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  • Title: [Three-dimensional printed drill guide template assisting percutaneous pedicle screw fixation for multiple-level thoracolumbar fractures].
    Author: Zeng B, Wu C, Li T, Wang X, Shang Q.
    Journal: Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi; 2021 Jun 15; 35(6):742-749. PubMed ID: 34142502.
    Abstract:
    OBJECTIVE: To evaluate the feasibility and safety of three-dimensional (3D) printed drill guide template-assisted percutaneous pedicle screw fixation for multiple-level thoracolumbar fractures. METHODS: Clinical data of 19 patients with multilevel thoracolumbar fracture without nerve injury who underwent surgical treatment between May 2017 and January 2019 were retrospectively analyzed. There were 9 males and 10 females and their age ranged from 22 to 63 years, with an average age of 43.6 years. Injury cause included traffic accident injury in 12 cases, and fall from height injury in 7 cases. A total of 40 fractured vertebrae were involved in T 10 to L 3 levels. According to AO classification, there were 29 fractures of type A1, 9 fractures of type A2, and 2 fractures of type A3. According to TANG Sanyuan classification, multiple-segment thoracolumbar fractures were classified as 17 cases of type ⅠA, 1 case of type ⅠB, and 1 case of type ⅡC. The time from injury to operation was 2-6 days, with an average of 3.1 days. The 3D-printed universal drill guide template was used for assisting percutaneous pedicle screw fixation during operation. Intraoperative blood loss, average operation time and fluoroscopy frequency of each screw were recorded. Visual analogue scale (VAS) score was used to evaluate the improvement of low back pain before operation, at 3 days after operation, and at last follow-up. According to the CT at 3 days after operation, the Gertzbein and Robbins scales were used to evaluate the accuracy of screw insertion (the grade A and grade B were regarded as accuracy, the grade A was regarded as excellent of screw insertion). The Cobb angle in sagittal plane of the fracture segment was measured, and the percentage of anterior edge of injured vertebral height was calculated. The consistency of the inclination of bilateral pedicle screws were analyzed postoperatively, and compared the angle of the intraoperative guide plate with the inclination of screw to verify the effectiveness of the guide plate in controlling the inclination. RESULTS: All the 19 patients completed the operation successfully, and the intraoperative blood loss was 44-67 mL, with an average of 54.3 mL. The average operation time for each screw insertion was 7.3-11.1 minutes, with an average of 9.6 minutes. The average fluoroscopy frequency of each screw insertion was 1.6-2.5 times, with an average of 2.0 times. No spinal cord, nerve root injury, infection, and other complications occurred. All patients were followed up 24-38 months, with an average of 28.7 months. The accuracy of pedicle screws was evaluated by using Gertzbein and Robbins scales: 145 screws were grade A and 11 screws were grade B. The accuracy of screw insertion was 100% and the excellent rate was 92.9%. The CT data at 3 days after operation showed no significant difference in the inclination between the left and right screws in the same vertebral body ( t=0.93, P=0.36). There was no significant difference between the angle of guide plate and the screw inclination ( P>0.05). The VAS score, Cobb angle in sagittal plane, and the percentage of anterior edge of injured vertebral height were significantly improved at 3 days after operation and at last follow-up, and the VAS score was declined at last follow-up compared with 3 days after operation, all showing significant differences ( P<0.05). There was no significant difference in the sagittal Cobb angle and the percentage of anterior edge of injured vertebral height between two postoperative time points ( P>0.05). At last follow-up, no internal fixators were loosened or broken, and all fractures healed well. CONCLUSION: For the multiple-level thoracolumbar fractures, 3D-printed drill guide template assisting percutaneous pedicle screw fixation can reduce the operation time, intraoperative blood loss, and fluoroscopy frequency and the screw insertion is accurate and has a good reduction effect. 目的: 评价 3D 打印皮外导板辅助经皮椎弓根螺钉植入治疗多节段胸腰椎骨折的可行性和安全性。. 方法: 回顾分析 2017 年 5 月—2019 年 1 月手术治疗的 19 例无神经损伤多节段胸腰椎骨折患者临床资料。其中男 9 例，女 10 例；年龄 22～63 岁，平均 43.6 岁。致伤原因：交通事故伤 12 例，高处坠落伤 7 例。骨折椎体涉及 T 10～L 3 共 40 个，单个椎体骨折按 AO 分型：A1 型 29 个，A2 型 9 个，A3 型 2 个；多节段胸腰椎骨折按唐三元分型：ⅠA 型 17 例，ⅠB 型 1 例，ⅡC 型 1 例。受伤至手术时间 2～6 d，平均 3.1 d。术中采用 3D 打印皮外导板辅助经皮椎弓根螺钉植入。记录术中出血量、平均每枚螺钉植入手术时间和透射次数；术前、术后 3 d 及末次随访时采用疼痛视觉模拟评分（VAS）评价腰痛改善情况。根据术后 3 d CT 采用 Gertzbein 和 Robbins 量表评价植钉准确性（A、B 级为植钉准确，A 级为植钉优秀），测量骨折节段矢状面 Cobb 角，计算伤椎前缘高度百分比；测量术后双侧椎弓根螺钉内倾角差值，分析其一致性，并与术中选用皮外导板的角度进行对比，以验证皮外导板控制内倾角的有效性。. 结果: 19 例患者均顺利完成手术，术中出血量 44～67 mL，平均 54.3 mL；平均每枚螺钉植入手术时间 7.3～11.1 min，平均 9.6 min；平均每枚螺钉植入透射次数 1.6～2.5 次，平均 2.0 次。无脊髓、神经根损伤及感染等并发症发生。患者均获随访，随访时间 24～38 个月，平均 28.7 个月。采用 Gertzbein 和 Robbins 量表评价植钉准确性：A 级 145 枚，B 级 11 枚；植钉准确率达 100%，优秀率 92.9%。术后 3 d CT 测量示同椎体左、右侧螺钉内倾角差异无统计学意义（ t=0.93， P=0.36）；术中选用皮外导板的内倾角与螺钉内倾角比较差异均无统计学意义（ P>0.05）。患者术后 3 d 与末次随访时腰痛 VAS 评分、矢状面 Cobb 角及伤椎前缘高度百分比均较术前显著改善，末次随访时腰痛 VAS 评分较术后 3 d 进一步改善（ P<0.05）；术后两时间点间矢状面 Cobb 角及伤椎前缘高度百分比比较，差异均无统计学意义（ P>0.05）。所有患者末次随访时均未见内固定物松动、断裂，骨折均愈合良好。. 结论: 使用 3D 打印皮外导板辅助经皮椎弓根螺钉植入治疗多节段胸腰椎骨折，可减少手术时间、术中出血量及透视次数，植钉准确，有较好的复位效果。.
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