摘要目的 探讨在治疗Ⅰ型神经纤维瘤病(neurofibromatosis type Ⅰ,NF1)合并营养不良性脊柱侧凸患者过程中应用O-arm三维导航系统的矫形效果及临床疗效.方法 回顾性分析2012年6月至2014年10月南京大学医学院附属鼓楼医院脊柱外科收治的41例NF1合并营养不良性脊柱侧凸并规律性随访18个月以上患者的资料,其中18例采用O-arm导航辅助置钉(O-arm三维导航组),23例采用C形臂X线机透视辅助下徒手置钉(徒手置钉组),术后及随访时行站立位全脊柱正侧位X线检查.计量资料以(－x)±s表示,采用t检验进行统计学分析;采用行×列x2检验分析不同手术组螺钉置入的准确性.结果 O-arm三维导航组和徒手置钉组NF1合并营养不良性脊柱侧凸患者术前冠状面Cobb角分别为63.2°±8.7°和66.9°±7.4°(P＞0.05),术后分别为23.1°±6.8°和30.2°±7.6°(t=2.231,P=0.031).O-arm三维导航组平均手术时间为(265.0±70.3)min,出血量为(1 024±465) ml;徒手置钉组平均手术时间为(243.0±49.6)min,出血量为(1 228±521)ml.两组患者手术时间和出血量的差异均无统计学意义(P值均＞0.05).随访截至2016年6月,平均随访(20.9±3.4)个月.O-arm三维导航组18例患者平均随访(20.3±3.1)个月,徒手置钉组23例患者平均随访(21.4±5.5)个月.O-arm三维导航组18例患者顶椎区共置入122枚螺钉,其中优89枚(72.9％),良27枚(22.1％),差6枚(4.9％),优良率为95.1％.徒手置钉组23例患者对应顶椎区共置入136枚螺钉,优66枚(48.5％),良46枚(33.8％),差24枚(17.6％),优良率为82.4％.O-arm三维导航组顶椎区置钉精确性较徒手置钉组高,差异有统计学意义(x2=10.140,P＜0.05).此外,O-arm三维导航组顶椎区平均植入物密度为(64.1±10.8)％,高于徒手置钉组的(44.3±15.3)％(t=4.652,P=0.000).末次随访时,O-arm三维导航组矫正丢失4.1°±1.5°,小于徒手置钉组的6.3°±2.6°,差异有统计学意义(t=2.719,P=0.009).结论 应用O-arm三维导航系统可提高NF1合并营养不良性脊柱侧凸患者的置钉精确性,提高顶椎区植入物密度,减少术后矫正丢失发生率,同时未增加手术时间和术中出血量.

abstractsObjective To investigate the clinical outcomes and the accuracy of O-arm-navigation system assisted pedicle screw insertion in dystrophic scoliosis secondary to neurofibromatosis type Ⅰ (NF-1).Methods A retrospective study was conducted in 41 patients with dystrophic NF-1-associated thoracic scoliosis who were surgically treated at Department of Orthopaedics,Nanjing Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School between June 2012 and October 2014 with more than 18 months follow-up.The patients were then divided into two groups:18 patients were under the assistance of O-arm-navigation-based pedicle screw insertion (O-arm group) and the remaining 23 patients' pedicle screws insertion were conducted by free-hand (free-hand group).The X-ray and CT were analyzed to investigate the correction rate and safety of pedicle insertion.t-test was used to analyze measurement data and x2 test was used to analyze accuracy of screw insertion between the two groups.Results The mean coronal Cobb angle was 63.2° ±8.7° in the O-arm group and 66.9° ±7.4° in the free-hand group (P＞ 0.05),which was then corrected into 23.1° ±6.8° and 30.2° ±7.6° (t =2.231,P =0.031) after surgery respectively.Operation time was (265.0±70.3)minutes and estimated blood loss was (1 024±465)ml in the O-arm group.Operation time and estimated blood loss was (243.0±49.6)minutes and (1 228±521)ml respectively in the free-hand group,which had no significant difference between the two groups.However,the implant density was higher in the O-arm group than that in the free-hand group ((64.1 ± 10.8) ％ vs.(44.3± 15.3) ％) (t =4.652,P =0.000).The O-arm group comprised 122 screws,of which 72.9％ were excellent,22.1％ were good and 4.9％ were bad.The free-hand group comprised 136 screws and 48.5％ of them were excellent,33.8％ were good and 17.6％ were bad.Accuracy of pedicle screw insertion was higher in the O-arm group than that in the free-hand group(x2=10.140,P＜0.05).By June 2016,the average follow-up period was (20.9±3.4) months(ranging from18 to 26 months),including (20.3±3.1) months in the O-arm group and (21.4±5.5)months in the free-hand group.At last follow-up point,coronal correction loss was significantly higher in the free-hand group than that in the O-arm group (6.3°±2.6° vs.4.4°±1.6°) (t =2.719,P =0.009).Conclusions Compared with free-hand technique,O-arm-navigation technique could enhance accuracy of pedicle insertion and implant density of dystrophic region in dystrophic NF-1-associated scoliosis patients,which result in a better correction rate and less correction loss.Besides,the advantage of O-arm-navigation do not increase operative time and estimate blood loss.