CN111920431A - Method for determining intervertebral disc incision depth in lumbar posterior intervertebral fusion - Google Patents

Abstract

The invention relates to a method for determining the intervertebral disc incision depth in a lumbar posterior intervertebral fusion, which comprises the following steps of (1) selecting a lumbar degenerative disease patient subjected to X-ray examination and CT (computed tomography) flat scan examination of a lumbar intervertebral disc as a sample; (2) removing unqualified samples; (3) standing the patient, irradiating X-ray film at the right side of lumbar vertebra, and scanning the patient in horizontal position; (4) measuring the lengths of the lower edges of vertebral bodies of L3 (third lumbar vertebra), L4 (fourth lumbar vertebra) and L5 (fifth lumbar vertebra) in an X-ray film, and taking the lengths as the X-ray depths of intervertebral spaces of L3/4, L4/5 and L5/S1; (5) statistical analysis is carried out by adopting SPSS18.0 software, and a table is made according to the analysis result; (6) and obtaining an alarm value of the depth of the cut-in of the intervertebral disc according to the data result. The method provides the warning value of the cutting depth of the nucleus pulposus clamp for medical staff implementing the lumbar posterior intervertebral fusion, and improves the safety and the success rate of the intervertebral fusion.

Description

Method for determining intervertebral disc incision depth in lumbar posterior intervertebral fusion

Technical Field

The invention relates to the field of intervertebral fusion, in particular to a method for determining the intervertebral disc incision depth in the lumbar posterior intervertebral fusion.

Background

Lumbar instability and lumbocrural pain caused by degenerative lumbar intervertebral disc diseases are common frequently-occurring diseases which always trouble patients, and the incidence rate of the patients is extremely high particularly among the elderly patients. To address this problem and improve patient quality of life, surgeons have designed and developed a variety of procedures to remove the diseased disc and promote lumbar fusion. PLF (posterolateral lumbar fusion) surgery reported by Watkins in 1953 has once become the most commonly used fusion procedure for treating lumbar degeneration even along the present day, due to the advantages of simple exposure, low surgical technical requirements, and low probability of nerve and dura mater damage during surgery. However, the PLF only carries out bone grafting between the transverse process and the vertebral plate, so the area of a bone grafting bed is small, and the incidence rate of non-fusion after operation is high. Therefore, Clo-ward et al improved PLIF (posterior lumbar interbody fusion) surgery on the basis of PLF. This art formula has not only realized 360 decompression to the canalis spinalis, simultaneously after excision pathological change intervertebral disc, gives between the centrum support, implants the bone fusion, has guaranteed the recovery of intervertebral height, has increased the bone grafting area, has improved the fusion rate greatly. In addition, PLIF has rebuild the mechanics of backbone stable through the fixed of way of escape pedicle of vertebral arch nail stick system, has showing the probability that bone grafting piece aversion and secondary lumbar vertebrae are unstable that has reduced. By virtue of these advantages, PLIF surgery is currently the most common standard procedure for the treatment of degenerative diseases of the lumbar intervertebral disc.

Although in order to avoid the injury that may be caused by the traction of cauda equina and nerve root in PLIF, later scholars invented TLIF (transformational lumbar interbody fusion), ALIF (anterior lumbar interbody fusion), oli (oblique lateral lumbar interbody fusion), XLIF (extreme lateral interbody fusion), and other new surgical approaches [4, 5 ]. However, these new procedures are limited by the indications and cannot replace PLIF surgery.

Neural decompression and reconstruction of spinal segment stability are always the two most central goals for PLIF surgery. Neural decompression may be achieved by opening the spinal canal, enlarging the nerve root canal, and removing the herniated disc. However, fixation relying solely on pedicle screw systems to reconstruct the stability of the spinal segment is unreliable because the internal fixation system will eventually fail if there is no bony fusion between the diseased segments. Therefore, the method can remove the original degenerated intervertebral disc as much as possible, increase the bone mass of intervertebral bone grafting, and improve the success rate of intervertebral bony fusion, and becomes a key factor for the success of PLIF operation.

The approach to the PLIF surgical removal of the disc is to open the spinal canal, retract the dura mater, cut one side of the posterior longitudinal ligament, and clear the disc from the posterior-anterior predatory diet. In this procedure, too great a dural traction may result in traction damage to the nerve roots of the corresponding segment or direct damage to the cauda equina, and thus dural traction beyond the spinal midline is generally recommended. This makes the incision on the posterior longitudinal ligament very limited, and the intervertebral disc can not be excised easily through the incision under direct vision, the upper and lower end plates are well treated, and the whole excision process basically depends on personal experience and 'hand feeling'. Once the disoperation depth of the intervertebral disc is mastered, the anterior longitudinal ligament is broken through and enters the abdominal cavity, the common iliac artery or abdominal viscera in front of the vertebral body can be damaged, and serious consequences such as heavy bleeding, viscera injury, even death and the like can be caused. Therefore, the incision depth of the intervertebral disc is strictly mastered, a certain early warning value is found, the safety of the PLIF operation is greatly improved, more intervertebral discs are conveniently removed, and the intervertebral fusion rate is increased.

In conclusion, the invention aims to find out the warning value of the cutting depth of the nucleus pulposus pincers in the lumbar posterior intervertebral fusion, reduce the dependence of medical personnel on personal experience and hand feeling when operating the nucleus pulposus pincers, provide scientific data support for manufacturing the novel nucleus pulposus pincers and avoid serious consequences of hemorrhage, organ injury, even death and the like caused by too deep cutting depth of the nucleus pulposus pincers.

Disclosure of Invention

The invention provides a method for determining the disc incision depth in posterior lumbar interbody fusion, which comprises the following steps:

(1) study sample inclusion criteria: selecting a patient for which the outpatient service preliminarily diagnoses the lumbar degenerative disease and passes through the X-ray examination at the lumbar positive side position and the CT flat scan examination of the lumbar intervertebral disc in the radiology department;

(2) sample exclusion criteria: removing the samples which meet the following conditions from the samples,

1. the age is less than 30 years old, 2, the age is more than 70 years old, 3, degenerative lateral bending and rotation of the spine exist, 4, osteophyte is massively proliferated, 5, osteoclastic diseases such as spinal tumor and tuberculosis exist together, 6, spondylolisthesis is more than III degrees, 7, the lumbar intervertebral disc has undergone surgical treatment;

(3) sample image acquisition: the patient is in a standing position when the patient irradiates the X-ray film at the right side of the lumbar vertebra, and the patient is in a horizontal position when the patient performs tomography;

(4) sample measurement indexes are as follows:

measuring the depth of intervertebral space in an X-ray film, taking a lumbar lateral X-ray film, and respectively measuring the lengths of the lower edges of vertebral bodies of L3 (third lumbar vertebra), L4 (fourth lumbar vertebra) and L5 (fifth lumbar vertebra) as the depth of the intervertebral space of L3/4, L4/5 and L5/S1;

measuring the CT intervertebral space vertical depth, setting 1/4 position of the transverse diameter of the vertebral canal as a starting point, making a vertical line of the transverse diameter line of the vertebral canal through the starting point, taking the intersection point of the vertical line and the rear edge of the lower endplate image of the vertebral body as a point A and the intersection point of the vertical line and the front edge as a point B, measuring the distances among AB points of L3, L4 and L5 vertebral bodies as the CT vertical depth of the intervertebral spaces L3/4, L4/5 and L5/S1 respectively;

measuring the oblique depth of the CT intervertebral space: setting the intersection point of the vertical line of the outer side boundary of the vertebral canal and the image of the top point of the facet joint as a maximum inclined point (0 point), connecting the 0 point with the A point to form a straight line, taking the point of the intersection of the straight line and the image front edge of the lower end plate of the vertebral body as a C point, measuring the distances among the AC points of the vertebral bodies of L3, L4 and L5, and respectively taking the distances as the CT inclined depths of intervertebral spaces of L3/4, L4/5 and L5/S1;

(5) and (3) sample statistical analysis: statistical analysis is carried out by adopting SPSS18.0 software, and normally distributed measurement data is expressed by mean +/-standard deviation; calculating the average value of the direct CT measurement value and the oblique CT measurement value, and describing the normal distribution condition; statistically comparing and analyzing the difference between the male and female in each segment of the intervertebral space depth and the difference between the intervertebral space depth measured by the X-ray film and the CT measured value; the comparison adopts a matched sample t test; p is less than 0.05, the difference is statistically significant;

(6) it is concluded that the warning value of the straight incision depth for the intervertebral disc incision of the posterior intervertebral fusion is 34mm, and the warning value of the oblique incision depth for the intervertebral disc incision of the posterior intervertebral fusion is 34 mm.

Further, in the step (5), the number of the male and the female is equal, and the total number is not less than 100.

Advantageous effects of the invention

The method solves the problem that the incision depth of the nucleus pulposus pincers is judged on site only by hand feeling and personal experience when medical personnel carry out the posterior lumbar intervertebral fusion operation, overcomes the wrong idea that part of the medical personnel use X-ray film measured values as reference values of the intervertebral depth, provides a real and reliable measuring scheme for measuring the intervertebral depth, provides a warning value of the insertion depth of the nucleus pulposus pincers for the medical personnel with insufficient clinical experience, can improve the success rate and the safety of the posterior lumbar intervertebral fusion operation, also provides scientific data support for novel nucleus pulposus pincers manufacture, and solves the problems that the nucleus pulposus pincers are cut too deeply to break through the front longitudinal ligament to enter the abdominal cavity, damage the common iliac artery or the abdominal cavity in front of the vertebral body, and cause the occurrence of the conditions of massive hemorrhage, organ damage, even death and the like from the physical angle.

Drawings

FIG. 1 is a schematic front view of a PLIF surgically removed disc;

FIG. 2 is a side view of a PLIF surgically removed disc;

FIG. 3 is a schematic diagram of a lumbar vertebrae lateral X-ray film intervertebral space measuring method;

FIG. 4 is a schematic view of a straight resection disc approach of the PLIF;

FIG. 5 is a schematic view of a PLIF oblique resection disc approach;

FIG. 6 is a schematic view of a scheme for measuring the depth of a CT slice in a straight direction and an oblique direction;

fig. 7 is a schematic diagram of an actual CT film measurement case.

Detailed Description

The present invention will now be described more fully hereinafter with reference to specific embodiments thereof.

The invention discloses a method for determining the disc incision depth in lumbar posterior intervertebral fusion, which comprises the following steps:

(1) study sample inclusion criteria: selecting patients who are preliminarily diagnosed as lumbar degenerative diseases by an outpatient service and undergo lumbar positive X-ray examination and lumbar intervertebral disc CT flat scan examination in a radiology department, wherein the outpatient service is selected from 1/1 day in 2019 to 12/31 days in 2019, the outpatient service in a second people hospital in Yunnan province is diagnosed as the lumbar degenerative diseases preliminarily, and the patients are subjected to examination such as lumbar positive X-ray examination and lumbar intervertebral disc CT flat scan examination according to the state of illness;

(3) sample exclusion criteria: removing samples meeting the following conditions that 1, the age is less than 30 years, and the measured value cannot be accurate due to the fact that the width of a vertebral body of a patient with too small age is continuously changed in the growth and development period; moreover, patients under 30 years old have extremely low incidence rate of lumbar degenerative diseases, few cases, mainly conservative treatment and little guiding significance of measured values, so that the patients are excluded;

2. the patient with the age of more than 70 years old has high probability of vertebral body deformation, osteophyte hyperplasia, vertebral body lateral bending, rotation and the like, is difficult to measure and has poor accuracy;

3. degenerative lateral bending and rotation of the spine;

4. massive proliferation of osteophytes;

5. the existing bone fracture diseases such as spinal tumor and tuberculosis are combined;

6. the slippage between the vertebral bodies is more than III degrees;

7. lumbar intervertebral discs have undergone surgical treatment;

based on the inclusion and exclusion criteria, 100 patients (50 men/50 women) were randomly selected from the images and the X-ray and CT images were measured. Of the 100 patients, the average age was 59.0 years (35-70 years) in the male group and 59.0 years (35-70 years) in the female group, and the age groups of the two groups were compared, with no statistical difference (P > 0.05), as detailed in Table 1.

TABLE 1 age Difference between two groups of men and women

(3) Sample image acquisition: the patient is in a standing position when the patient irradiates the X-ray film at the right side of the lumbar vertebra, and the patient is in a horizontal position when the patient performs tomography;

(4) sample measurement indexes (as shown in figures 1-7):

x-ray disc intervertebral space depth: taking a lumbar lateral X-ray film, and respectively measuring the lengths of the lower edges of the vertebral bodies of L3 (third lumbar), L4 (fourth lumbar) and L5 (fifth lumbar) as the depth of the intervertebral space of L3/4, L4/5 and L5/S1;

CT intervertebral space depth in the straight direction: since the dura mater retraction distance is at most up to the midline of the spinal canal, the scope of visualization and manipulation is only half of the anterior wall of the spinal canal (the side of the surgical procedure). In this operating region, the posterior longitudinal ligament is routinely self-medially dissected and the anterior disc is reprocessed. Therefore, when the depth of the vertical intervertebral space is measured, 1/4 position of the transverse diameter of the vertebral canal is set as a starting point, a perpendicular line of the transverse diameter line of the vertebral canal is drawn through the starting point, the intersection point of the perpendicular line and the rear edge of the lower endplate image of the vertebral body is taken as a point A, the intersection point of the perpendicular line and the front edge is taken as a point B, and the distances among AB points of the L3 vertebral bodies, L4 vertebral bodies and L5 vertebral bodies are measured and respectively taken as the CT vertical depth of the intervertebral spaces L3/4, L4/5 and L5/S1.

Oblique depth of CT intervertebral space: during PLIF surgical procedures, the angle of inclination of the cutting tool, such as a nucleus clamp, is limited when the disc is cut contralaterally from the posterior longitudinal ligament incision due to the preservation of the facet joints and some of the lateral lamina structure. Therefore, the intersection point of the perpendicular line of the outer side boundary of the vertebral canal and the top image of the facet joint is set as the maximum inclined point (point 0), the point 0 is connected with the point A to form a straight line, and the point where the straight line intersects with the front edge of the image of the vertebral inferior endplate is set as the point C. The distances among the AC points of the vertebral bodies of L3, L4 and L5 are measured and respectively taken as the CT oblique depths of the intervertebral spaces of L3/4, L4/5 and L5/S1.

(5) And (3) sample statistical analysis: statistical analysis is carried out by adopting SPSS18.0 software, and normally distributed measurement data is expressed by mean +/-standard deviation; calculating the average value of the direct CT measurement value and the oblique CT measurement value, and describing the normal distribution condition; statistically comparing and analyzing the difference of the intervertebral space depth of each segment and the difference of the intervertebral space depth measured by the X-ray film and the CT measured value; the comparison adopts a matched sample t test; p is less than 0.05, the difference is statistically significant;

1. difference between lumbar vertebra lateral position X-ray sheet intervertebral space depth and CT sheet intervertebral space vertical depth

The statistical comparison of the lumbar lateral X-ray disc intervertebral space depth measured at the L3/4, L4/5, L5/S1 spaces with the CT disc intervertebral space depth shows that the difference between the two groups of data is statistically significant (P < 0.05). The intervertebral space depth measured on the lateral lumbar X-ray is compared with the intervertebral space straight depth measured on the CT sheet, and an error exists. See Table 2 for details

TABLE 2 difference between lateral X-ray lumbar intervertebral space depth and direct X-ray CT intervertebral space depth (unit: mm)

2. Difference between vertical depth and oblique depth of intervertebral space of lumbar CT (computed tomography) plate

The difference between the vertical depth and the oblique depth of the intervertebral space of the CT slices of each segment of the lumbar vertebra measured by all patients is analyzed, and the difference between the two groups of data is shown to have statistical significance (P is less than 0.05). The oblique depth of each segmental intervertebral space is indeed deeper (about 2mm) than the depth of the straight intervertebral space. See Table 3 for details

TABLE 3 difference between the depth of the intervertebral space of the lumbar CT plate in the vertical direction and the depth of the intervertebral space in the oblique direction (unit: mm)

3. Difference between segments of straight and oblique depth of intervertebral space of lumbar CT (computed tomography) sheet

The difference between the three segments of the lumbar CT disc intervertebral space depth in the straight direction and the oblique direction measured by all patients is analyzed, and the difference of the three groups of data is not statistically significant (P is more than 0.05). The depth differences of the L3/4, L4/5 and L5/S1 intervertebral spaces are not large and are basically similar. See table 4 for details

TABLE 4 measurement of the difference between the depth of the lumbar CT plate L3/4 and the depth of the lumbar intervertebral space L4/5 in the vertical and oblique directions (unit: mm)

(6) It is concluded that the warning value of the straight incision depth for the intervertebral disc incision of the posterior intervertebral fusion is 34mm, and the warning value of the oblique incision depth for the intervertebral disc incision of the posterior intervertebral fusion is 36 mm.

Claims (2)

1. A method of determining a depth of disc incision for posterior lumbar interbody fusion, comprising: the method comprises the following steps:

(1) study sample inclusion criteria: selecting a patient for which the outpatient service preliminarily diagnoses the lumbar degenerative disease and passes through the X-ray examination at the lumbar positive side position and the CT flat scan examination of the lumbar intervertebral disc in the radiology department;

(2) sample exclusion criteria: removing the samples which meet the following conditions from the samples,

1. the age is less than 30 years old, 2, the age is more than 70 years old, 3, degenerative lateral bending and rotation of the spine exist, 4, osteophyte is massively proliferated, 5, osteoclastic diseases such as spinal tumor and tuberculosis exist together, 6, spondylolisthesis is more than III degrees, 7, the lumbar intervertebral disc has undergone surgical treatment;

(3) sample image acquisition: the patient is in a standing position when the patient irradiates the X-ray film at the right side of the lumbar vertebra, and the patient is in a horizontal position when the patient performs tomography;

(4) sample measurement indexes are as follows:

measuring the depth of intervertebral space in an X-ray film, taking a lumbar lateral X-ray film, and respectively measuring the lengths of the lower edges of vertebral bodies of L3 (third lumbar vertebra), L4 (fourth lumbar vertebra) and L5 (fifth lumbar vertebra) as the depth of the intervertebral space of L3/4, L4/5 and L5/S1;

measuring the CT intervertebral space vertical depth, setting 1/4 position of the transverse diameter of the vertebral canal as a starting point, making a vertical line of the transverse diameter line of the vertebral canal through the starting point, taking the intersection point of the vertical line and the rear edge of the lower endplate image of the vertebral body as a point A and the intersection point of the vertical line and the front edge as a point B, measuring the distances among AB points of L3, L4 and L5 vertebral bodies as the CT vertical depth of the intervertebral spaces L3/4, L4/5 and L5/S1 respectively;

measuring the oblique depth of the CT intervertebral space: setting the intersection point of the vertical line of the outer side boundary of the vertebral canal and the image of the top point of the facet joint as a maximum inclined point (0 point), connecting the 0 point with the A point to form a straight line, taking the point of the intersection of the straight line and the image front edge of the lower end plate of the vertebral body as a C point, measuring the distances among the AC points of the vertebral bodies of L3, L4 and L5, and respectively taking the distances as the CT inclined depths of intervertebral spaces of L3/4, L4/5 and L5/S1;

(5) and (3) sample statistical analysis: statistical analysis is carried out by adopting SPSS18.0 software, and normally distributed measurement data is expressed by mean +/-standard deviation; calculating the average value of the direct CT measurement value and the oblique CT measurement value, and describing the normal distribution condition; statistically comparing and analyzing the difference of the intervertebral space depth of each segment and the difference of the intervertebral space depth measured by the X-ray film and the CT measured value; the comparison adopts a matched sample t test; p is less than 0.05, the difference is statistically significant;

(6) it is concluded that the warning value of the straight incision depth for the intervertebral disc incision of the posterior intervertebral fusion is 34mm, and the warning value of the oblique incision depth for the intervertebral disc incision of the posterior intervertebral fusion is 34 mm.

2. The method of determining the depth of disc incision for posterior lumbar interbody fusion as recited in claim 1, wherein: in the step (5), the number of the male and the female is equal, and the total number is not less than 100.

Images