新型3D打印多孔钛人工椎体在猪脊柱模型置换前后的生物力学测试研究

目的通过对新型3D打印多孔钛人工椎体在猪脊柱模型置换前后的生物力学测试比较研究,评价该新型3D打印人工椎体的活动范围情况和即刻的生物力学稳定性。方法选取18具新鲜相近的猪脊柱标本(L1-L6),根据L3椎体置换前后,分为置换前组和置换后组。分别测试前屈、后伸、左右侧屈、左右旋转的位移角度变化。结果在0~8N.m逐级加载中,置换后组运动节段在前屈、后伸、左右侧屈各向量的位移角度变化明显小于置换前组,差异有统计学意义(0.05),而在轴位旋转位上,两者无显著性差异(0.05)。结论新型3D打印人工椎体的设计具有合理性和创新性,在猪脊柱模型L3椎体置换后,即刻可获得良好的生物力学稳定性。     

3D打印在中国骨科应用的现状与未来

3D打印正以惊人的速度向医疗领域渗透。所有领先的骨科医疗器械公司都开始利用3D打印技术研发新的植入产品。现在,在骨科领域,3D打印正快速的完成从实验室到临床的科技成果转化。不仅仅用3D打印技术制作各种解剖模型、手术导板,也用它来研制各种新型的植入物,如髋臼臼杯、脊柱椎体等。未来3D打印将会发挥其更大的优势——制作患者定制型的假体。因此,只有真正意义上的临床转化才能展现3D打印的价值和未来。目前,3D打印技术面临的一个主要的制约是来自于政府的政策监管,特别是对于患者定制型假体这一领域。3D打印技术的出现,也许给了中国骨科研发自主创新的医疗器械赶上西方发达国家一个机会。     

3D打印个体化人工椎体在胸腰椎肿瘤整块切除后脊柱稳定性重建中的应用

目的探索3D打印个体化人工椎体在胸腰椎肿瘤整块切除后脊柱稳定性重建中的临床疗效。方法回顾性分析华中科技大学同济医学院附属同济医院2015年7月至2020年6月收治的接受一期后路全脊椎整块切除术的胸腰椎肿瘤患者28例,分为2组,每组14例。其中3D组使用3D打印个体化人工椎体重建,常规组使用钛笼重建。对比两组的住院时间、手术时间、术中出血量,记录术前、术后7 d及末次随访时视觉模拟评分(VAS),Frankel分级情况,测量节段高度及角度,评估临床疗效。结果两组患者住院时间、手术时间、术中出血量和VAS评分比较,差异无统计学意义。共8例患者Frankel评分获得一个等级的改善(28.6%)。3D组椎间高度丢失(1.9±2.2)mm,内植物沉降2例,沉降率14.3%;常规组椎间高度丢失(6.6±5.5)mm,内植物沉降8例,沉降率57.1%;两组比较差异有统计学意义(<0.05)。在节段角度丢失方面组间差异无统计学意义(=0.571)。3D组所有患者内固定良好,常规组1例患者发生断棒情况。结论 3D打印人工椎体可以更好地维持节段高度,降低椎间隙塌陷和内固定失败的风险。     

3D打印假体与单纯钉棒系统用于全骶骨切除重建的有限元分析比较

目的 比较3D打印假体与单纯钉棒系统用于全骶骨切除后腰椎-骨盆稳定性重建效果的有限元分析差异.方法 创建三种腰椎-骨盆重建的有限元分析模型:模型1为单侧双髂骨钉双棒重建;模型2为单侧双髂骨钉双棒+3D打印假体重建,其中下方髂骨钉穿过假体;模型3为单侧双髂骨钉双棒+3D打印假体重建,髂骨钉不穿过假体.在有限元分析软件中为...     

经后路全脊椎切除术在胸腰椎肿瘤治疗中的应用

目的:探讨经后路全脊椎切除、自体骨移植与内固定治疗胸腰段脊柱肿瘤的可行性和临床疗效.方法:对2007年6月~2010年8月间11例胸腰段脊柱肿瘤患者采取经后路全脊椎切除、自体骨移植与钉棒内固定术,其中肋骨移植6例、自体髂骨移植2例、骨水泥重建3例.按 Tomita分型,1型2例,2型2例,4型6例,5型1例.Frankel分级术前 A级1例,B级1例,C级2例,D级4例,E级3例.结果:手术时间150~380min,平均270min,出血量400ml~4000ml,平均2230ml.术后随访9~48个月.3例死亡,其中1例肾母细胞瘤 T4转移,术后5个月与死于肺转移呼吸衰竭;1例肺癌 T9转移,同时局部复发于术后8个月死于呼吸衰竭;1例肝癌 L1转移,术后6个月死于上消化道大出血.其余未见复发.本次随访时 Frankel分级 C级3例,D级4例,E级4例.结论:按照 Tomita分型选择适合的胸腰段脊柱肿瘤,采用单一后路全脊椎切除、自体骨移植与钉棒内固定重建,能获得创伤小、并发症少,疗效可靠的临床效果.     

3D打印技术在脊柱外科中的应用进展

总结国内外脊柱外科,特别是在复杂脊柱疾病中（尤其是严重脊柱畸形和脊柱肿瘤）使用3D打印技术的文献,重点关注提到的3D打印种类、具体应用方法、治疗效果以及成本效益分析。对在脊柱外科手术中使用3D打印技术的文献进行电子检索,国内文献使用中国知网数据库进行检索,国外文献使用PubMed以及Web of Science数据库进行检索。检索词为:脊柱外科、3D打印技术、增材制造、快速成型、脊柱畸形、脊柱肿瘤;英文词为:Spine、Scoliosis、Spinal Tumor、3D printing、Additive manufacturing、Rapid prototyping。并对纳入的文献进行分类总结,检索到文献116篇（中文72篇,英文44篇）,进行全文阅读分析后纳入文献35篇（中文15篇,英文20篇）。根据文献内容将3D打印应用分为手术导板、解剖模型以及个体化植入物。纳入文献提到的优点主要有减少手术时间、出血量、术中照射次数以及手术并发症发生率、改善治疗效果、提高患者满意度等。主要局限在于该技术目前缺乏统一标准、额外的打印费用、增加的学习成本、设计3D打印物耗费的时间以及植入物远期可靠性等。3D打印技术在脊柱疾病的治疗中确有价值,但在常见脊柱疾病中使用3D打印技术的意义和价值并不大,只有在较为复杂的病例中使用这项技术才能符合成本效益原则。     

生长棒不同固定术式治疗早发性脊柱侧凸的生物力学分析

目的 研究生长棒技术治疗早发性脊柱侧凸过程中不同上固定节段选择对术后脊柱生物力学特性的影响。方法 利用有限元技术分别建立同一患者行生长棒术前以及术后T1～L4、T2～L4、T3～L4固定共4个脊柱模型（C6～S1节段）,在C6上表面分别施加7 N·m力矩载荷和1 rad角位移载荷,分析上固定椎体邻近结构的生物力学特性。结果 生长棒术后脊柱整体活动度（range of motion, ROM）显著下降,固定T2～L4节段时,脊柱活动受限最大,邻近椎体代偿性活动显著增加,椎间盘应力增大最明显。结论 生长棒上固定选择T2节段时,术后发生交界性胸椎后凸和脊柱退行性病变的风险最高,在临床手术中应加以避免。     

3D打印辅助经皮穿刺椎体成形术治疗重度骨质疏松性椎体压缩骨折的疗效

目的 探讨3D打印技术辅助经皮穿刺椎体成形术（PVP）治疗重度骨质疏松性椎体压缩骨折（OVCF）的疗效。方法 回顾性分析我院收治的82例重度OVCF患者的临床资料,根据手术方式不同将患者分为对照组（42例,采用常规PVP治疗）和观察组（40例,采用3D打印技术辅助PVP治疗）。比较2组手术和术后恢复相关指标、骨折椎体影像学指标、腰椎功能、疼痛程度、生活质量及并发症。结果 观察组穿刺定位时间、手术时间短于对照组（P<0.05）,透视次数少于对照组（P<0.05）,骨水泥渗漏发生率低于对照组（P<0.05）。2组术后腰椎功能、骨折椎体影像学指标、疼痛程度、生活质量均较术前改善（P<0.05）,但组间比较差异无统计学意义（P>0.05）。结论 3D打印技术辅助PVP治疗重度OVCF可缩短穿刺定位时间和手术时间,减少术中透视次数,降低骨水泥渗漏风险。     

保留椎弓连续性的有限椎管次环状减压术式的研究

目的为减少传统的椎管次全环状减压术所造成的脊椎结构破坏过多、导致脊柱不稳的发生,探索一种保留椎弓连续性的有限椎管次环状减压新术式。方法首先对T11～L3脊椎骨(脊柱骨折的好发部位)标本进行测量。得到可靠数据后,再进行临床操作。结果发现该段脊柱椎板与椎弓根的位置关系,完全不在同一平面上,且椎板有足够宽度,只需将椎板的上缘部分切除,即可显露椎弓根结构,经椎弓根达到椎体后缘的显露,再解除椎管前方的碎骨块压迫。结论椎管次环状减压术,无须按传统的方法破坏过多的脊柱后部的结构,使椎弓的环状完整性有效保留。保留椎弓连续性的椎管次环状减压术存在可行性,该术式既保留脊椎的稳定性,又达到了椎管减压彻底的目的。     

3D打印技术在骨科临床的应用研究及展望

近年来3D打印技术快速发展,在临床的应用越来越广泛,尤其在骨科的应用涉及到了各个亚专科。3D打印实物模型与X线片、CT、MRI等影像资料相比具有独特的直观性、可触摸和体外操作性。利用3D打印模型可进行术前的规划和手术方案的优化,指导内固定装置置入,也可进行模拟手术。3D打印导板同样为内固定物的置入提供了新的方法。同时个体化模板辅助置钉法能缩短手术时间,减少术中的放射线暴露时间。个性化内植物的使用可简化手术步骤,减少组织损伤。使内植物更加贴合骨面,比较完美地解决传统假体不能完全匹配患者骨骼的问题,而且可以打印出适合任何形状骨缺损的假体。3D打印技术的应用使复杂的骨科手术变得相对容易,手术的效果也就得到了提高。随着3D打印技术的进步和完善,其在医学领域的应用范围会越来越广泛,打印精度和材质适应性也会越来越高,具有推广的价值。本文在复习国内外有关3D打印文献的基础上结合本科应用病例的实际情况对3D打印技术在骨科临床的应用进行综述。     

Changes in Spinal Canal Diameter and Vertebral Body Height with Age

Purpose

All structures of the spine, including the spinal canal, change continuously with age. The purpose of this study was to determine how the spinal canal of the lumbar spine changes with age. The L4/5 is the most common site of spinal stenosis and has the largest flexion-extension motion, whereas the T5/6 has the least motion. Therefore, we measured the spinal canal diameter and vertebral body height at T5, T6, L4, and L5 with age.

Materials and Methods

This was a retrospective study of aged 40 to 77 years. We reviewed whole spine sagittal MRIs of 370 patients with lumbar spinal stenosis (LSS) (Group 2) and 166 herniated cervical disc (HCD) (Group 1). Each group was divided into four age groups, and demographic parameters (age, gender, height, weight, BMI), the mid-spinal canal diameter, and mid-vertebrae height at T5, T6, L4, L5 were compared. Within- and between-group comparisons were made to evaluate changes by age and correlations were carried out to evaluate the relationships between all parameters.

Results

Height, weight, and all radiologic parameters were significantly lower in Group 2 than Group 1. Group 1 did not show any differences, when based on age, but in Group 2, height, weight, and T6, L4, and L5 height were significantly decreased in patients in their 70''s than patients in their 40''s, except for spinal canal diameter. Age was associated with all parameters except spinal canal diameter.

Conclusion

Vertebral height decreased with age, but spinal canal diameter did not change in patients with either LSS or HCD. Mid-spinal canal diameter was not affected by aging.     

Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy

BACKGROUND: Chronic reflex sympathetic dystrophy (also called the complex regional pain syndrome) is a painful, disabling disorder for which there is no proven treatment. In observational studies, spinal cord stimulation has reduced the pain associated with the disorder. METHODS: We performed a randomized trial involving patients who had had reflex sympathetic dystrophy for at least six months. Thirty-six patients were assigned to receive treatment with spinal cord stimulation plus physical therapy, and 18 were assigned to receive physical therapy alone. The spinal cord stimulator was implanted only if a test stimulation was successful. We assessed the intensity of pain (on a visual-analogue scale from 0 cm [no pain] to 10 cm [very severe pain]), the global perceived effect (on a scale from 1 [worst ever] to 7 [best ever]), functional status, and the health-related quality of life. RESULTS: The test stimulation of the spinal cord was successful in 24 patients; the other 12 patients did not receive implanted stimulators. In an intention-to-treat analysis, the group assigned to receive spinal cord stimulation plus physical therapy had a mean reduction of 2.4 cm in the intensity of pain at six months, as compared with an increase of 0.2 cm in the group assigned to receive physical therapy alone (P<0.001 for the comparison between the two groups). In addition, the proportion of patients with a score of 6 ("much improved") for the global perceived effect was much higher in the spinal cord stimulation group than in the control group (39 percent vs. 6 percent, P=0.01). There was no clinically important improvement in functional status. The health-related quality of life improved only in the 24 patients who actually underwent implantation of a spinal cord stimulator. Six of the 24 patients had complications that required additional procedures, including removal of the device in 1 patient. CONCLUSIONS: In carefully selected patients with chronic reflex sympathetic dystrophy, electrical stimulation of the spinal cord can reduce pain and improve the health-related quality of life.     

14例脊柱骨样骨瘤的临床特征及外科治疗

目的 探讨脊柱骨样骨瘤的临床特征和外科切除的临床疗效。方法 回顾性分析武汉大学中南医院2008年6月至2018年6月诊治的14例脊柱骨样骨瘤患者。其中男8例,女6例;平均年龄（37.4±11.2）岁（11 ～ 63岁）;病程（7.5±2.1）个月（4 ～ 13个月）。病灶位于颈椎2例、胸椎4例、腰椎5例、骶椎3例,所有患者术前均行X线、CT及MRI检查,术后病理结果均证实为骨样骨瘤。临床疗效评价采用疼痛视觉模拟评分（VAS）、Oswestry功能障碍指数问卷表（ODI）及美国脊髓损伤协会（ASIA）制定的神经功能评分来评估脊髓功能,随访期间观察并发症、术前症状和脊髓功能恢复情况。结果 本组所有患者均获随访,平均（31±2）个月（19 ～ 42个月）,VAS评分由术前（6.4±1.8）分减小到（0.7±0.7）分,VAS变化存在统计学意义（P<0.001）,ODI评分由术前（53.8±8.1）分减小到（21.2±5.9）分（P<0.001）,差异具有统计学意义;术前神经功能ASIA分级：C级2例,D级7例,E级5例。术后3个月随访D级2例,E级12例,末次随访中术前有脊髓神经功能障碍者均恢复至ASIA E级。术后1例患者出现手术切口脂肪液化,1例出现神经功能损害加重的症状,经对症治疗后逐渐缓解,余末次随访均未见肿瘤复发或恶变等并发症。结论 位于椎体及附件的脊柱骨样骨瘤临床表现复杂多样,薄层CT能够快速准确诊断及定位瘤巢,而对于毗邻神经及血管的肿瘤,积极的手术切除仍是脊柱骨样骨瘤的有效治疗方式。     

螺旋型髋臼与压配型髋臼的临床应用分析

背景：在人工全髋关节置换髋臼假体的选择上,多数研究认为螺旋型髋臼较压配型髋臼能的稳定性好。 目的：对比螺旋型髋臼与压配型髋臼两种不同全髋关节置换的临床疗效。 方法：回顾性分析选择螺旋型髋臼与压配型髋臼两种不同人工全髋关节置换39例患者临床资料。 结果与结论：①随访时间：随访4~51个月,平均32.6个月。②Harris评分：末次随访时两组Harris评分均较置换前明显提高(P < 0.05),且螺旋型髋臼假体组稍高于压配型髋臼假体组,但差异无显著性意义。③不良反应：压配型髋臼假体组置换1年后松动1例,术后行走疼痛3例,髋臼假体周围成骨6例,髋臼假体周围出现透亮带3例,髋臼假体周围骨硬化1例,髋臼假体周围骨吸收1例;螺旋型髋臼假体组髋臼假体周围成骨3例,髋臼假体周围出现透亮带1例,髋臼假体周围骨吸收1例。表明螺旋型髋臼假体的初始稳定性优于压配型髋臼假体。      

基于单幅X线图像和CT数据的2D/3D配准系统

目的建立基于统一计算架构(CUDA)下以单幅X线图像及CT扫描数据为数据源的2D/3D配准系统,并应用于膝关节在体运动及植入假体稳定性研究。方法首先应用张正友标定法对采集X线图像设备进行标定;其次基于CUDA构架利用光线跟踪算法生成数字影像重建图像,以相关性函数为相似性测度计算2D/3D配准参数;最后以三维激光扫描仪所获得的点云数据进行3D/3D配准,以验证2D/3D配准结果。结果以标本整体位置变换进行配准实验,6自由度平均误差中,位移小于1mm,旋转小于1°。结论此2D/3D配准系统达到了运动检测精度的要求,可以作为研究膝关节运动情况和假体在体稳定性研究的计算平台。     

Estimation of 3D location and orientation of human vertebral facet joints from standing digital radiographs

This study provides a biplanar radiographic reconstruction method of volumes of interest to evaluate the location, dimensions and orientation of human facet joints. Visibility of facet anatomical landmarks and areas of interest was evaluated on digital radiographs of 20 idiopathic scoliotic adolescents. Areas of interest have provided the most reliable evaluation of facet joints on postero-anterior and lateral digital radiographs. Volumes of interest of a thoracic and lumbar spinal segment (T1 to L3) were computed using the proposed biplanar 3D reconstruction method and compared with serial tomographic reconstructed models. Differences of 1.5±0.7 mm in 3D location and 1.8±1.2° in sagittal orientation of volumes of interest were observed between both representations. This in vivo geometric information on human vertebral facet joints will help us to understand their role in spinal disorders and will provide important data for personalised biomechanical simulations.     

Surgical Impacts of Metastatic Non-small Cell Lung Cancer to the Thoracic and Lumbar Spine

BackgroundSurgery for spinal metastasis is rapidly increasing in frequency with procedures ranging from laminectomy to spondylectomy combined with stabilization. This study investigated the effect of various surgical procedures for spinal metastasis of non-small cell lung cancer (NSCLC).MethodsA single-center consecutive series of patients who underwent surgery for spinal metastasis of NSCLC were retrospectively reviewed. Patients'' characteristics, radiographic parameters, operative data, clinical outcomes, and complications were analyzed. Surgical outcomes were assessed according to pain and performance status before and after surgery. Overall survival (OS) rate was estimated using the Kaplan-Meier method. Multivariate analysis was performed to detect factors independently associated with OS using a Cox proportional hazards model.ResultsTwenty-one patients were treated with laminectomy, 24 with corpectomy, 13 with spondylectomy (piecemeal or total en bloc fashion), and all procedures were combined with stabilization. Back pain and performance status improved significantly after surgical treatment among the three groups. Revision surgery due to tumor progression at the index level or spinal metastasis at another level were four patients (19.0%) in the laminectomy group, six patients (25.0%) in the corpectomy group, and one patient (7.7%) in the spondylectomy group. A Charlson comorbidity index and the number of spinal metastasis negatively affected OS (hazard ratio [HR], 19.613 and 2.244). Postoperative chemotherapy, time to metastasis, spondylectomy, and corpectomy had favorable associations with OS (HR, 0.455, 0.487, 0.619, and 0.715, respectively).ConclusionPostoperative chemotherapy was the most critical factor in OS of patients with metastatic NSCLC to the spine. An extensive surgical procedure (corpectomy/spondylectomy) with stabilization also could be beneficial for limited patients with spinal metastasis of NSCLC.     

Type 3 reovirus neuroinvasion after intramuscular inoculation: viral genetic determinants of lethality and spinal cord infection

To better understand the mechanisms by which neurotropic viruses invade peripheral nerve pathways and produce CNS disease, we defined the type 3 (T3) reovirus genes that are determinants of the capacity of reovirus T3 strain Dearing (T3D) and T3 clone 9 (C9) to infect the spinal cord and kill mice after hindlimb injection. T3D and C9 viruses are both highly virulent (LD(50) < 10(1) PFU) after intracranial injection of neonatal mice. However, C9 is significantly more lethal than T3D after either intramuscular injection (LD(50) < 10(1) vs LD(50) 10(4) PFU) or peroral injection (LD(50) 10(3.4) vs LD(50) > 10(8.3) PFU). Using reassortant viruses containing different combinations of genes derived from T3D and C9, we found that the S1 gene, encoding the cell attachment protein sigma 1 and the nonstructural protein sigma 1s, and the L3 gene, encoding the core shell protein lambda 1 were the primary determinants of lethality after intramuscular injection. The L3 gene and the L2 gene encoding spike protein, lambda 2, determined differences in spinal cord titer after intramuscular injection. A C9 x T3D mono-reassortant containing all T3D genes except for the C9-derived L3 was lethal after peroral injection. These studies indicate that the S1, L2, and L3 genes all play a potential role in neuroinvasiveness and provide the first identification of a role in pathogenesis for the L3 gene.     

CNS-infiltrating CD4+ T lymphocytes contribute to murine spinal nerve transection-induced neuropathic pain

We previously reported leukocytic infiltration into the lumbar spinal cord in a rodent spinal nerve L5 transection (L5Tx) neuropathic pain model. Here, we further investigated the role of infiltrating T lymphocytes in the etiology of persistent pain following L5Tx. T lymphocyte-deficient nude mice showed no evident mechanical hypersensitivity after day 3 of L5Tx compared to wild-type BALB/c mice. Through FACS analysis, we determined that significant leukocytic infiltration (CD45(hi)) into the lumbar spinal cord peaked at day 7 post L5Tx. These infiltrating leukocytes contained predominantly CD4(+) but not CD8(+) T lymphocytes. B lymphocytes, natural killer cells and macrophages were not detected at day 7 post L5Tx. No differences in the activation of peripheral CD4(+) T lymphocytes were detected in either the spleen or lumbar lymph nodes between L5Tx and sham surgery groups. Further, CD4 KO mice displayed significantly decreased mechanical hypersensitivity after day 7 of L5Tx, and adoptive transfer of CD4(+) leukocytes reversed this effect. Decreased immunoreactivity of glial fibrillary acidic protein observed in CD4 KO mice post L5Tx indicated possible T lymphocyte-glial interactions. These results strongly support a contributing role of spinal cord-infiltrating CD4(+) T lymphocytes versus peripheral CD4(+) T lymphocytes in the maintenance of nerve injury-induced neuropathic pain.     

Efficacy of Percutaneous Epidural Neuroplasty Does Not Correlate with Dural Sac Cross-Sectional Area in Single Level Disc Disease

Purpose

Percutaneous epidural neuroplasty (PEN) is a minimally invasive treatment. The efficacy of PEN has been relatively well investigated; however, the relationship between the clinical effectiveness of PEN and the severity of spinal canal stenosis by disc material has not yet been established. The purpose of this study was to compare clinical outcomes of PEN according to the dural sac cross-sectional area in single level disc disease.

Materials and Methods

This study included 363 patients with back pain from single level disc disease with and without radiculopathy. Patients were categorized into groups according to spinal canal compromise by disc material: Category 1, less or more than 50%; and Category 2, three subgroups with lesser than a third, between a third and two thirds, and more than two thirds. Clinical outcomes were assessed according to the Visual Analog Scale (VAS) score for back pain and leg pain and Odom''s criteria at 1, 3, 6, 12, and 24 months after treatment.

Results

The demographic data showed no difference between groups according to spinal canal compromise by disc material except age (older age correlated with more spinal canal compromise). The dural sac cross-sectional area did not correlate with the VAS scores for back and leg pain after PEN in single level disc disease in Groups 1 and 2. Odom''s criteria after PEN were also not different according to dural sac cross-sectional area by disc material.

Conclusion

PEN is an effective procedure in treating single level lumbar disc herniation without affecting dural sac cross-sectional area.