无力及皮肤深、浅感觉明显减退。影像学提示后方钢丝与前方枢椎椎体后上缘之间的空间非常狭窄,自前方和后方压迫脊髓。在神经电生理监护下对该患者行ASRO手术,并在术后测量患者截骨角度、截骨深度、上颈椎椎管最窄距离、延髓脊髓角度,采用颈椎日本骨科协会(Japanese Orthopaedic Association Scores,JOA)评分评价术后疗效。结果:ASRO最小、最大截骨角度分别为14.7°±4.36°和33.0°±8.67°,截骨轨迹距关节面内侧最小距离、最大距离分别为(6.0±1.80) mm和(12.2±3.17) mm,枢椎侧块上关节面内外侧距离为(17.2±1.90) mm,截骨轨迹距关节面内侧最小距离、最大距离与上关节面内外侧距离的比值分别为34%±8.7%和70%±15.0%;枢椎截骨面上端、下端及最窄处截骨深度分别为(18.1±1.47) mm、(13.7±2.67) mm和(9.9±1.53) mm。患者术后影像学显示截骨角度为17.1°(左侧)和16.5°(右侧),枢椎截骨面上端、下端及最窄处截骨深度左侧分别为17.1 mm、13.2 mm和9.1 mm和右侧分别为17.4 mm、11.8 mm、8.46 mm,均满足影像解剖学研究所示范围。患者上颈椎椎管最窄距离由6.58 mm增大至术后15.28 mm,延髓脊髓角度由131.7°增大至术后153.8°,提示术后椎管空间明显增加,脊髓前方压迫明显减轻。颈椎JOA评分由7分恢复至14分,患者症状明显改善。结论:ASRO技术可用于上颈椎后路手术失败的翻修,以及治疗由前方组织骨性融合导致的难复性脱位;通过前路对脊髓进行直接减压以避免齿突切除,是安全、可行的新技术。

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abstracts:

Objective:To introduce a novel technique note about anterior decompression through transoral axis slide and rotation osteotomy (ASRO) and identify its imaging parameters related to osteotomy, and to explore its clinical application value.Methods:CT data of cervical spine of 90 subjects were collected, including 54 males and 36 females. The age ranged from 26 to 72 years, with an average age of 48.7 years. The Mimics software was used to reconstruct the atlantoaxial three-dimensional model. We plan to perform osteotomy on both sides of the axis of the vertebral body in the anteroposterior direction and the ASRO related anatomical parameters were measured, including the minimum osteotomy angle, the maximum osteotomy angle, the minimum and maximumdistance between the osteotomy trajectory and the inner side of the articular surface, the length of the upper articular surface of the axis side mass, the depth of osteotomy at the highest point and lowest point of the axial osteotomy surface and the minimum osteotomy depth. A 56-year-old female patient was admitted to the hospital due to atlantoaxial dislocation with failure of occipital-cervical fusion, difficulty walking, weakness and hypoaesthesia in four limbs. Imaging revealed that narrow space between the transversal walking wire and upper-posterior of the odontoid process, compressing the spinal cord from the front and the back respectively. The ASRO technique was performed on the patient under neuro-electrophysiological monitoring, and the osteotomy angle, osteotomy depth, narrowest width of the upper cervical spinal canal, the medullary, spinal cord angle were measured and Japanese Orthopaedic Association Scores (JOA) cervical myelopathy evaluation were performed after the operation to evaluate the surgical treatment effect.Results:The minimum osteotomy angle and the maximum osteotomy angle was 14.7°± 4.36° and 33.0°± 8.67°. The minimum and maximumdistance between the osteotomy trajectory and the inner side of the articular surface, and the length of the upper articular surface of the axis side mass was 6.0±1.80 mm, 12.2±3.17 mm, and 17.2±1.90 mm, the ratio of the former two to the latter was 34%±8.7% and 70%± 15.0%. The depth of osteotomy at the upper edge, lower edge and narrowest place of the axial osteotomy surface were 6.0±1.80 mm, 12.2±3.17 mm and 17.2±1.90 mm. The postoperative imaging of the patient showed that the osteotomy angle was 17.1° on left side and 16.5° on right side, and the depth of osteotomy at the upper edge, lower edge and narrowest place of the axial osteotomy surface were 17.1 mm, 13.2 mm, and 9.1 mm on left side, and 17.4 mm, 11.8 mm, 8.46 mm on right side. All measured values met the ranges which were shown in the imaging anatomical study. The narrowest width of the upper cervical spinal canal increased from 6.58 mm to 15.28 mm, the medullary spinal cord angle increased from 131.7° to 153.8°postoperatively, and the cervical spine JOA score recovered from 6 points to 14 points, suggesting that the postoperative spinal canal space is obvious increased, the compression on the front of the spinal cord was significantly reduced. The patient's symptoms improved significantly.Conclusion:ASRO technique is a good choice for salvage of failed posterior occipitocervical fusion and some irreducible atlantoaxial dislocation because of the anterior bony fusion. It could direct decompress the spinal cord anteriorly, avoid the odontoid resection, which is a safe and feasible new technique.

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作者: 金海明 [1] 吴爱悯 [1] 王向阳 [1] 窦海成 [1] 盛孙仁 [1] 潘翔翔 [1] 黄崇安 [1] 林焱 [1]
期刊: 《中华骨科杂志》2022年42卷11期 675-684页 ISTICPKUCSCD
栏目名称: 临床论著
DOI: 10.3760/cma.j.cn121113-20210331-00270
发布时间: 2022-07-31
基金项目:
国家自然科学基金 浙江省自然科学基金 温州市基础性科研项目 National Nature Foundation of China Natural Science Foundation of Zhejiang Province Basic scientific research project of Wenzhou
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