臺灣博碩士論文加值系統

脊椎融合手術合併內固定器是治療腰椎不穩定的傳統方式，然而臨床上發現脊椎融合手術會有加速鄰近椎節退化的問題，因而研發動態脊椎內固定器DYNESYS。DYNESYS能保留植入端的活動度，進而舒緩鄰近端加速退化的情形，但使用DYNESYS後還是有螺釘鬆脫和斷裂的問題，臨床觀察發現DYNESYS螺釘長度改變會影響螺釘鬆脫的機率，因此本研究目的為比較不同螺釘長度動態固定器植入腰椎後的鬆脫情形。本研究使用完整腰椎模型進行有限元素分析，分別植入3種不同螺釘長度的固定器，包括全長螺釘模型(long screw model, LS)、中等長度螺釘模型(median screw model, MS)和最短螺釘模型(short screw model, SS)，接著在第一節腰椎頂部施予150牛頓的預力與四種不同方向的力矩，讓腰椎達到前彎20度、後彎15度、扭轉8度和側彎20度，模型固定在第五椎節底部。結果顯示MS在四種動作下螺釘滑移值最小，且螺釘位移值除了側彎外皆比LS小；三組DYNESYS模型有相似的活動度，前彎時模型在鄰近端增加30%的活動度，增加幅度最大；MS在前彎和側彎時螺釘應力最大，SS在後彎有最大螺釘應力。本研究發現MS有最小的螺釘滑移值，因此推測中等螺釘長度的DYNESYS可以減少螺釘發生鬆脫的機率。

Lumbar fusion with spinal internal fixator was traditionally used to treat instability of the lumbar spine. However, several clinical studies indicated that lumbar spinal fusion may accelerate degeneration at the adjacent segments. The DYNESYS dynamic stabilization system could maintain mobility of the lumbar spine to decrease the probability of degeneration at the adjacent segment. Although the DYNESYS releases degeneration at the adjacent segment, there are still some complications like screw loosening and breakage. Clinical studies reported that screw length of the DYNESYS may influence the chance of screw loosening. Therefore, the study was aimed to investigate the effect of screw length on screw loosening. Finite element (FE) software, ANSYS 14.5, was used to build an intact lumbar spine model, implanting three different screw lengths of the DYNESYS in L4-L5 motion segment of the lumbar spine. Three different models are long screw model(LS), median screw model(MS) and short screw model(SS). Three hundred Newton were applied on the cord. Preload 150N on L1 and pure moments incrementally were applied in order to produce the flexion, extension, rotation and lateral bending of ROM reached 20, 15, 8 and 20 degrees in each model. All FE models were constrained at the bottom of the fifth vertebra. MS model had the minimal sliding distance in all movements. Furthermore, the screw displacement of MS model also decreased comparing to LS model except for lateral bending. The results of ROM are similar in all DYNESYS models. The ROM at the adjacent region of three models had a higher increase in flexion about 30%. As for screw stress, MS model had the highest screw stress in flexion and lateral bending. In extension, SS model had the highest screw stress. The study found that MS model had the smallest sliding distance. It means that DYNESYS with the median length of screw maybe has lower chance of screw loosening.

致謝 I
摘要 II
Abstract III
圖目錄 VI
表目錄 VIII
第1章 前言 1
1-1. 研究背景與現況 1
1-2. 脊椎的解剖構造與功能 2
1-3. 動態脊椎內固定器DYNESYS之介紹 6
1-4. DYNESYS臨床文獻回顧 10
1-5. 生物力學文獻回顧 16
1-6. 研究動機及目的 27
第2章 材料與方法 29
2-1. 完整腰椎有限元素模型 31
2-2. 完整腰椎植入DYNESYS之模型 37
2-3. 邊界條件與負荷條件 41
2-4. 腰椎元件生物力學分析 41
第3章 結果 45
3-1. 椎節活動度 45
3-2. 螺釘位移與滑移值 47
3-3. 椎間盤環帶應力 50
3-4. 小面關節接觸力 56
3-5. 螺釘應力 58
第4章 討論 61
4-1. 研究結果討論與比較 61
4-1-1. 椎節活動度 61
4-1-2. 螺釘位移和滑移值 64
4-1-3. 椎間盤應力 66
4-1-4. 鄰近端小面關節接觸力 68
4-1-5. 螺釘應力 70
4-2. 研究限制 71
4-3. 未來研究方向 72
第5章 結論 73
參考文獻 74
附錄 四組模型原始結果 79


圖目錄
圖 1 1 人體脊柱解剖構造前面觀、側面觀及後面觀 3
圖 1 2 椎體解剖圖15 4
圖 1 3 椎間盤解剖圖16 4
圖 1 4 脊椎之韌帶分佈15 5
圖 1 5 DYNESYS之元件 7
圖 1 6 使用DYNESYS前彎和後彎之情形 8
圖 1 7 施加彈性帶預張力方式 8
圖 1 8 市面上椎足螺釘動態脊椎內固定器21 9
圖 1 9使用DYNESYS的併發症 13
圖 1 10 植入不同長度螺釘之鬆脫情形 14
圖 1 11 植入不同脊椎固定器之腰椎大體31 19
圖 1 12 不同螺釘植入角度32 20
圖 1 13 四種不同螺釘植入方式33 20
圖 1 14 植入螺釘深度不同對螺釘最大應力之影響34 21
圖 1 15 小面關節接觸力結果35 21
圖 1 16 植入不同固定器之有限元素腰椎模型36 22
圖 1 17 植入不同固定器之有限元素腰椎模型37 23
圖 1 18 不同動作下之椎間盤應力分佈圖37 24
圖 1 19 植入不同固定器之有限元素腰椎模型38 25
圖 2 1 研究流程圖 30
圖 2 2 完整腰椎有限元素模型 33
圖 2 3 完整腰椎有限元素模型驗證結果 36
圖 2 4 DYNESYS動態脊椎內固定器 38
圖 2 5 DYNESYS植入腰椎之模型 38
圖 2 6 不同螺釘長度之DYNESYS 39
圖 2 7 螺釘滑移和位移示意圖 42
圖 2 8腰椎活動度之計算方式 44
圖 3 1 不同螺釘長度之固定器L4-L5(植入端)椎節活動度分析 46
圖 3 2不同螺釘長度之固定器L3-L4(鄰近端)椎節活動度分析 46
圖 3 3 不同螺釘長度之固定器螺釘滑移值比較 47
圖 3 4不同螺釘長度之固定器螺釘位移值比較 48
圖 3 5 前彎時螺釘位移分佈圖 (unit: m) 48
圖 3 6後彎時螺釘位移分佈圖 (unit: m) 49
圖 3 7扭轉時螺釘位移分佈圖 (unit: m) 49
圖 3 8側彎時螺釘位移分佈圖 (unit: m) 49
圖 3 9 前彎時植入端椎間盤應力分佈 (unit: Pa) 51
圖 3 10後彎時植入端椎間盤應力分佈 (unit: Pa) 51
圖 3 11扭轉時植入端椎間盤應力分佈 (unit: Pa) 52
圖 3 12側彎時植入端椎間盤應力分佈 (unit: Pa) 52
圖 3 13 不同螺釘長度之固定器植入端椎間盤最大應力分析 53
圖 3 14前彎時鄰近端椎間盤應力分佈 (unit: Pa) 53
圖 3 15後彎時鄰近端椎間盤應力分佈 (unit: Pa) 54
圖 3 16扭轉時鄰近端椎間盤應力分佈 (unit: Pa) 54
圖 3 17側彎時鄰近端椎間盤應力分佈 (unit: Pa) 55
圖 3 18不同螺釘長度之固定器鄰近端椎間盤最大應力分析 55
圖 3 19不同螺釘長度之固定器植入端小面關節接觸力分析 57
圖 3 20不同螺釘長度之固定器鄰近端小面關節接觸力分析 57
圖 3 21不同螺釘長度之固定器螺釘最大應力之比較 58
圖 3 22前彎時螺釘應力分布圖 (unit: Pa) 59
圖 3 23後彎時螺釘應力分布圖 (unit: Pa) 59
圖 3 24扭轉時螺釘應力分布圖 (unit: Pa) 60
圖 3 25側彎時螺釘應力分布圖 (unit: Pa) 60
圖 4 1本研究與先前研究(Kiapour et al.54)植入端椎節活動度之比較 62
圖 4 2本研究與先前研究(Kiapour et al.54)鄰近端椎節活動度之比較 63
圖 4 3 前彎時不同螺釘長度對脊椎骨的破壞路徑 65
圖 4 4本研究與先前文獻(Shin et al.38)植入端椎間盤應力之比較 67
圖 4 5本研究與先前文獻(Shin et al.38)鄰近端椎間盤應力之比較 67
圖 4 6本研究與先前文獻(Tsuang et al.60)鄰近端小面關節接觸力之比較 69
圖 4 7先前文獻螺釘最大應力分佈位置38 70



表目錄
表 1 1 DYNESYS之臨床文獻回顧 15
表 1 2 四種動作下的椎足螺釘應力35 22
表 1 3 DYNESYS之生物力學文獻回顧 26
表 1 4 不同螺釘長度的DYNESYS發生鬆脫機率，55mm螺釘鬆脫機率和其餘長度有顯著差異，P<0.00940 28
表 2 1 腰椎有限元素模型材料參數表 34
表 2 2 腰椎有限元素模型元素表 35
表 2 3 DYNESYS各元件之材料參數 40
表 4 1臨床與有限元素模擬結果之對照 65

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