Tian Wei, Xu Yunfeng, Liu Bo, Liu Yajun, He Da, Yuan Qiang, Lang Zhao, Lyu Yanwei, Han Xiaoguang, Jin Peihao
Medical Center, Tsinghua University, Beijing 100084, China; Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China. Email:
Medical Center, Tsinghua University, Beijing 100084, China; Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing 100035, China.
Chin Med J (Engl). 2014;127(22):3852-6.
Percutaneous pedicle screw use has a high rate of cranial facet joint violations (FVs) because of the facet joint being indirectly visualized. Computer-assisted navigation shows the anatomic structures clearly, and may help to lower the rate of FVs during pedicle screw insertion. This study used computed tomography (CT) to evaluate and compare the incidence of FVs between percutaneous and open surgeries employing computer-assisted navigation for the implantation of pedicle screw instrumentation during lumbar fusions.
A prospective study, including 142 patients having lumbar and lumbosacral fusion, was conducted between January 2013 and April 2014. All patients had bilateral posterior pedicle screw-rod instrumentation (top-loading screws) implanted by the same group of surgeons; intraoperative 3-dimensional computer navigation was used during the procedures. All patients underwent CT examinations within 6 months postoperation. The CT scans were independently reviewed by three reviewers blinded to the technique used.
The cohort comprised 68 percutaneous and 74 open cases (136 and 148 superior-level pedicle screw placements, respectively). Overall, superior-level FVs occurred in 20 patients (20/142, 14.1%), involving 27 top screws (27/284, 9.5%). The percutaneous technique (7.4% of patients, 3.7% of top screws) had a significantly lower violation rate than the open procedure (20.3% of patients, 14.9% of top screws). The open group also had significantly more serious violations than did the percutaneous group. Both groups had a higher violation rate when the cranial fixation involved the L5. A 1-level open procedure had a higher violation rate than did the 2- and 3-level surgeries.
With computer-assisted navigation, the placement of top-loading percutaneous screws carries a lower risk of adjacent-FVs than does the open technique; when FVs occur, they tend to be less serious. Performing a single-level open lumbar fusion, or the fusion of the L5-S1 segment, requires caution to avoid cranial adjacent FVs.
由于小关节是间接可视化的，经皮椎弓根螺钉置入术导致高位小关节侵犯（FV）的发生率较高。计算机辅助导航能清晰显示解剖结构，可能有助于降低椎弓根螺钉置入过程中FV的发生率。本研究采用计算机断层扫描（CT）评估并比较在腰椎融合术中采用计算机辅助导航的经皮手术和开放手术之间FV的发生率。
在2013年1月至2014年4月期间进行了一项前瞻性研究，纳入142例行腰椎和腰骶部融合术的患者。所有患者均由同一组外科医生植入双侧后路椎弓根螺钉-棒器械（顶装螺钉）；手术过程中使用术中三维计算机导航。所有患者在术后6个月内接受CT检查。CT扫描由三位对所使用技术不知情的审阅者独立评估。
该队列包括68例经皮手术和74例开放手术病例（分别有136枚和148枚上位椎弓根螺钉置入）。总体而言，20例患者（20/142，14.1%）发生高位FV，累及27枚顶装螺钉（27/284，9.5%）。经皮技术组患者的侵犯率（7.4%）和顶装螺钉的侵犯率（3.7%）显著低于开放手术组（患者为20.3%，顶装螺钉为14.9%）。开放手术组的侵犯也比经皮手术组严重得多。当高位固定涉及L5时，两组的侵犯率均较高。单节段开放手术的侵犯率高于双节段和三节段手术。
在计算机辅助导航下，顶装式经皮螺钉置入术比开放技术发生相邻FV的风险更低；当发生FV时，往往不太严重。进行单节段开放腰椎融合术或L5-S1节段融合术时，需要谨慎操作以避免高位相邻FV。
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