NGOAI KHOA SO DAC BIET 1,2,3/2012
DANH GIA MUrC DO CHINH XAC KY THUAT VIT QUA CUONG TRONG CHAN THirOTNG COT SONG CO
Nguyen Van Thach, Nguyin Hoang Long Nguyen Le Bao Ti8n, Vu Van Cirffng(*)
TOM TAT
Muc tieu: danh gia dp chinh xac ky thuat vit qua cudng trong chan thu'dng cot song co theo ky thuat "key - slot".
0di t&dng va ph&dng phap: nghien cdu mo ta tien ciTu 46 vit qua cudng cdt sdng co (5 benh nhan) ap dung ky thuat bat vit "key - slot".
Ket qua: Tren phim chup CT 64 Idp cat sau mo cd difng hinh dong mach dng sdng chiing toi (3a phan tich va danh gia rnifc dp chinh xac ciia vit nhu' sau; Op 0 (khdng vd cuong) 78.2% (36 vi't), dp 1 (vd cudng < 2 5 % du'dng kinh vit) 4 . 3 % (2 vit), dp 2 (v8 cudng 25 - 5 0 % du'dng kfnh vit) 13.2% (6 vit), dp 3 ( vd cudng > 5 0 % du'dng kinh vit) 4.3% (2 vit). Vdi dp 2 va dp 3 la vi't khong chinh xac. Cd 1 tru'dng hdp ton thu'dng dong mach dng sdng va khdng tru'dng hdp nao ton thu'dng tiiy song do vit.
Ket luan: Chiing toi da tien hanh bat vi't qua cuong cot sdng co trong chan thu'dng cdt song cd ton thu'dng tiiy co da tang sir dung ky thuat key - slot vdi dp chinh xac 8 0 % va chi cd 1 tru'dng hdp tdn thu'dng ddng mach ong sdng tuy nhien khdng de lai bien chirtig nang ne tren lam sang. Day la ky thuat cd the ap dung du'dc d nhieu trung tam phau thuat va cd dp an toan cao da du'dc chirng minh tren the gidi.
SUMMARY
EVALUATION OF ACCURACY A N D SAFETY OF A TECHNIQUE FOR CERVICAL PEDICLE
SCREW PLACEMENT
Objective: To present the accuracy and safety of a novel "key s l o t " technique for cervical
(*) Benh vien Viet D&c
pedicle screw placement.
i^ateriai and method: A prespective study of 46 subaxial GPS in 5 patients had been inserted using author's technique were reviewed.
Resuits: On the postoperative vascular- enhanced computed tomography scan, we analyzed the direction and grade of pedicle perforation grade 0 (no perforation) 78.2%, gradel ( < 2 5 % of screw diameter) 4.3%, grade 2 (20% to 50%) 13.2%, grade (>50%) 4.3%.
Grade 2 and 3 were considered as incorrect position.
Conclusion: These techniques are highly secure, while minimizing bone loss in screw placement, ensuring physiological curves in the cervical spine.
I. OAT VXN o f
Cac nghien ctru ve giai phau hpc va hinh thai hpc da chung minh rang bat vit qua cudng cdt sdng cd cd dinh cdt sdng vung chac hem so vai cac ky thuat cd dinh cdt sdng khac nhu bat vit khdi ben, budc vdng gai sau, vit qua dien khdp ... Ke tir khi Albumi va cdng sir thdng bao 1 tnrcmg hop chan thucmg cot sdng cd cd tdn thucmg tuy cd da tang dugfC phau thuat vit qua cudng cot sdng cd nam 1994 den nay da cd nhieu tac gia tren thd gidi cai tien ky thuat nay va chimg minh ring day la ky thuat an toan va hieu qua khi di6u tri cho nhiing benh nhan cd tdn thuong tiiy cd mat viing da tang. Nhieu nghien ciju da chung minh dugc uu diem ciia vit qua cudng cdt sdng cd sau trong cac tdn thuang
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DAI HOI Hpi NGOAI KHOA VN LAN THLT XII VA HQI NGH] KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
cdt sdng ma benh nhan cd loang xucmg nang, gii cdt sdng cd va khdi u cdt sdng cd.
Ky thuat bat vit cd sau dugc Albumi gidi thieu dku tien nam 1994. Ky thuat albumi tuong ddi an toan cho vit qua cudng cdt sdng cd tuy nhien ky thuat nay cd su mat xuang ldn tai vi tri tao diem vao cudng ddng thdi gay nguy ca tdn thuong cudng giam tinh viing chac ciia vit qua cudng cdt sdng cd. Ky thuat key - slot da chirng minh dugc giam sy mat xuang tai vi tri bat vit ddng thdi lam tang tinh chinh xac cua vit qua cudng cdt sdng cd [1].
Ky thuat bat vit cdt sdng cd sau theo ky thuat key-slot [4]:
•^ Tat ca benh nhan dugc cao gay trudc mo
•^ Nam sap cd gdi ke, tu the cd trung gian
^ Rach dudng cd sau tir C2 - C7, phlu tich can ca canh sdng hai ben cho tdi bd ngoai dien khdp
•^ Tien hanh bat vit dudi hudng dan ciia C.arm
^ Diem bat vit;
Xac dinh bd trong va ngoai cua dien khdp
• Dimg khoan mai DK 3mm mai Vi ngoai dudng thang ndi bd trong va ngoai dien khdp khi mai sau khoang 3mm.
Su dung probe cong dau (15dd) di vao cudng theo goc chech da khao sat trudc phau thuat dya tren MSCT cot sdng cd. Thudns gdc nav nam trone khoang 25 - 45 dp.
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NGOAI KHOA SO DAC BIET 1,2,3/2012
• Dung tham danh gia cac thanh cua cuong. Neu vd cudng cd the thay ddi hudng probe hoac bd qua vit.
^ Sir dung ta ro dat do dai thudng 18 - 24 mm. Chieu dai ciia vit dugc xac dinh tren phim chup MSCT cdt sdng cd de vit dugc 1/3 than ddt sdng.
v' Bat vit qua cudng cdt sdng cd
•^ Dat rod, md cung sau cot sdng cd rong rai tiiy theo sd tang tdn thuang
•^ Dan lim, ddng cac lap giai phlu II. Odi TUONG VA PHUONG PHAP NGHIEN CUU
1. P h u o n g p h a p nghien ciiu: Nghien
cuu md ta tien cun 2. Boi tu'ffng nghien cihi
• Tiiu chuan lira chpn benh nhan: 5 benh nhan bi chan thuang cdt sdng cd cd mat viing cdt sdng va tdn thuang tuy sdng da tang (> 3 tang)
Tat ca benh nhan deu dugc chup:
"•^ MRI cdt sdng cd: danh gia muc dd tdn thuong tuy, sd tang tdn thuang tiiy.
^ MS CT cot sdng cd: danh gia tinh trang tdn thuang than dot sdng, cudng sdng, cung sau. Khao sat dudng kinh cudng sdng, danh gia gdc md ciia cudng sdng so vdi dudng giiia.
• Tiiu chuan loai trir
& Tkt ca benh nhan cd dudng kinh cudng sdng < 3.5mm va gdc m d cudng sdng so vdi dudng giiia > 50 do. Cac benh nhan cd t6n thuang v 5 cudng sdng khdng cd chi dinh phau thuat vit qua cudng cdt sdng cd [2].
3. Ddnh gia ket qua sau mo Danh gia tinh trang lam sang sau md
1 ngay, 7 ngay va 3 thang.
• Tdt ca benh nhan dugc chup MSCT cdt sdng cd dyng hinh ddng mach ddt sdng sau md.
Danh gia do chinh xac theo thang d i g m [ l ] , [8]
I Dp 0: khdng vd cudng
Dp 1: va cudng < 25% dudng kinh vit 331
DAI HOI HOI NGOAI KHOA VN LAN THIS XII VA HOI NGHj KHOA HOC NGOAI KHOA TOAN QUOC LAH XIV
Dp 2: va cudng 25 - 50% dudng kinh vit Dp 3: vo cudng > 50% dudng kinh vit
Danh gia tinh trang tdn thuong ddng mach ddt sdng va dng sdng
III. KET QUA
Chung tdi da tien hanh bat 46 vit qua cudng cdt sdng cd (5 benh nhan) chan thuong cdt sdng cd tdn thuang tiiy sdng da tang. Cac vit dugc bk d cac ddt sdng cd thap tir C3 - C7.
Sd t^ng bat vit trung binh: 4.6 ± 0.25 tAng Sd tang md cung sau trung binh: 3.6
± 0.25 t5ng
Cd 3 trudng hgp tdn thuang tiiy sdng keo dai bat vit d 5 ddt sdng tir C3 - C7. 2 trudng hgp bat vit tir C3 - C6. Tat ca cac trudng hgp nay deu dugc bat vit va cd djnh cdt sdng vUng chac sau dd mdi tien hanh md cung sau cdt sdng de dam bao tinh an toan.
khdng tdn thuang them tiiy sdng. TSt ca cac trucmg hgp deu dugc chii ddng md rpng lo lien hgp C34, C45, C56 nhiim muc dich giai ep, dy phdng tdn thuang rl sau phau thuat.
Dudng kinh cudng sdng trung binh:
• C3: 5.42 ±0.27 mm C4: 5.24 ±0.3 mm C5: 5.12 ±0.36 mm C6: 5.48 ± 0.32 mm C7: 5.78 ±0.31mm
Theo ket qua nghien cuu ciia Sang Hun Lee va cdng sy, dudng kinh cudng sdng trung binh cua cot sdng cd ngudi trudng thanh la 5.4 ± 0.7mm. Kdt qua ciia chung tdi
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NGOAI KHOA SO DAC BIET 1,2,3/2012
di lech tiiy theo timg vi tri cua ddt sdng cd:
dirdng kinh cao nhk la d C7 (5.78) va thip nhat la d C5 (5.12). Khi xac dinh dudng kinh cudng sdng se giup ph§u thuat vien xac dinh
dugc dudng kinh cua vit khi tidn hanh phlu thuat. Tat ca benh nhan ciia chimg tdi dgu dugc su dung vit cd dudng kinh 3.5 mm.
• Goc raff giu'a cuong song va dirong giu'a trung binh:
Vitri C3 C4 C5 C6 C7
Goc md 46.9 ± 0.5 do 40.8 ± 1.2 do 38.4 ± 0.6 do 37.6 ± 0.8 do 34.7 ± 0.5 do
Theo nghien ciru ve hinh thai hgc cdt sdng cd ciia nhieu tac gia tren the gidi gdc md cu6ng sdng trung binh 30 - 45 do. Theo M. Reinhold gdc md cudng sdng cao nhkt a C3 47.8 dp va thap nhat d C7 38.7 dp. Trong nghien cim cua chung tdi tdt ca benh nhan cd gdc md cudng sdng tren 50 do deu loai khdi nghien cim [7].
Banh gia do chinh xac cua vit Co
06 0 Do I B o l l 06 III
n
n 36
2 6 2 46
»/o 78.2
4.3 13.2 4.3 100 Theo phan loai dp chinh xac ciia vit
dirge cho la chinh xac khi d do 0 va do 1 (82.5%). Trong nghien cuu ciia Sang Hun Lee danh gia dp chinh xac cua vit khi ap dung ky thuat key - slot tren 277 vit d 50 b?nh nhan la 90.3%). Trong nghien cuu cua chung tdi cd 2 trudng hgp va cudng tren 50%
dudng kinh vit. 1 trudng hgp va thanh ngoai va 1 trudng hgp vd thanh trong cua cudng.
Ca hai vit nay deu nam d vit tri C7. Mac dii C7 la ddt sdng cd gdc md cudng sdng thap nhat, tuy nhien trong qua trinh bat vit lai bi ban che gdc md do can trd cua khdi ca dyng sdng hai ben, vi vay can chii y phau tich rdng rai khi phai bat vit qua cudng C7 [4], [6].
Goc md cua vit sau phau thuat Danh gia tren phim chup MSCT cdt sdng cd sau md chimg tdi da danh gia. tai gdc md cua viL
V j t r i C3 C4 C5 C6 C7
Goc md tru'dc phau thuat X ± SD (do)
46.9 ± 0.5 40,8 ± 1.2 38.4 ± 0.6 37.6 ± 0.8 34.7 ± 0.5
Goc md sau phau thuat X ± SD (So)
31.9 ±0.6 31.4 ±0.6 28.6 ± 0.4 28.3 ±0.6 24.4 ± 1.1
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DAI HOI HOI NGOAI KHOA VN LAN THLT XII VA HOI NGHi KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
Tai bien va bien chii-ng
Cd 2 trudng hgp vo cudng > 50% dudng kinh vit. 1 Trudng hgp cd tdn thuang ddng mach dng sdng phat hien sau khi chup MSCT cot sdng cd cd dung hinh dpng mach ddt sdng. Trudng hgp nay trong qua trinh md khdng thay chay mau nhieu tir Id bat vit.
Theo cac nghien cuu tren the gidi ty ie tdn thuong ddng mach dng sdng khi vit qua cudng cot sdng cd chiem 0.1 - 0.3%. Cac trudng hgp nay van dugc bat vit binh thudng.
Cac tac gia ciing dua ra hudng xu tri cho cac
truiing hgp tdn thuang ddng mach dng song chay mau nhieu bang each niit mach. Tuy nhien trong nghien cuu ciia chung tdi truong hgp tdn thuang ddng mach dng sdng khong chay mau nhieu, benh nhan dugc nit dan Imi sau 3 ngay va khdng thay tdn thuong thin kinh them tren lam sang [ 1 ], [4], [8].
1 trudng hgp vd thanh trong ciia cudng tuy nhien khi kiem tra tuy sdng sau khi mcr cung sau cdt sdng cd khdng thay tdn thucmg tuy sdng.
• Bac diem chung phau t h u a t Dac diem Thdi qian phau thuat
Mu'c dd mau mat
n 216 ± 34.4 phut
435 ± 27.5 ml
Bac diem lam sang
Frankel A B C D E
Tru'dc mo 3 1 1 0 0
Sau mo 0 2 2 1 0
Sau md cd sy tien trien lam sang rat tdt, trudc md benh nhan chii yeu lam sang d muc dp nang (Frankel A va B) chiem 80%, sau md lam sang khdng cdn trudng hgp nao Frankel A chu yeu la B va C.
IV. BAN LUAN
Vit qua cudng cdt sdng cd lan dau tien dugc thyc hien bdi Leconte nam 1964, sau dd Borne va cdng sy da ap dung ky thuat nay de cd djnh cdt sdng cho benh nhan gay Hangman nam 1984 [3]. Nhung nd da khdng dugc img dung nhieu cho den dau nhirng nam 1990 Alnumi va cdng sy da dua ra ky
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thuat hoan chinh cho vit qua cudng cdt song cd de thyc hien an toan va hieu qua hon.
Nam 2003 Kotani da danh gia do an toan cua vit qua cudng cdt sdng cd va cho thay muc do vd cudng chi la 1,3%. Trong 1 nghien cuu khac, Ito da dua ra do chinh xac cua bat vit qua cudng la 97.3%) nam 2008 [2],
Phuang phap key - slot chi la sira doi ky thuat bat vit ciia Albumi nham tang dp chinh xac va giam thieu sy mat xuong tai v; tri bat vit. Nam 2001 Albumi da dua ra tdng kk sau hem 10 nam img dung ky thuat Albumi ty le vd cudng la 6.7% [4].
Thuang tdn ddng mach dng sdng dugc xem nhu la tai bien nang nhit trong ky thuat
NGOAI KHOA SO DAC BIET 1,2,3/2012
bat vit qua cudng, tuy nhien ty le nay rat nhd:
theo Albumi 2001 ty le nay la 1/180 trudng hgp, theo Yukawa nam 2006 la 1/100 trudng hgp. Tuy nhien cac trudng hgp nay deu dugc cam mau bang sap xuong va khdng de lai bien chiing nang tren than nao va tieu nao la hai vi tri thudng bj tdn thucmg khi tdn thuang 4.
dpng mach dng sdng [8].
V. KET LUAN
Day la ky thuat bat vit cd dp an toan cao, 5.
han che dugc muc dp mat xuong tai vi tri bat vit, dam bao dugc kha nang cd dinh viing
chac cot sdng cd. 6.
TAI UEU THAM KHAO
1. Abuml K, Itch H, Taneichi H, et al (1994).
"Transpedicular screw fixation for ti-aumatic lesions of the middle and lower cervical '•
spine:description of the techniques and preliminary report". J Spinal Disord. 7:19-28.
2. Ito Y, Sugimoto Y, Tomioka M, et al (2008). "Clinical accuracy of 3D ^^
fluoroscopy-assisted cervical pedicle screw insertion ". J Neurosurg. 9:450^53.
3. Leconte P (1964). ''Fracture et luxation des deux premieres vertebres cervicales. In:
Judet R. ed. Luxation Congenitale de la Hanche Fractures du Cou-de-pied Rachis Cervical Aclualites de Chirurgie Orthopedique de I 'Hospital Raymond- Poincare Vol 5''. Paris: Masson et Cie:147- 166.
Lee S.H, et al (2011). "Cervical Pedicle Screw Placement Using the "Key Slot Technique" The Feasibility and Learning Curve". J Spinal Disord Tech
Ludwig SC, Kramer DL, Vaccaro AR, et al (1999). "Transpedicle screw fixation of the cervical spine". Clin Orthop;359:77-88.
Panjabi MM, Duranceau J, Goel V, Oxiand T, Takata K (1991) ''Cervical human vertebrae. Quantitative three- dimensional anatomy of the middle and lower regions". Spine 16(8):861-869 Reinhold.M et al (2007). ''Cervical pedicle screw placement: feasibility and accuracy of two new insertion techniques based on morphometric data". Eur Spine J 16: 47-56 Yukawa Y, Kato F, Yoshihara H, et al (2006). "Cervical pedicle screw fixation in 100 cases of unstable cervical mjuries:
pedicle axis views obtained using fluoroscopy". J Neurosurg Spine.5:488—493.
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