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Design and cadaveric study of a 3-dimensional foramen guiding deviceObjective A 3-dimensional foramen guiding device was designed and applied to a cadaveric experiment to evaluate its feasibility and accuracy,aiming to provide theoretical basis for clinical application of foramen puncture.Methods According to the principle of reverse positioning,the concept was initially conceived,and the schematic diagram of 3-dimensional intervertebral foramen guider was drawn on the software.The 3-dimensional intervertebral foramen guider is divided into two parts: guiding frame and universal guider,which can be disassembled and assembled.The guiding frame is made of ABS plastic printing,and the universal guider device is customized by the medical device manufacturer.After the completion of the 3-dimensional foramen guider,its feasibility was preliminarily verified on six cadaveric specimens.36 intervertebral foramen were punctured in sequence from L3-4,L4-5 and L5-S1.The puncture was performed by the same senior associate chief physician of spinal surgery.Before the experiment,the doctor had received the training of TESSYS surgery,and completed more than 100 cases of TESSYS surgery independently.The doctor used the unarmed puncture method(the control group)and the puncture method assisted by the intervertebral foramen guider(the experimental group)to complete the puncture of all intervertebral foramen in sequence.The puncture time,puncture times,fluoroscopy times,significant error times and the overall positioning puncture completion time of a single intervertebral foramen were compared between two methods,and the learning curve of the total puncture completion time of a single intervertebral foramen was drawn.Results There was no significant difference in puncture time between the experimental group and the control group(P > 0.05).The puncture times,fluoroscopy times,significant error times and the total puncture completion time of single intervertebral foramen in the experimental group were less than those in the control group,and the difference was statistically significant(P < 0.05).The learning curve of the experimental group was lower than that of the control group,and the total positioning puncture time firstly decreased and then showed a horizontal trend with the increase of puncture,while the total positioning puncture time of the control group had a downward trend,but showed a fluctuating state.Conclusion The design of the guiding device is rigorous and compact.It can shorten the learning curve;reduce the puncture injury and the times of fluoroscopy.Part ? The establishment of finite element model and biomechanical analysis of facet joint arthroplasty in transforaminal endoscopic spinal surgeryObjective To establish the normal L1-S1 segment finite element model and verify its validity,and analyze the influence of facet joint arthroplasty in transforaminal endoscopic spine surgery on the biomechanics of lumbar spine.Methods Lumbar 3-dimensional CT of a volunteer without previous lumbar disease were selected,and the data were transformed into 3-dimensional image by Mimics software.The mesh surface was divided by the module.We modeled and optimized each intervertebral disc,articular cartilage,ligament and joint capsule,and the normal L1-S1 segment finite element model was obtained by giving them material attributes.Compared with the previous literature,the validity of this model is verified.On the basis of the normal L1-S1 segment model,the L4-5 disc herniation model(M1),the 5mm facet joint arthroplasty model(M2)and the 7.5mm facet joint arthroplasty model(M3)were established.The degree of L4-5 segment displacement,the stress distribution in L4-5 bilateral facet joints,and the stress distribution in L3-4,L4-5 and L5-S1 intra-disc pressure were analyzed under flexion,extension,left and right lateral flexion,and left and right rotation conditions.Results We established a normal L1-S1-segment finite element model and compared it with previous studiy to verify the validity.Based on the established model,the model of L4-5 disc herniation(M1),the model of 5 mm facet joint arthroplasty model(M2)and the model of 7.5 mm facet joint arthroplasty model(M3)were established.The mechanical analysis of the three models showed that the L4 vertebral body displacement increases after facet joint arthroplasty under six working conditions,but there is no significant difference between two kinds of arthroplasty in the L4 vertebral body displacement.The analysis of stress distribution in the L4-5 left facet joint showed that stress of this joint in M2 and M3 is decreased than that in M1 under flexion condition(P<0.05);stress of this joint in M2 and M3 is increased than that in M1 under left latereal flexion condition(P<0.05);There was no significant difference in the stress of this joint between the three groups under conditions of extension,right lateral flexion,left rotaion and right rotation(P>0.05).The analysis of stress distribution in the L4-5 right facet joint showed that stress of this joint in M2 and M3 is increased than that in M1 under flexion condition(P<0.05);under left rotaion condition,stress of this joint in M3 is increased than that in M2,and the stress of this joint in M2 is increased than that in M1(P<0.05);There was no significant difference in the stress of this joint between the three groups under conditions of extension,left lateral flexion,right lateral flexion and right rotation(P > 0.05).The analysis of stress distribution in the L4-5 disc showed that the stress in M2 and M3 is increased than that in M1 under flextion,left rotation,left lateral flexion and right lateral flextion conditions,the difference is not significant(P>0.05);the stress in M3 is increased than that in M1 and M2 under extension condition(P<0.05);under right rotation condition,the stress in M3 is increased than that in M2,and the stress in M2 is increased than that in M1(P<0.05).There is no significant difference in the stress distribution in L3-4 and L5-S1 discs among three models under six working conditions.Conclusion The finite element model of normal L1-S1 segment was successfully verified,and the predicted results of FE model were reliable,which could be used for biomechanical analysis and surgical simulation.Compared with 5 mm facet arthroplasty,7.5 mm facet arthroplasty in transforaminal endoscopic spinal surgery will increase the stress of facet joint and segmental disc,but it will not cause the degeneration of adjacent disc.Part ? Clinical study of facet joint arthroplasty or non-arthroplasty on the treatment of lumbar disc herniation via endoscopic transforaminal approachObjective To explore the effect of facet joint arthroplasty on patients through endoscopic transforaminal approach.The perioperative and clinical outcomes were compared between two groups treated with facet joint arthroplasty and nonarthroplasty.Methods From May 2016 to may 2018,98 patients underwent endoscopic lumbar discectomy via transforaminal approach.50 patients underwent facet joint arthroplasty during the operation(th experimental group),and 48 patients did not undergo facet arthroplasty(the control group).The puncture time,fluoroscopy times, blood loss and operative time of two groups were compared;the visual analogue scale(VAS)scores of lumbar and limb pain at 1 week,3 months and 1 year after operation,and the Japanese Orthopedic Association(JOA)and Oswestry disability index(ODI)of lumbar spine before and 1 year after surgery were compared.The modified Mac Nab criteria was used to evaluate the treatment satisfaction of all patients at the last follow-up.The postoperative complications of two groups were recorded.Results The fluoroscopy times,puncture times and operative time in the experimental group were less than those in the control group(P < 0.05).The amount of bleeding in the control group was less than that in the experimental group,the difference was statistically significant(P < 0.05).The lumbar VAS scores of two groups were significantly lower than those before operation at 1 week,1 month and 1 year after operation(P < 0.05),but there was no significant difference between two groups(P > 0.05).The VAS scores of the affected limbs of the two groups were significantly lower than those before the operation at 1 week,1 month and 1 year after operation(P < 0.05),but the VAS score in the experimental group was better than that in the control group at 1 week and 1 month after operation,and the difference was statistically significant(P < 0.05),but there was no significant difference between two groups at 1 year after operation(P > 0.05).The JOA and ODI scores of two groups were significantly improved 1 year after operation(P < 0.05),but there was no significant difference between two groups(P > 0.05).The satisfaction rate in the experimental and control group at the last follow-up were 90% and 87.5%,respectively,and the difference was not statistically significant(P > 0.05).No obvious complications occurred in both groups.Conclusion Facet joint arthroplasty via endoscopic transforaminal approach is a safe and effective method.Compared with the technique of non-facet joint arthroplasty,it has the advantages of faster symptom relief,shorter operative time and less fluoroscopy and puncture times. |
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