摘要
目的 评估骨科机器人辅助及徒手椎弓根螺钉植入技术对上颈椎手术安全性及准确性的影响.方法 回顾性分析2017年1月至2023年3月63例上颈椎疾病患者的病历资料,依据置钉技术不同分为机器人辅助置钉组(41例)和徒手置钉组(22例).机器人辅助置钉组行枕颈融合术9例和寰枢椎及以远椎体固定融合术32例,徒手置钉组分别为8例和14例.术后随访至少6个月,采用影像学参数、美国脊柱损伤协会(American Spinal Injury Association,ASIA)脊髓损伤分级、疼痛视觉模拟评分(visual analogue scale,VAS)和日本骨科协会(Japanese Orthopaedic Association scores,JOA)评分评估术后疗效.比较两组患者的病程、手术时间、术中出血量、透视次数和辐射剂量、住院时间、治疗费用、并发症、椎弓根螺钉置入率、上颈椎椎弓根螺钉置入的准确性及影响因素.结果 机器人辅助置钉组中枕颈融合患者和寰枢椎及以远椎体固定融合患者的椎弓根螺钉置入率分别为100％和89.6％(138/154),超过徒手置钉组的43％(18/42)和78％(54/69),差异有统计学意义(x2=37.403,P＜0.001;x2=5.128,P=0.024).机器人辅助置钉组两类手术患者的透视辐射剂量和手术时间均超过徒手置钉组(P＜0.05).与徒手置钉组相比,机器人辅助置钉组C1螺钉准确性由42％(11/26)提高至80％(51/64),差异有统计学意义(x2=13.342,P=0.004);C2螺钉准确性由77％(33/43)提高至88％(63/72),差异无统计学意义(x2=2.863,P=0.413).机器人辅助置钉组C1和C2椎弓根螺钉置入的准确性与导针置入顺序相关(r=0.580,P＜0.001;r=0.369,P=0.001).两组患者手术前后延髓角、Chamberlain线、McGregor线、Boogard角、Bull角、斜坡椎管角、枕颈角、后枕颈角、C2～C7角及寰齿前间隙的组间差异均无统计学意义(P＞0.05);两组患者术后ASIA脊髓损伤分级均有不同程度提高,术前、术后及末次随访时的组间差异均无统计学意义(P＞0.05);两组患者VAS评分和JOA评分术后及末次随访时较术前均改善(P＜0.05),而术前、术后及末次随访时的组间差异均无统计学意义(P＞0.05).两组患者均未发生与置钉相关的并发症.结论 骨科机器人辅助与徒手椎弓根螺钉置入技术治疗上颈椎疾病均取得满意的疗效.机器人辅助能减少透视辐射剂量,提高置钉准确性,但需避免优先导针置入产生的椎体位移.
Abstract
Objective To evaluate the impact of orthopedic robotic assistance and conventional freehand methods on surgical strategies,the safety of pedicle screw placement,and clinical efficacy in patients with upper cervical spine diseases.Methods From January 2017 to March 2023,a total of 63 cases with upper cervical spine disease,were divided into two groups based on the screw placement technique:the robot-assisted pedicle screw placement(RA)group(41 cases)and the conventional freehand pedicle screw placement(CF)group(22 cases),were retrospectively included.These patients in the RA and CF groups underwent two types of posterior cervical surgery,including occipitocervical fusion(9 cases and 8 cases)and fixation and fusion of atlantoaxial and distal vertebrae(32 cases and 14 cases).The outcome parameters,including the disease course,surgical time,in-traoperative blood loss,fluoroscopy frequency,radiation dose,hospital stay,treatment costs,complications,the rate of the pedicle screw placement,accuracy of upper cervical pedicle screw placement,and the risk factors that possibly affected the accuracy were recorded and analyzed.Postoperative follow-up was conducted for at least 6 months,and the efficacy of patients was assessed us-ing imaging parameters,ASIS classification,VAS,and JOA scores.Results Both groups had no screw-related complications and no spinal cord or vertebral artery injuries.In the RA group,the pedicle screw placement rates for the patients with occipitocervical fusion,and fixation and fusion of atlantoaxial and distal vertebrae were 100％(48/48)and 89.6％(138/154),respectively,far ex-ceeding the placement rate in the CF group 42.9％(18/42)and 78.3％(54/69)(x2=37.403,P＜0.001;x2=5.128,P=0.024).The fluo-roscopic exposure dose and operation time of the two types of surgical patients in the RA group were both higher than those in the CF group(P＜0.05).Compared with the CF group,the accuracy of C,screws in the RA group increased from 42％(11/26)to 80％(51/64),with statistical significance(x2=13.342,P=0.004);while the accuracy of C2 screws improved from 77％(33/43)to 88％(63/72)with no statistical difference(x2=2.863,P=0.413).Non-parametric correlation analysis found a significant correlation be-tween the accuracy of C1 and C2 pedicle screw placement and the order of guide wire insertion in the RA group(r=0.580,P＜0.001;r=0.369,P=0.001).Postoperatively,both groups showed significant differences in cervicomedullary angle(CMA),Chamberlain an-gle(CL),McGregor angle,Boogard angle,Bull angle,clivus-canal angle(CCA),occipitocervical(C0-C2)angle,posterior occipito-cervical angle(POCA),C2-C7 angle,and anterior atlantodental interval(ADI)(P＜0.05).The ASIA classification improved to vary-ing degrees for both groups postoperatively,but there were no statistically significant differences between preoperative,postopera-tive,and last follow-up evaluations.VAS and JOA scores significantly improved for both groups postoperatively and at the last fol-low-up(P＜0.05).Conclusion Both orthopedic robotic-assisted and conventional freehand pedicle screw placement techniques achieved satisfactory therapeutic effects in the treatment of upper cervical spine diseases.The orthopedic robot can effectively en-sure the accuracy of upper cervical pedicle screw placement,the increase placement rate of pedicle screws in the upper cervical spine,and reduce fluoroscopy exposure.However,it is necessary to avoid the vertebral displacement caused by the priority inser-tion of the guide needle,which may affect the accuracy of subsequent planning.
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