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1、1寰枢椎椎弓根影像学测量及临床应用作者：贾卫斗，郑铁钢，杨博贵，白桂有，许英杰，云德才【摘要 】 目的探讨利用影像学资料，测量寰枢椎椎弓根的数据，提高寰枢椎椎弓根置钉的成功率。 方法对寰枢椎 CR、DR X 线片、MRI 及 64 排 CT 片，通过图像储存传输系统，测量寰椎椎弓根进行进钉点、进钉角度的测量。 结果寰椎椎弓根进钉点：左侧(19.931.32)mm，右侧(19.161.30)mm；寰椎椎弓根向内侧进钉角度：左侧 23.722.09，右侧 23.351.91；寰椎向头侧进钉角度 91.2。枢椎椎弓根进钉点：左侧(13.140.82)mm，右侧(13.850.79)mm；枢椎椎弓根向
2、内侧进钉角度：左侧 24.521.26，右侧 20.421.42；枢椎向头侧进钉角度 253。对 48例患者行寰枢椎椎弓根经椎弓根内固定手术。其中男 35 例，女 13例。年龄 2261 岁，平均 43.60 岁。型陈旧性齿状突骨折 22 例，齿状突不连 12 例，横韧带损伤 14 例。所有患者 X 线片示寰椎完全复位，枢椎齿状突骨折处对位良好。平均 10.6 个月，均获得骨性融合。按 JOA 评分标准，优 31 例，良 14 例，可 2 例，差 1 例，优良率 93.75。 结论利用影像学资料测量，对寰枢椎椎弓根内固定手术的实际操作有良好的指导意义。 【关键词】 寰枢椎； 椎弓根； 影像学资
3、料； 测量； 内固定2Abstract：ObjectiveTo provide quantitative data of atlantoaxial pedicle for its surgical screw internal fixation by imageology measurement and improve the success rate of the surgical treatment. Method The examinations ofCR, DRX, MRI and 64-row CT were performed in each patient preoperativ
4、ely, and the atlantoaxial pedical screw entry points and screw entry angles were then measured by PACsee system.ResultThe atlas pedicle screw entry points were localized position which its distance to the left of the atlas pedicle midline was ( 19.931.32) mm, and to the right of the atlas pedicle mi
5、dline was (19.161.30)mm. The screw entry angles to the inside of the atlas pedicle were localized position which its distance to the left of the atlas pedicle midline was (23.722.09), and to the right of the atlas pedicle midline was (23.351.91). The screw entry angle to the head of the atlas pedicl
6、e was (9.001.20). The axis pedicle screw entry points were localized position which its distance to the left of the axis pedicle midline was (13.14+0.82) mm, and to the right of the axis pedicle midline was (13.850.79)mm. The screw entry angles to inside of the axis pedicle were localized position w
7、hich its distance to the 3left of the axis pedicle midline was (24.521.26), and to the right of the axis pedicle midline was (20.421.42),The screw entry angle to the head of the axis pedicle was (253).48 patients were taken treatment with atlantoaxial pedicle surgical screw intemal fixation. Among t
8、hese patients, there were 35 males and 13 females with a mean age 43.60 years old (ranged 22 to 61 years old), 22 patients with type II old odontoid fracture,12 patients with odontoid nonunion and 14 patients disruption of the transverse ligament. The x-ray and CT scans of all post-surgery patients
9、could prove the atlas were completely reduced, axis odontoid fracture had good reduction and bony fusion were achieved after 10.6 months. The JOA evaluation standards showed 31 patients were excellent, 14 patients were good, 2 patients were fair and a patient was poor, excellent and good ratio was 9
10、3.57%.ConclusionThe imageology measurement quantitative data of atlantoaxial pedicle could guide effectively the screw internal fixation surgery.Key words：atlantoaxial pedicle; imageology measurement; the screw intemal fixation surgery42001 年 10 月2007 年 9 月，作者于术前采用自行设计的方案，对影像学资料测量个性化定位方案，术中利用自制的寰枢椎椎
11、弓根定位导向器，对 48 例患者行寰枢椎经椎弓根固定手术，收到较好治疗效果。报告如下。1 资料与方法1.1 一般资料男 35 例，女 13 例。年龄 2261 岁，平均 43.60 岁。型陈旧性齿状突骨折 22 例，齿状突不连 12 例，横韧带损伤 14 例。1.2 术前准备术前常规摄颈椎正、侧位及过屈、过伸位 X 线片，并行 CT 或MRI 检查，明确损伤节段、损伤类型及神经损伤程度。64 排 CT 扫描层为 1 mm，以观察椎弓根及其松质骨宽度。CT 个性化测量：（1）测量进钉点：利用图像储存传输系统(以下简称 Pacs)，通过寰枢椎前结节或椎体及后结节或棘突划一垂直线，分别划与垂直线平行
12、的椎弓根内缘线、椎弓根中线、椎弓根外缘线。测量寰枢椎垂直线与椎弓根内缘线、椎弓根中线、椎弓根外5缘线距离；（2）测量进钉角度：在气管后缘正中设一点为 O 点，通过 O 点划一垂直线，经左右椎弓根内缘至 O 点的连线，形成 2个锐角；经左右椎弓根中点至 O 点连线，形成 2 个锐角；经左右椎弓根外缘与 O 点连线，形成 2 个锐角。X 线片测量矢状位进钉角度：取颈椎侧位片，通过寰椎前结节上缘划一水平线，测量寰椎椎弓根及前结节中点角度。通过枢椎椎体上缘划一水平线，测量枢椎椎弓根与椎体中上 13 交界处角度。按照上述测量方法，作者对 200 例寰枢椎 X 线片及 CT 片利用Pacs 进行测量，认为
13、寰椎椎弓根安全进钉点(距寰椎后弓结节中点) ：左侧(19.931.32)mm，右侧(19.161.30)mm；寰椎椎弓根宽度：左侧(9.151.32)mm，右侧(9.461.3 ）mm；寰椎椎弓根向内进钉角度：左侧 23.722.09，右侧 23.351.91；寰椎向头侧进钉角度 91.2，为寰椎椎弓根安全进钉角度。枢椎椎弓根进钉点( 距枢椎棘突后正中)：左侧(13.140.82)mm，右侧(13.850.79)mm，为安全进钉点；枢椎椎弓根向内进钉角度：左侧 24.521.26，右侧 20.421.42，枢椎向头侧进钉角度 253，为枢椎安全进钉角度（表 1、2 ） 。 表 1 寰枢椎进钉点
14、测量结果 表 2 寰枢椎进钉角度测量结果（1.3 手术方法6采用气管插管全麻，取头高足低俯卧位，后正中切口，显露出寰椎后弓及枢椎的椎板、椎弓根及峡部。根据术前测量的进钉点及入钉角度，采用自制的寰枢椎椎弓根定位导向器定位后，在后弓用直径 2 mm 尖手锥破骨皮质。沿椎弓根缓慢钻孔至 2025 mm，无异常后扩孔至 3 mm，对侧同样操作。枢椎根据术前测量的进钉点、向内侧及头侧倾斜角度，采用自制的寰枢椎椎弓根定位导向器定位后，沿椎弓根钻孔至 2528 mm，无异常后扩孔至 3 mm,对侧同样操作。C 型臂 X 线机透视观察定位针的位置，寰枢椎拧入直径33.5 mm，长度 2224 mm 的椎弓根螺
15、钉 2 枚，枢椎拧入直径33.5 mm，长度 2628 mm 的椎弓根螺钉 2 枚，将钛板预弯、固定。将寰椎后弓及枢椎椎板骨皮质咬至点状出血的粗糙面，取髂骨 2030 g 松质骨，制作成 3 cm0.2 cm0.2 cm 骨柴及 2 mm2 mm2 mm 颗粒状骨，先以骨柴纵行置于寰椎后弓及枢椎椎板之间，然后以颗粒状骨充填，逐层缝合。2 结 果2 例术后出现枕大神经痛，经对症治疗 1 个月后痊愈；2 例螺钉穿破寰椎左侧椎弓根外侧壁，未发现脊髓、椎动脉损伤。所有患者X 线片示寰椎完全复位，枢椎齿状突骨折处对位良好。平均 10.6 个月，均获得骨性融合。按 JOA 评分标准，优 31 例，良 14
16、 例，可2 例，差 1 例，优良率 93.75。未发现钉板断裂。7典型病例，男，54 岁。陈旧性齿状突 型骨折，寰椎向前脱位，行后路经寰枢椎椎弓根钉板内固定术，术后随访 18 个月，X 线片和CT 片。图 1 术前侧位 X 线片 图 2 术后 2 周正位 X 线片 图 3 术后 2 周侧位 X 线片 图 4 术后 2 周寰椎 CT 片 图 5 术后 2 周枢椎CT 片 图 6 术后 18 个月侧位 X 线片3 讨 论3.1 经寰枢椎椎弓根固定的优越性寰枢椎融合的方法较多，传统的手术治疗方法固定强度差，抗旋转强度更低，手术操作难度较大，容易发生脊髓损伤。寰枢椎椎弓根钉板固定可使寰枢椎即刻得到坚强的三维固定，为植骨融合创造了有利条件。经寰椎椎弓根螺钉固定较经其侧块螺钉固定具有螺钉通道长、把持力好、螺钉与后部钢板容易锁定、术中出血少
