Nottmeier Eric W, Seemer Will, Young Phillip M
Departments of Neurosurgery, University of North Florida, Jacksonville, Florida, USA.
J Neurosurg Spine. 2009 Jan;10(1):33-9. doi: 10.3171/2008.10.SPI08383.
The goal of this study was to analyze the placement accuracy and complications of thoracolumbar pedicle screws (PSs) inserted using 3D image guidance in a large patient cohort.
The authors reviewed the charts of 220 consecutive patients undergoing posterior spinal fusion using 3D image guidance for instrumentation placement. A total of 1084 thoracolumbar PSs were placed using either the BrainLAB Vector Vision (BrainLAB, Inc.) or Medtronic StealthStation Treon (Medtronic, Inc.) image guidance systems. Postoperative CT scanning was performed in 184 patients, allowing for 951 screws to be graded by an independent radiologist for bone breach. All complications resulting from instrumentation placement were noted. Using the intraoperative planning function of the image-guided system, the largest diameter screw possible in each particular case was placed. The screw diameter of instrumentation placed into the L3-S1 levels was noted.
No vascular or visceral complications occurred as a result of screw placement. Two nerve root injuries occurred in 1084 screws placed, resulting in a 0.2% per screw incidence and a 0.9% patient incidence of nerve root injury. Neither nerve root injury was associated with a motor deficit. The breach rate was 7.5%. Grade 1 and minor anterolateral "tip out" breaches accounted for 90% of the total breaches. Patients undergoing revision surgery accounted for 46% of the patients in this study. Accordingly, 154 screws placed through previous fusion mass could be evaluated using postoperative CT scanning. The breach rate in this specific cohort was 7.8%. A total of 765 PSs were placed into the L3-S1 levels in this study; 546 (71%) of these screws were > or = 7.5 mm in diameter. No statistical difference in breach rate was noted in PSs placed through revision spinal levels versus nonrevision spinal levels (p = 0.499). Additionally, no increase in breach rate was noted with placement of 7.5-mm-diameter screws.
Three-dimensional image guidance is a useful adjunct to placement of spinal instrumentation. The complication rate in this study was low, and accurate placement of instrumentation was achieved despite the high percentage of revision surgery cases in our patient population. Additionally, because active fluoroscopy was not used for instrumentation placement, there was minimal to no radiation exposure to the surgeon or operating room staff.
本研究的目的是分析在一大群患者中使用三维图像引导置入胸腰椎椎弓根螺钉（PSs）的置入准确性和并发症情况。
作者回顾了220例连续接受后路脊柱融合术并使用三维图像引导进行器械置入的患者病历。使用BrainLAB Vector Vision（BrainLAB公司）或美敦力StealthStation Treon（美敦力公司）图像引导系统共置入了1084枚胸腰椎PSs。184例患者术后进行了CT扫描，由一名独立放射科医生对951枚螺钉进行骨皮质穿破分级。记录器械置入引起的所有并发症。利用图像引导系统的术中规划功能，在每个特定病例中置入尽可能大直径的螺钉。记录置入L3 - S1节段的器械的螺钉直径。
螺钉置入未导致血管或内脏并发症。在置入的1084枚螺钉中有2例神经根损伤，导致每枚螺钉的发生率为0.2%，患者神经根损伤发生率为0.9%。两例神经根损伤均未伴有运动功能障碍。骨皮质穿破率为7.5%。1级和轻微的前外侧“尖端穿出”型骨皮质穿破占总穿破的90%。接受翻修手术的患者占本研究患者的46%。因此，可通过术后CT扫描评估154枚通过既往融合块置入的螺钉。该特定队列中的骨皮质穿破率为7.8%。本研究中共有765枚PSs置入L3 - S1节段；其中546枚（71%）螺钉直径≥7.5 mm。翻修脊柱节段与非翻修脊柱节段置入的PSs的骨皮质穿破率无统计学差异（p = 0.499）。此外，置入7.5 mm直径螺钉时骨皮质穿破率未增加。
三维图像引导是脊柱器械置入的有用辅助手段。本研究中的并发症发生率较低，尽管我们患者群体中翻修手术病例的比例较高，但仍实现了器械的准确置入。此外，由于器械置入未使用术中透视，术者和手术室工作人员所受辐射极少或无辐射暴露。
