Schiffer G, Goldmann S, Faymonville C, Müller L, Stein G
Unfallchirurgie, Handchirurgie und Orthopädie, Vinzenz Pallotti Hospital, Bergisch Gladbach.
Unfall-, Hand- und Ellenbogenchirurgie, Uniklinik Köln.
Z Orthop Unfall. 2016 Oct;154(5):483-487. doi: 10.1055/s-0042-105957. Epub 2016 Jun 13.
Placing transpedicular screws in the cervical spine is a special challenge for spine surgeons, due to the anatomical features of this part of the spine. During the last 15 years, computer-aided navigation systems have been developed to facilitate this procedure and to make it safer for patients. One option is navigation by intraoperatively acquired data sets with the use of an 3D C-arm. Our retrospective study evaluates transpedicular screws in the cervical spine placed by 3D C-arm navigation, within a 6 year period in a level 1 trauma centre. We recorded epidemiological data, operation time and especially general adverse events, as well as revision surgery, including reasons for revision. We used a C-arm Arcardis Orbic 3D (Siemens, Munich), connected to a navigation system (VectorVision, Brainlab, Munich). Between July 2007 and July 2013, 207 transpedicular screws were placed in 58 patients. The main indications were trauma (69 %), rheumatic diseases (20.7 %) and tumour (8.6 %). The most commonly instrumented cervical spine segments were C2 (53.5 %)%), C7 (10.3 %) and C5 (8.6 %). In nearly 95 % of the cases, we performed an intraoperative 3D scan after screw or k-wire placement to control the screw position. We found unacceptable malposition in 7.2 % of patients. This was corrected at once. Ten patients had to be revised: seven times due to wound problems, twice because of implant failure and once for treatment of CSF leakage. Three screws (1.5 %) led to injuries of the vertebral artery, once with a lethal outcome. Analysis of these cases showed that the 3D scan gave reduced data quality, due to reduced bone density or anatomical factors. Intraoperative 3D C-arm navigation seems to be a reliable option for transpedicular screw placement in the cervical spine. Complication rates were comparable to published values. 7.2 % of all screws were corrected intraoperatively after a control scan. Therefore possible revisions could be avoided during primary surgery. Analysis of problematic cases led to a change in our treatment strategy: in patients with poor bone quality and/or anatomical problems which lead to 3D scans of poor quality, we avoid transpedicular screw placement in C6 or higher, in order to prevent injuries of the vertebral artery.
由于颈椎的解剖学特征，对于脊柱外科医生而言，在颈椎中置入椎弓根螺钉是一项特殊挑战。在过去15年中，已开发出计算机辅助导航系统以促进该手术并使其对患者更安全。一种选择是使用3D C型臂通过术中获取的数据集进行导航。我们的回顾性研究评估了在一家一级创伤中心6年期间通过3D C型臂导航在颈椎中置入的椎弓根螺钉。我们记录了流行病学数据、手术时间，特别是一般不良事件以及翻修手术，包括翻修原因。我们使用了连接到导航系统（VectorVision，Brainlab，慕尼黑）的C型臂Arcardis Orbic 3D（西门子，慕尼黑）。在2007年7月至2013年7月期间，58例患者中共置入207枚椎弓根螺钉。主要适应症为创伤（69%）、风湿性疾病（20.7%）和肿瘤（8.6%）。最常置入螺钉的颈椎节段为C2（53.5%）、C7（10.3%）和C5（8.6%）。在近95%的病例中，我们在置入螺钉或克氏针后进行了术中3D扫描以控制螺钉位置。我们发现7.2%患者的螺钉位置存在不可接受的错位，并立即进行了纠正。10例患者需要进行翻修：7次是由于伤口问题，2次是由于植入物失败，1次是由于脑脊液漏的治疗。3枚螺钉（1.5%）导致椎动脉损伤，其中1例导致死亡。对这些病例的分析表明，由于骨密度降低或解剖学因素，3D扫描的数据质量下降。术中3D C型臂导航似乎是颈椎椎弓根螺钉置入的可靠选择。并发症发生率与已发表的值相当。在控制扫描后，所有螺钉中有7.2%在术中得到纠正。因此可以避免一期手术期间可能的翻修。对有问题病例的分析导致我们的治疗策略发生改变：对于骨质质量差和/或存在解剖学问题导致3D扫描质量差的患者，我们避免在C6或更高节段置入椎弓根螺钉，以防止椎动脉损伤。
