CN104224306A - Method for utilizing three-dimensional modeling for looking for optimum inserting point for inserting pedicle screw - Google Patents
Method for utilizing three-dimensional modeling for looking for optimum inserting point for inserting pedicle screw Download PDFInfo
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- CN104224306A CN104224306A CN201410517671.5A CN201410517671A CN104224306A CN 104224306 A CN104224306 A CN 104224306A CN 201410517671 A CN201410517671 A CN 201410517671A CN 104224306 A CN104224306 A CN 104224306A
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
- A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
- A61B17/68—Internal fixation devices, including fasteners and spinal fixators, even if a part thereof projects from the skin
- A61B17/70—Spinal positioners or stabilisers ; Bone stabilisers comprising fluid filler in an implant
- A61B17/7074—Tools specially adapted for spinal fixation operations other than for bone removal or filler handling
- A61B17/7091—Tools specially adapted for spinal fixation operations other than for bone removal or filler handling for applying, tightening or removing longitudinal element-to-bone anchor locking elements, e.g. caps, set screws, nuts or wedges
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
- A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
- A61B17/88—Osteosynthesis instruments; Methods or means for implanting or extracting internal or external fixation devices
- A61B17/90—Guides therefor
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B2017/00681—Aspects not otherwise provided for
- A61B2017/00707—Dummies, phantoms; Devices simulating patient or parts of patient
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/10—Computer-aided planning, simulation or modelling of surgical operations
- A61B2034/101—Computer-aided simulation of surgical operations
- A61B2034/105—Modelling of the patient, e.g. for ligaments or bones
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/10—Computer-aided planning, simulation or modelling of surgical operations
- A61B2034/108—Computer aided selection or customisation of medical implants or cutting guides
Abstract
The invention discloses a method for utilizing three-dimensional modeling for looking for an optimum inserting point for inserting a pedicle screw. The method comprises the steps that firstly, an optimum channel plane for inserting the pedicle screw is determined, then an optimum safety channel for inserting the pedicle screw is determined, and finally the optimum inserting point for inserting the pedicle screw is determined. The inserting point is located through the method, a patient does not need to be in contact with X-rays, trauma is reduced, operation time is saved, and no matter whether the vertebral pedicle and the zygopophysis of the centrum of the patient are varied or varied to a certain degree, the accuracy and success rate of inserting the pedicle screw at one time are high.
Description
Technical field
The present invention relates to field of spinal surgery, particularly a kind of utilize three-dimensional modeling to find to insert pedicle screw best enter method a little.
Background technology
The various diseases of spinal column and fracture, need to utilize pedicle screw to rebuild the stability of spinal column when performing the operation, pedicle screw is popularized in the application of spinal surgery, its conventional method for posting is free-hand after having anatomic landmark to locate inserts method, C arm diascopy etc., these methods respectively have pluses and minuses, some produces serious complication, as neurologic defict causes lower limb and fecal and urinary functions obstacle, Great Vascular Injury jeopardizes the life of patient, the cancer generation etc. of x-ray infringement, how to improve accuracy and the disposable success rate inserted that pedicle screw inserts, it is the target that spinal surgery circle is pursued always.
Free-hand method of inserting is current most popular method, it utilizes articular process anatomical landmarks as entering a little, to enter point location mistake be the primary factor that causes pedicle screw to insert failure and most common factors, the generation of consecutive complications some be continuity and the inevitable outcome of this mistake, before and after have cause effect relation, and usually to enter a defining method be following 4 kinds:
Roy-camille method: across both sides transverse process horizontal line be connected 1mm place under upper and lower facet joint central vertical line intersection point;
Weinstein method: the horizontal line of two point of two transverse process and the intersection point of the lateral border and vertical line that are connected vertebral body superior articular process;
Mager method: superior articular process's outer rim vertical line and the horizontal intersection point of transverse process;
Louis method: on horizontal line above superior articular process's articular surface lower edge 1mm, vertical line to be joint space be sagittal, then through joint space outer most edge, as in volume shape, then gets articular process outer 1/3rd.
Locate free-hand screw of inserting after into point in above method, main armrest sense adds C arm perspective.On corpus vertebrae, each anatomical structure is often because congenital or acquired disposition cause variation, and modal variation has:
1, the variation of articular process: hammer into some superior articular process at place, position and an anapophysis at pedicle of vertebral arch screw, usually there is hypertrophy, hypertrophy, cohesion, cause normal morphology disappearance, the disappearance of zygapophysial joints gap, free-handly cannot search out normal anatomic landmark when inserting method, just can not disposable or accurately find into point, often will expand and appear transverse process, compare with transverse process and judge into point, while increase wound and operating time, still have higher mortality.
2, pedicle of vertebral arch also often has multiple variation, as pedicle diameter diminish even pulp cavity disappear, pedicle of vertebral arch leaning angle on axial plane is variable large or diminish, on coronalplane the cohesion angle of cephalad variable large (both sides pedicle of vertebral arch is the Eight characters) or reduce (both sides pedicle of vertebral arch is parallel), the form of pedicle of vertebral arch is all not oval on coronalplane, also have in up-small and down-big drops, up big and down small exclamation mark shape, I shape identical up and down, circular etc., these pedicles of vertebral arch with enter to make a variation, often cause repeatedly finding into point, repeatedly puncture, pedicle screw trajectory is worn out, screw hold declines, and the severe complication of spinal nerves and blood vessel injury may be produced, even jeopardize patients ' lives.
Method is inserted due to free-hand behind employing anatomic landmark location, often because of the variation of pedicle of vertebral arch itself, the variation of articular process and failure, therefore only have under utilizing C arm X-ray perspective to guide and carry out inserting of pedicle of vertebral arch, to improve its accuracy, its shortcoming is that doctor and patient all can cause various cancer by the infringement of x-ray for a long time occur being subject to the X-ray infringement to human body, particularly medical worker.
Summary of the invention
The object of the invention is the deficiency existed for prior art, there is provided a kind of utilize three-dimensional modeling to find to insert pedicle screw best enter method a little, this method is utilized to locate into point, do not need to contact X-ray, the X-ray that minimizing doctor and patient is subject to, to the infringement of human body, reduces wound, saves operating time, no matter patient vertebral body pedicle of vertebral arch and whether articular process makes a variation or much variations, it is disposable inserts that the accuracy rate of pedicle screw is high, success rate is high.
The object of the present invention is achieved like this: a kind of utilize three-dimensional modeling to find to insert pedicle screw best enter method a little, comprise the steps:
1) choose vertebral body dicom data and set up vertebral body threedimensional model in three-dimensional reconstruction software;
2) the optimal channel plane that pedicle screw is inserted is determined: in three-dimensional reconstruction software, choose partition tools, according to the optimal channel plane that optimal channel flat normal determination pedicle screw is inserted, with the optimal channel plane determined for vertebral body is divided into upper and lower two parts by divisional plane, vertebral body is upper, 1/3 intersection for this plane is arranged in for optimal channel flat normal, and parallel with the upper and lower soleplate of vertebral body;
3) the best safety passage that pedicle screw is inserted is determined: the upper part hiding vertebral body in three-dimensional reconstruction software, manifest the optimal channel plane of vertebral body, choose the cylindrical tool of CAD, the optimal channel plane of vertebral body arranges left and right two cylinders, two cylinders lay respectively at two pedicle of vertebral arch narrowest position of vertebral body, as follows to these two cylinder adjustment:
first adjust body diameter: the circumferential wall of cylinder is contacted with the lateral border of cortex, the medial border of lateral cortex inside pedicle of vertebral arch narrowest position respectively, when the body diameter now obtained is operation, insert the maximum gauge of pedicle screw;
next adjusts body length: make cylinder front end reach 75-80% in vertebral body sclerotin, cylinder rear end contacts with articular process sclerotin, inserts the greatest length of pedicle screw when the distance between the forward and backward two ends of cylinder is operation;
adjustment cylinder and vertebral body are through the angular relationship of the median sagittal plane of spinous process: premised on cylinder total length is all in sclerotin, cylinder is contacted with the lateral border of cortex, the medial border of lateral cortex inside pedicle of vertebral arch narrowest position, and the cylinder now obtained is best introversion angular relationship with the maximum leaning angle of median sagittal plane through spinous process;
the overlying relation of adjustment cylinder and spinous process: make cylinder parallel with upper and lower soleplate, now through the plane of left and right cylinder axial line, be step 2) the optimal channel plane determined, judge that the head of pedicle screw inclines degree according to the infall of this plane and spinous process; Through the adjustment of above-mentioned steps, the best safety passage that when cylinder position is operation, pedicle screw is inserted;
4) determine that the best that pedicle screw is inserted enters a little: the axial line of the best safety passage finding pedicle screw to insert, this axial line and vertebral body left and right superior articular process's cortex joining are the best that pedicle screw inserts and enter a little.
The method of the axial line of the best safety passage looking for pedicle screw to insert in step 4) is: in three-dimensional reconstruction software, carry out original position to left and right two cylinders copy, and change into other color marks, two body diameters after copying are revised as the cylinder of 1mm diameter, be the axial line of the best safety passage that pedicle screw is inserted, now, cylinder and its outer best safety passage of 1mm diameter are two concentric cylinders.
By carrying out virtual perspective to vertebral body in step 4), observing the axial line of two cylinders and cylinder whether in the pedicle of vertebral of left and right, and having certain introversion; Whether parallel with upper and lower soleplate.
CT scanning is carried out to vertebral body, obtains its dicom data, carry out reconstructing three-dimensional model by its dicom data importing three-dimensional reconstruction software.
CT sweep parameter is: Scan slice thickness is 0.75-1.5mm, voltage 120kV, obtains dicom data.
The diameter of the pedicle screw of inserting when the diameter of the best safety passage that pedicle screw is inserted is more than or equal to operation, the length of the pedicle screw of inserting when the length of the best safety passage that pedicle screw is inserted is more than or equal to operation.
Have employed such scheme, the present invention had the following advantages:
1) the present invention is by setting up vertebral body threedimensional model on computers, vertebral body threedimensional model first finds optimal channel plane, the best safety passage that optimal channel plane finds pedicle screw to insert and the best enter a little, it is a little that pedicle of vertebral arch and zygapophysial joints by studying each patient is arranged that best safety passage and the best enter, no matter patient vertebral body pedicle of vertebral arch and whether articular process makes a variation or much variations, it is disposable inserts that the accuracy rate of pedicle screw is high, success rate is high.
2) as long as enter a little to insert pedicle screw from the best when performing the operation, make the pedicle screw of inserting all the time in best safety passage, pedicle of vertebral arch inside and outside wall just can be avoided to be the worse for wear, reduce hold generation; Damage segmental vessels or trunk after avoiding wearing out pedicle of vertebral arch outer wall, even jeopardize the generation of patients ' lives; Spinal nerves is produced after avoiding wearing out pedicle of vertebral arch inwall.
3) in art without the need to appearing transverse process, only appear a little outside superior articular process, greatly shorten operating time, reduce wound with hemorrhage, do not need transfuse blood and reduce surgery cost.
4) because by this method no matter patient vertebral body pedicle of vertebral arch and whether articular process makes a variation or much variations, the best that can both accurately find pedicle screw to insert enters a little, no longer need repeatedly by C arm perspective, doctors and patients need not contact X-ray, avoid increasing carcinogenic chance.
5) adopt this method to locate into point, have easy to learn, do not need longer learning curve, do not need expensive equipment and special operating apparatus.
Below in conjunction with drawings and Examples, the invention will be further described.
Accompanying drawing explanation
Fig. 1 is three-dimensional modeling figure of the present invention;
Fig. 2 is the front view of the divisional plane in segmentation nail road of the present invention;
Fig. 3 is the right view of Fig. 2;
Fig. 4 is the left view of Fig. 2;
Fig. 5 is the schematic diagram of the cut-off rule in segmentation nail road of the present invention;
Fig. 6 is the schematic diagram of the upper and lower two parts different colours display of vertebral body of the present invention;
Fig. 7 is vertebral body lower part schematic diagram of the present invention;
Fig. 8 is the left view of vertebral body optimal channel plane of the present invention;
Fig. 9 is schematic diagram optimal channel plane of the present invention being arranged best safety passage;
Figure 10 is schematic diagram optimal channel plane of the present invention being arranged best safety passage and axial line;
Figure 11 is schematic diagram optimal channel plane of the present invention being arranged the axial line of best safety passage;
Figure 12 is the schematic diagram that the present invention only shows best safety passage on complete cone;
Figure 13 is the perspective view of Figure 12;
Figure 14 is the front view that the present invention shows best safety passage and axial line on complete cone simultaneously;
Figure 15 is the perspective view of Figure 14;
Figure 16 is the right view that the present invention shows best safety passage and axial line on complete cone simultaneously;
Figure 17 is the perspective view of Figure 16;
Figure 18 is the present invention's front view of the only axial line of display best safety passage on complete cone under fluoroscopy;
Figure 19 is the right view of Figure 18;
Figure 20 is the schematic diagram that the best of the present invention enters a little;
Figure 21 of the present inventionly locates into point methods and existing comparison diagram of locating into point methods;
Figure 22 is the perspective view of Figure 21;
Figure 23 adopts of the present inventionly locate into point methods and existingly locate the simulation schematic diagram of inserting screw into point methods;
Figure 24 is the perspective view of Figure 23;
Figure 25,26,27 displays adopt Weinstein methods, Mager method insert screw after nail worn out the schematic diagram of pedicle of vertebral arch inwall;
Figure 28 show adopt Roy-Camille method to insert screw after nail worn out the schematic diagram of pedicle of vertebral arch inwall;
Figure 29 is the perspective view of Figure 28;
Figure 30 is the schematic diagram of whole spinal column.
Detailed description of the invention
Below in conjunction with drawings and Examples, the invention will be further described:
Utilize three-dimensional modeling to find to insert pedicle screw best enter a method a little, comprise the steps:
1) see Fig. 1, choose spinal column dicom data and set up vertebral body threedimensional model in three-dimensional reconstruction software: CT scanning patient's lesion segment spinal column being carried out to standard position, sweep parameter: Scan slice thickness is 0.75-1.5mm, voltage 120kV, obtains dicom data.Open mimics10-17 version software, import the dicom data obtained, (minimum threshold values is for showing outside limbus corticalis in pedicle of vertebral arch to select the threshold values in certain limit, the highest threshold values is taken from and dynamic is imported peak after data), select the best in quality of software default to carry out three-dimensional reconstruction, obtain spinal three-dimensional model.
2) the optimal channel plane that pedicle screw is inserted is determined: in three-dimensional reconstruction software, choose partition tools, see Fig. 2-4, and adjust divisional plane up and down, rotate spinal vertebral, according to the optimal channel plane that optimal channel flat normal determination pedicle screw is inserted, with the optimal channel plane determined for vertebral body is divided into upper and lower two parts by divisional plane, vertebral body is upper, 1/3 intersection for this plane is arranged in for optimal channel flat normal, and parallel with the upper and lower soleplate of vertebral body.
3) the best safety passage that pedicle screw is inserted is determined: see Fig. 5, hide segmentation plane, observe cut-off rule, see Fig. 6, of the present inventionly upper and lower two parts different colours is divided into show vertebral body, see Fig. 7, the upper part of vertebral body is hidden in three-dimensional reconstruction software, manifest the optimal channel plane of vertebral body, see Fig. 8, adjustment display optimal channel plane, see Fig. 9, choose the cylindrical tool of CAD, the optimal channel plane of vertebral body arranges a left side, right two cylinders, two cylinders lay respectively at two pedicle of vertebral arch narrowest position of vertebral body, as follows to these two cylinder adjustment:
first body diameter is adjusted: the circumferential wall of cylinder is contacted with the lateral border of cortex, the medial border of lateral cortex inside pedicle of vertebral arch narrowest position respectively, and the diameter now obtained, is the diameter of pedicle screw.
next adjusts body length: make cylinder front end reach 75-80% in vertebral body sclerotin, cylinder rear end contacts with articular process sclerotin, and the distance between two is the length of pedicle screw.
adjustment cylinder and vertebral body are through the angular relationship of the median sagittal plane of spinous process: premised on ensureing that cylinder total length is all in sclerotin, cylinder is contacted with the lateral border of cortex, the medial border of lateral cortex inside pedicle of vertebral arch narrowest position, the cylinder now obtained be best introversion angular relationship through the maximum leaning angle of median sagittal plane of spinous process, the leaning angle that when determining operation, pedicle screw is inserted.
adjustment cylinder and the overlying relation of spinous process: make left and right cylinder axial line all be positioned at step 2) in the optimal channel plane determined, and make cylinder parallel with upper and lower soleplate, judge that the head of pedicle screw inclines degree according to the infall of this plane and spinous process.See Figure 30, represented by dotted arrows optimal channel plane, this plane is parallel with the upper soleplate of waist 5 vertebral body, but with regard to whole spinal column, this plane is that cephalad tilts, so, it must be crossing with the spinous process of upper lumbar vertebra and waist 4 vertebral body, the spinous process of waist 4 vertebral body is divided into upper and lower two halves, and the angle [alpha] of cephalad inclination that Here it is, this angle directly can judge according to optimal channel plane and spinous process intersection in art.Be pointed out that: in figure, left side is the tail side of spinal column, and right side is the head side of spinal column.
Through the adjustment of above-mentioned steps, cylinder position is the best safety passage that pedicle screw is inserted;
The criterion of this cylinder in best pedicle channel is:
The cylinder that is defined as of body diameter just contacts be limited with the lateral border of cortex, the medial border of lateral cortex inside pedicle of vertebral arch narrowest position.
Body length be defined as that its front end reaches 75-80% in vertebral body sclerotin, rear contacts with articular process sclerotin and is limited.
The inside inclination angle (with the angulation of the median sagittal plane through spinous process) of cylinder is defined as screw and just contacts be limited with the lateral border of cortex, the medial border of lateral cortex inside pedicle of vertebral arch narrowest position.
Cylinder is defined as be limited parallel with upper and lower soleplate to inclination angle when optimal channel plane (be actually its plane be as the criterion with spinous process intersection) of side end to end.
Above-mentioned every determination, be in software by repeatedly adjust simulation pedicle screw in upper and lower, left and right, inside and outside incline and rotate vertebral body come real.
The diameter of the pedicle screw of inserting when the diameter of the best safety passage that pedicle screw is inserted is more than or equal to operation, the length of the pedicle screw of inserting when the length of the best safety passage that pedicle screw is inserted is more than or equal to operation, as long as enter a little to insert pedicle screw from the best during operation, make the pedicle screw of inserting all the time in best safety passage, pedicle of vertebral arch inside and outside wall just can be avoided to be the worse for wear, reduce hold generation; Damage segmental vessels or trunk after avoiding wearing out pedicle of vertebral arch outer wall, even jeopardize the generation of patients ' lives; Spinal nerves is produced after avoiding wearing out pedicle of vertebral arch inwall.It is a little that pedicle of vertebral arch and zygapophysial joints by studying each patient is arranged that best safety passage and the best enter, no matter patient vertebral body pedicle of vertebral arch and whether articular process makes a variation or much variations, it is disposable inserts that the accuracy rate of pedicle screw is high, success rate is high, and improves safety coefficient.Normally used nail diameter is 5.5mm, 6.0mm, 6.5mm clinically, the most frequently used nail be after both.
4) determine that the best that pedicle screw is inserted enters a little: the axial line of the best safety passage finding pedicle screw to insert, this axial line and vertebral body left and right superior articular process's cortex joining are the best that pedicle screw inserts and enter a little.See Figure 10, in three-dimensional reconstruction software, choose the cylindrical tool of CAD, respectively generation step 3) in the axial line of two cylinders.The method of the axial line of the best safety passage looking for pedicle screw to insert in step 4) is: in three-dimensional reconstruction software, carry out original position to left and right two cylinders copy, and change into other color marks, two body diameters after copying are revised as the cylinder of 1mm diameter, be the axial line of the best safety passage that pedicle screw is inserted, now, cylinder and its outer best safety passage of 1mm diameter are two concentric cylinders.The setting of 1mm diameter is artificial setting, represent we at ordinary times naked eyes can just see structure clearly and be limited.
By carrying out virtual perspective to vertebral body in step 4), observing the axial line of two cylinders and cylinder whether in the pedicle of vertebral of left and right, and having certain introversion; Whether parallel with upper and lower soleplate.
Concrete steps are: see Figure 11, hide two cylinders, retain the axial line of two cylinders, whole vertebral body is shown by three-dimensional reconstruction software, see Figure 12 and Figure 13, display cylinder, hide axial line, again virtual fluoroscopic observation cylinder is carried out whether in the pedicle of vertebral of standard to vertebral body, see Figure 14 and Figure 15, show cylinder and axial line simultaneously, again virtual perspective is carried out to vertebral body, observe two cylinders and axial line whether in the pedicle of vertebral of standard, see Figure 16 and Figure 17, rotate vertebral body, whether the axial line of arbitrarily angled observation two cylinders is parallel with upper and lower soleplate, see Figure 18, display axial line, hide cylinder, again virtual fluoroscopic observation axial line is carried out whether in the pedicle of vertebral of standard to vertebral body, see Figure 19, rotate vertebral body, whether the axial line of arbitrarily angled observation two cylinders is parallel with upper and lower soleplate, see Figure 20, if, cancel virtual perspective, now the axial line of two cylinders is left with vertebral body respectively, upper right articular process cortex joining is the best that pedicle screw inserts and enters a little.
Adopt the above-mentioned steps of this method to find pedicle of vertebral arch screw to hammer into a little, by modeling vertebral body, virtual nail designs, sectional drawing copies in the lump into operating room computer and display on a display screen, stand-by, instructs the puncture of pedicle nail in art.Through way of escape vertebral plate outer or through spatium intermusculare appear the superior articular process that needs to insert pedicle screw and crista lambdoidalis a little, be exposed to preoperative planning enter to hammer into a little, without the need to whole articular process or transverse process are revealed.To enter some place in the best, according to the sectional drawing of step 3) judge pedicle screw enter to follow closely direction, insert pedicle screw; C arm perspective can verify pedicle of vertebral arch whether in optimal design passage.Postoperatively again can also scan operated level vertebral body, rebuild, whether the metal pedicle screw of checking reality is consistent with the simulation pedicle screw designed in mimics software.Only needing to appear when spatium intermusculare approach into point, without the need to appearing upper inferior articular process and one's own department or unit transverse process, retaining the rami posteriores nervorum lumbalium outside zygapophysial joints and blood vessel as far as possible.Look at hypograph method for registering in employing art straight and determine that into hammering into be a little crucial, enter to hammer in an art to look at straight hypograph method for registering specific operation process: after appearing superior articular process or crista lambdoidalis, the binocular visual field of operator moves on on operating room computer display screen, by on the anatomical structure in art and display screen enter to hammer into a little and surrounding structure carries out careful comparison, thus accurately determine pedicle nail inlet point.Open a way to after the first opening of pedicle of vertebral arch subsequently, all the time utilize in opening open circuit process the angle of virtual awl and upper spinous process on display screen, with upper spinous process upper, middle and lower position relationship to instruct the practical operation in art, the feel entered in conjunction with awl front end slowly screws in passage-opening awl, detect after the bottom in bone tunnel and wall be bone structure with probe again, insert along the tapping of bone tunnel the pedicle nail determining that diameter length is suitable, after C arm perspective pedicle nail position is without exception, carry out other operating procedures.
Flow process of the present invention is as follows:
Collect the dicom formatted data of patient vertebral body CT scan
→import modeling in mimics
→determine the optimal channel plane that left and right pedicle screw is inserted
→design pedicle screw optimal channel, length, diameter, with through angulation (size) relation of the median sagittal plane of spinous process, position (axial plane of the inclination) relation with spinous process
→determine that the best of pedicle screw enters a little and sectional drawing
→modeling vertebral body, virtual nail designs, sectional drawing are copied operating room computer in the lump and are presented on screen, with practical structures comparison in art determine the best enter a little copy in the lump into operating room computer and show on a display screen, stand-by
→the superior articular process needing to insert pedicle screw vertebra is appeared in art
→direct-view hypograph registration finds the best to enter point (being exactly that articular process form in art and modeling articular process form are contrasted and found into point)
→enter a place in the best and insert pedicle screw with reference to the optimal channel design of pedicle screw by step
→whether C arm perspective checking pedicle of vertebral arch is in optimal design passage.
The inventive method is adopted to do clinical experiment:
Case is totally 503 examples, wherein male 384 example, women 119 example, unstable 83 examples of lumbar vertebra compression fracture 124 example, degenerative lumbar scoliosis, simple lumbar spinal stenosis 24 example, lumbar spondylolisthesis 128 example, prolapse of lumbar intervertebral disc combined side crypts or spinal canal stenosis 126 example, Chest vertebrae nodules 18 example.Thoracic vertebra 65 example, lumbar vertebra 438 example, pedicle screw adds up to 2267: thoracic vertebra 160, lumbar vertebra 2001, sacral 106.Wherein 318 examples have the variation of the different structure such as articular process, pedicle of vertebral arch, vertebral body.
Through the deep research of applicant and clinical trial certificate, find pedicle of vertebral arch screw after Thoracolumbar disk modeling and hammer into method a little to instruct inserting of pedicle screw, in the once success rate of inserting pedicle nail and accuracy, be obviously better than the conventional freehand technology of bibliographical information, be worthy to be popularized.
See Figure 21 and 22, locate into point methods and existing comparison diagram of locating into point methods for of the present invention, what green arrow pointed to enters a little for what adopt Roy-Camille method to determine, red arrow point to for adopting Weinstein method, Mager method is determined enters a little, what yellow arrows was pointed to is entering a little of adopting this method to determine.The vertebral model selected in figure is the vertebral model of articular process variation.See Figure 23 to 29, of the present inventionly locate into point methods for utilizing and existingly locate the simulation comparison diagram of inserting screw into point methods respectively, C is the simulation screw adopting Roy-Camille method, B is the simulation screw adopting Weinstein method, Mager method, and A adopts simulation screw of locating into point methods of the present invention.As can be seen from Figure 25 to 26, the pedicle nail subdivision on the left of Weinstein method, Mager method, outside pedicle of vertebral arch, has namely been the worse for wear outside pedicle of vertebral arch.As can be seen from Figure 27, even if strengthen the inside inclination angle of nail, the pedicle of vertebral arch nail B in left side is still partly outside pedicle of vertebral arch.Inside Figure 28 and 29, Roy-Camille normal direction, have some inclination angles, pedicle of vertebral arch inwall just worn out by nail, enter canalis spinalis, namely C is inside the pedicle of vertebral arch of right side, can't see this image, and the screw adopting method of the present invention to insert does not wear out pedicle of vertebral arch inwall completely when not breaking through at all.As can be seen from these figures, entering of adopting this method to determine a little is being inserted in the accuracy of screw, safety, is obviously better than employing Roy-Camille method, Weinstein method, Mager method are determined enters a little.
This method focuses on research pedicle of vertebral arch and zygapophysial joints is determined into point, it not picture Roy-Camille method, Weinstein method, Mager method, Louis method etc. utilizes the position relationship of transverse process and superior articular process or anatomical landmarks to determine into hammering into a little, the present invention determines into point by research pedicle of vertebral arch and zygapophysial joints, first the best utilizing this method determination pedicle screw to insert on model enters a little, the partial structurtes feature of a position is entered according to the best, find vertebral body in art enter to hammer into a little, without the need to not appearing transverse process in art, only appear a little outside superior articular process, greatly shorten operating time, reduce wound and hemorrhage, do not need blood transfusion and reduce surgery cost.
Clinical follow index is the complication relevant to nail: 1, whether pedicle screw wears out pedicle of vertebral arch inwall, cause the cerebrospinal leak that nerve root injury and dural sac break, 2, whether pedicle screw wears out pedicle of vertebral arch and vertebral body outer wall causes blood vessel injury, and 3, the accuracy of pedicle screw position.This group case is not because of the concurrent blood vesssls and nerves injuries of pedicle screw and cerebrospinal leak.For the accuracy of screw position, whether main basis wears out pedicle of vertebral arch inside and outside wall judges, employing Rao etc. wear out the accuracy that grouping criterion evaluation puts nail: 0 grade: without wearing out; 1 grade: wear out < 2mm; 2 grades: 2mm≤wear out < 4mm; 3 grades: wear out >=4mm.Result is 0 grade 2255; 1 grade 11; 2 grades 1; 3 grades 0.Employing the inventive method pedicle of vertebral arch rate of not wearing out is 99.5%, disposable success rate of inserting is 87.5 %, and wearing out incidence rate is 0.5%.And the incidence rate of wearing out that conventional freehand inserts its bibliographical information of method is 9% ~ 47%.Most scholar thinks that inner side is worn out < 2mm and just belonged to " safety zone ".
Compare other pedicle screws and insert method defining method, the present invention have easy to learn, do not need longer learning curve, do not need expensive equipment and special operating apparatus, doctor not to need contact X-ray, reduce wound, saving operating time, (no matter patient vertebral body pedicle of vertebral arch and whether articular process makes a variation or much variations, it is disposable inserts pedicle screw) high accuracy for examination, be significantly better than other and enter point methods.
Claims (6)
1. utilize three-dimensional modeling to find to insert pedicle screw best enter a method a little, it is characterized in that, comprise the steps:
1) choose vertebral body dicom data and set up vertebral body threedimensional model in three-dimensional reconstruction software;
2) the optimal channel plane that pedicle screw is inserted is determined: in three-dimensional reconstruction software, choose partition tools, according to the optimal channel plane that optimal channel flat normal determination pedicle screw is inserted, with the optimal channel plane determined for vertebral body is divided into upper and lower two parts by divisional plane, vertebral body is upper, 1/3 intersection for this plane is arranged in for optimal channel flat normal, and parallel with the upper and lower soleplate of vertebral body;
3) the best safety passage that pedicle screw is inserted is determined: the upper part hiding vertebral body in three-dimensional reconstruction software, manifest the optimal channel plane of vertebral body, choose the cylindrical tool of CAD, the optimal channel plane of vertebral body arranges a left side, right two cylinders, two cylinders lay respectively at two pedicle of vertebral arch narrowest position of vertebral body, as follows to this two cylinders adjustment: first to adjust body diameter: the circumferential wall making cylinder respectively with pedicle of vertebral arch narrowest position inside the lateral border of cortex, the medial border contact of lateral cortex, the maximum gauge of pedicle screw is inserted when the body diameter now obtained is operation, next adjusts body length: make cylinder front end reach 75-80% in vertebral body sclerotin, cylinder rear end contacts with articular process sclerotin, inserts the greatest length of pedicle screw when the distance between the forward and backward two ends of cylinder is operation, adjustment cylinder and vertebral body are through the angular relationship of the median sagittal plane of spinous process: premised on cylinder total length is all in sclerotin, cylinder is contacted with the lateral border of cortex, the medial border of lateral cortex inside pedicle of vertebral arch narrowest position, and the cylinder now obtained is best introversion angular relationship with the maximum leaning angle of median sagittal plane through spinous process, adjustment cylinder and the overlying relation of spinous process: make left and right cylinder axial line all be positioned at step 2) in the optimal channel plane determined, and make cylinder parallel with upper and lower soleplate, through the adjustment of above-mentioned steps, the best safety passage that when cylinder position is operation, pedicle screw is inserted,
4) determine that the best that pedicle screw is inserted enters a little: the axial line of the best safety passage finding pedicle screw to insert, this axial line and vertebral body left and right superior articular process's cortex joining are the best that pedicle screw inserts and enter a little.
2. according to claim 1 insert pedicle screw best enter method a little, it is characterized in that: the method for the axial line of the best safety passage looking for pedicle screw to insert in step 4) is: in three-dimensional reconstruction software, original position is carried out to left and right two cylinders and copy, and change into other color marks, two body diameters after copying are revised as the cylinder of 1mm diameter, be the axial line of the best safety passage that pedicle screw is inserted, now, cylinder and its outer best safety passage of 1mm diameter are two concentric cylinders.
3. according to claim 1 insert pedicle screw best enter method a little, it is characterized in that: by carrying out virtual perspective to vertebral body in step 4), observing the axial line of two cylinders and cylinder whether in the pedicle of vertebral of left and right, and having introversion; Whether parallel with upper and lower soleplate.
4. according to claim 1 insert pedicle screw best enter method a little, it is characterized in that: CT scanning is carried out to vertebral body, obtain its dicom data, carry out reconstructing three-dimensional model by its dicom data importing three-dimensional reconstruction software.
5. according to claim 4 insert pedicle screw best enter method a little, it is characterized in that: CT sweep parameter is: Scan slice thickness is 0.75-1.5mm, voltage 120kV, acquisition dicom data.
6. according to claim 1 insert pedicle screw best enter method a little, it is characterized in that: the diameter of the pedicle screw of inserting when the diameter of the best safety passage that pedicle screw is inserted is more than or equal to operation, the length of the pedicle screw of inserting when the length of the best safety passage that pedicle screw is inserted is more than or equal to operation.
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