臺灣博碩士論文加值系統

提升小面關節的穩定性已逐漸廣泛應用於腰椎後位穩定手術。此技術所採行的策略乃是利用墊片植入小面關節或以骨釘將上、下小面關節鎖固。本研究目的是利用體外實驗方法，比較小面關節墊片(Facet spacer)，小面關節骨釘，椎弓骨釘和脊突間固定器等四種不同固定裝置，應用於腰椎穩定手術後的力學穩定差異性。
採用單一活動單元豬腰椎取代人類真實腰椎，每一活動單元腰椎包含兩個鄰近椎體和一個椎間盤，利用材料試驗機進行體外力學測試。每一試件均清除小面關節周圍軟組織，但保留所有韌帶結構。經上述處理後之單一活動單元腰椎（未植入固定裝置腰椎），依前述不同固定裝置區分以下四組（每組六件）：1) 小面關節墊片組，將兩個墊片分別植入兩側上、下小面關節間； 2) 小面關節骨釘組，將兩根骨釘分別鎖入兩側上、下小面關節間； 3) 椎弓骨釘組，將四支骨釘分別由兩側上、下椎弓鎖入，並輔以骨棒固定； 4) 脊突間固定器組，利用兩個固定板鎖固上、下後脊突。針對前述未植入固定裝置及四組植入不同固定裝置之單一活動單元腰椎，分別進行前彎、後仰、側彎及軸向扭轉等四種不同力學測試。測試過程中，同步記錄施加力矩、腰椎總位移、兩椎體間位移，兩椎體間旋轉角度等參數，借以比較前述四種不同固定裝置，應用於腰椎穩定手術後的力學穩定差異性。
結果顯示：植入脊突間固定器在前彎與後彎勁度值分別為4936.94±1842.15 N-mm/deg與4659.40±2095.91；椎弓骨釘在側向彎曲勁度值為2949.97±1197.17 N-mm/deg；軸向扭轉在植入小面關節骨釘勁度值為4821±1120.6 N-mm/deg；植入小面關節墊片神經孔面積平均增加7.06%。
結論：四種不同固定裝置（小面關節墊片、小面關節骨釘、椎弓骨釘、脊突間固定器）均能有效改善術後的脊椎力學穩定性。其中，小面關節骨釘提供較好的軸向扭轉穩定性；椎弓骨釘提供較好的側向彎曲穩定性；脊突間固定器提供較好的前彎與後彎穩定性；而小面關節墊片也提升後彎動作穩定性。此外，小面關節墊片能有效增加神經孔面積，有利於椎體減壓手術。

Facet stabilization is gaining popularity for lumbar posterior stability. The strategy behind this technique is to fuse the facet joints with intra-articular spacer or fix the superior and inferior facets with perforating screws. The purpose of this study was to compare the biomechanical properties of lumbar facet spacer, facet screws, pedicle screw and interspinous process fixator using an in vitro model.
Twenty-four motion units of porcine lumbar spine were studied using material testing machine. Each motion unit had two adjacent vertebrae and one intervertebral disc. Each specimen was tested un-instrumented and then followed by instrumentation with four different facet stabilization procedures. In Group I (facet spacer implantation), two facet spacers were inserted into the joint spaces of bilateral superior and inferior facets respectively. In Group II (facet screw fixation), two perforating screws were used to trans-fix the bilateral superior and inferior facets respectively. In Group III (pedicle screw fixation), four pedicle screws were used to implant the bilateral superior and inferior lamina respectively. In Group IV (interspinous process fixator), two plates were used to trans-fix the bilateral superior and inferiorspinous process respectively. Each group had 6 specimens. The tests included flexion (maximum 4000 N-mm), extension (maximum 6000 N-mm), lateral bending (maximum 6000 N-mm) and rotation (maximum 6000 N-mm). Parameters, including applied moment, displacement and angle deviation, were collected for analysis.
In Group IV (interspinous process fixator), the stiffness of flexion and extension was 4936.94±1842.15 N-mm/deg and 4659.40±2095.91 N-mm/deg; in Group III (pedicle screw fixation), the stiffness of bending was 2949.97±1197.17 N-mm/deg; in Group II (facet screw), the stiffness of rotation was 4821±1120.6 N-mm/deg. An average increase of 7.06% in foramen area was found for facet spacer implantation, which may be beneficial for spinal decompression surgery.
In conclusions, the results indicate, regardless of implant types, implantation of various implants (facet spacer, facet screw, pedicle screw or interspinous process fixator) improve the postoperative stability of spinal construct. Facet screw fixation provided better stabilization in rotation, and pedicle screw fixation provided better stabilization in lateral bending, and interspinous process fixator provided better stabilization in flexion and extension, while facet spacer implantation provided stabilization in extension. Implantation of facet spacer increases the foramen area, which is beneficial for spinal decompression surgery.

目錄
指導教授推薦書
口試委員會審定書
授權書
致謝i
中文摘要ii
英文摘要iv
目錄vi
圖目錄x
表目錄xvii
第一章 緒論1
1.1 前言1
1.2 研究背景3
1.3 研究動機4
1.4 研究目的5
第二章 文獻回顧6
2.1 脊椎結構與功能6
2.1.1 脊椎解剖構造簡介6
2.1.2 脊椎功能簡介8
2.1.3 腰椎椎體的生物力學特性9
2.1.4 腰椎椎間盤的生物力學特性10
2.1.5 腰椎小面關節之構造與生物力學特性11
2.1.6 腰椎周圍韌帶之生物力學特性15
2.2 脊椎疾病與臨床診療方式17
2.2.1 脊椎的病變17
2.2.2 脊椎病變治療的方式20
2.2.3 脊椎固定器的介紹23
第三章 研究方法33
3.1 研究流程33
3.2 研究材料與設備36
3.2.1 脊椎植入物元件36
3.2.2 豬隻脊椎38
3.2.3 壓克力快速成型膠40
3.2.4 材料試驗機41
3.2.5 位移量測器43
3.2.6 夾具設計45
3.3 研究試樣準備50
3.4 實驗方法58
3.4.1 前彎測試59
3.4.2 後彎測試60
3.4.3 側向彎曲測試60
3.4.4 軸向扭轉測試61
3.4.5 彎曲力矩之理論計算61
3.4.6 勁度之理論計算63
3.5 數據紀錄及分析63
3.6 神經孔面積量測64
3.7 生物統計法64
第四章 結果65
4.1 前導實驗65
4.2 脊椎單一活動單元前彎之比較71
4.3 脊椎單一活動單元後彎之比較77
4.4 脊椎單一活動單元側向彎曲之比較83
4.5 脊椎單一活動單元軸向扭轉之比較87
4.6 植入小面關節墊片神經孔洞面積變化90
第五章 討論92
5.1 勁度與椎間盤間位移之比較92
5.2 植入小面關節墊片對脊椎活動單元影響94
5.3 植入小面關節骨釘對脊椎活動單元影響95
5.4 植入椎弓骨釘對脊椎活動單元影響96
5.5 植入脊突間固定器對脊椎活動單元影響97
5.6 植入不同植入物的生物力學比較99
5.7 植入小面關節墊片對神經孔面積增加量之探討104
5.8 本研究的限制105
第六章 結論106
參考文獻107
附錄112
 
圖目錄
圖1-1 (A)正常椎孔結構； (B)為椎孔狹窄示意圖 2
圖2-1 脊椎解剖構造 (A)前視； (B)側視7
圖2-2 脊椎運動模式8
圖2-3 椎體與椎弓10
圖2-4 椎間盤11
圖2-5 脊椎小面關節接觸面之方向 (A.頸椎 B.胸椎 C.腰椎) 13
圖2-6 頸椎至腰椎各椎節活動度14
圖2-7 小面關節之解剖圖14
圖2-8 腰椎韌帶之解剖圖16
圖2-9 腰椎小面關節增生18
圖2-10 黃韌帶增厚情形18
圖2-11 骨刺生成情形19
圖2-12 老化所引起椎間盤退化和損傷可能是引起背痛的來源19
圖2-13 機械性過度負荷導致椎間盤退化和損傷可能是引起背痛的來源20
圖2-14 三種不同骨螺釘固定方式之脊椎融合手術：A. 小面關節骨釘固定 (Translaminar facet screw fixation)；B. 小面關節骨釘 (Transfacet pedicle screw fixation)；C. 傳統椎弓骨釘固定 (Traditional pedicle screw)24
圖2-15 三種不同骨螺釘固定方式之脊椎融合手術： (A)椎籠 + 小面關節骨釘 (Cage + Translaminar screws (TS, Mathys))； (B)椎籠 + 腰椎小面關節骨釘 (Cage + Lumbar facet interference screws (LFIS, Mathys))； (C)椎籠 + 椎弓骨釘 (Cage + Pedicle screw (USS, Mathys)) 24
圖2-16 椎弓骨螺釘 (左)水平固定法 (右)對角固定法之三維有限元素模型26
圖2-17 勾桿系統後方內固定26
圖2-18 椎弓骨釘系統後方內固定27
圖2-19 Coflex脊突間植入物29
圖2-20 Diam脊突間植入物30
圖2-21 第二代Wallis 脊突間植入物30
圖2-22 X-stop脊突間植入物31
圖2-23 各種椎間融合器 (A)SynCage-Open (Synthes Spine, Inc., Mathys Medical Ltd., Bettlach, Switzerland)； (B)O.I.C. (Stryker Spine, Mahwah, New Jersey, USA)； (C)AVS-TL (Stryker Spine, Mahwah, New Jersey, USA)31
圖3-1實驗流程架構圖33
圖3-2 小面關節墊片植入單一活動單元之脊椎 (A)實際照片；及 (B)X光照片34
圖3-3 小面關節骨釘植入單一活動單元之脊椎 (A)實際照片；及 (B)X光照片34
圖3-4 椎弓骨釘植入單一活動單元之脊椎 (A)實際照片；及 (B)X光照片35
圖3-5 脊突間固定器植入單一活動單元之脊椎 (A)實際照片；及 (B)X光照片35
圖3-6 小面關節墊片三方向特徵圖 (I-Lock, Paonan Corp., Taiwan)36
圖3-7 小面關節墊片3D示意圖 36
圖3-8 小面關節骨釘37
圖3-9 椎弓骨釘系統 (A) 椎弓骨釘；(B)骨棒37
圖3-10 脊突間固定器 (A)固定板；(B)脊突間墊片37
圖3-11 豬脊椎39
圖3-12 工業用固化膠40
圖3-13 MTS雙軸材料試驗機42
圖3-14 力傳感器42
圖3-15 位移量測器43
圖3-16 位移量測器-架設於活動單元椎體前緣，測量受力時椎間盤間距變化圖44
圖3-17 萬向夾具45
圖3-18 脊椎活動單元之下夾具工程圖46
圖3-19 脊椎活動單元之下夾具3D示意圖46
圖3-20 將豬之脊椎固定之下夾具圖46
圖3-21 脊椎活動單元之上夾具工程圖47
圖3-22 脊椎活動單元之上夾具3D示意圖47
圖3-23 將豬之脊椎固定之上夾具圖48
圖3-24 彎曲測試夾具安裝圖48
圖3-25 脊椎活動單元之扭轉測試夾具3D示意圖49
圖3-26 軸向扭轉測試夾具圖49
圖3-27 軸向扭轉測試夾具安裝圖50
圖3-28 (A)新鮮豬骨； (B) 單一脊椎活動單元51
圖3-29 脊椎固定於平板與對正於中心之裝置圖52
圖3-30 上夾具與下夾具呈水平狀態圖52
圖3-31 後彎測試夾具安裝圖53
圖3-32 軸向扭轉測試試樣安裝圖54
圖3-33 器械裝置圖55
圖3-34 植入小面關節墊片實際圖56
圖3-35 植入小面關節骨釘實際圖56
圖3-36 植入椎弓骨釘實際圖57
圖3-37 脊突間固定器實際圖57
圖3-38 測試實驗架構示意圖。施力桿置於脊椎試件100 mm，並施以軸向力62
圖3-39 小面關節墊片植入單一活動單元椎體之X-ray照片 (A)植入前；(B)植入後64
圖4-1 施予軸向壓力0~40N進行前彎測試 66
圖4-2 施予軸向壓力0~60N進行後彎測試 66
圖4-3 施予軸向壓力0~30N進行側向彎曲測試67
圖4-4 施予軸向扭轉0~6000N-mm進行扭轉測試67
圖4-5 植入小面關節墊片進行靜態前彎破壞測試68
圖4-6 植入小面關節墊片進行靜態後彎破壞測試69
圖4-7 植入小面關節墊片進行靜態側向彎曲破壞測試69
圖4-8 植入小面關節墊片進行軸向扭轉破壞測試70
圖4-9 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態前彎動作之位移-力量曲線比較圖73
圖4-10 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態前彎勁度比較73
圖4-11 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態前彎椎間盤間位移之比較75
圖4-12 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態後彎動作之位移-力量曲線比較圖79
圖4-13 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態後彎勁度比較79
圖4-14 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態後彎椎間盤間位移之比較81
圖4-15 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態側向彎曲之位移-力量曲線比較圖85
圖4-16 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態側向彎曲勁度之比較85
圖4-17 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器軸向扭轉之位移-力量曲線比較圖89
圖4-18 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器軸向扭轉勁度之比較89
圖4-19 植入小面關節墊片神經孔面積變化91
圖5-1 未植入與不同植入物於椎體間勁度之比較92
圖5-2 未植入與不同植入物於椎間盤間位移之比較93
圖5-3 未植入與植入小面關節墊片於椎體間勁度百分比95
圖5-4 未植入與植入小面關節骨釘於椎體間勁度百分比96
圖5-5 未植入與植入椎弓骨釘於椎體間勁度百分比97
圖5-6 未植入與植入脊突間固定器於椎體間勁度百分比98
圖5-7 在前彎動作中，以椎體間未植入為基準去比較植入不同植入後勁度之百分比99
圖5-8 在後彎動作中，以椎體間未植入為基準去比較植入不同植入後勁度之百分比101
圖5-9 在側向彎曲中，以椎體間未植入為基準去比較植入不同植入後勁度之百分比102
圖5-10 在軸向扭轉中，以椎體間未植入為基準去比較植入不同植入後勁度之百分比103
圖5-11 植入小面關節墊片神經孔面積變化104
 
表目錄
表4-1 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態前彎動作位移數據72
表4-2 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態前彎動作之椎間盤間位移數據74
表4-3 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態前彎動作P值， (*)表示p < 0.05在統計學上有顯著差異75
表4-4 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態前彎動作椎間盤間位移P值， (*)表示p < 0.05在統計學上有顯著差異76
表4-5 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態後彎動作數據78
表4-6 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態後彎動作之椎間盤間位移數據80
表4-7 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態後彎動作P值， (*)表示p < 0.05在統計學上有顯著差異81
表4-8 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態後彎動作椎間盤間位移P值， (*)表示p < 0.05在統計學上有顯著差異82
表4-9 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態側向彎曲動作數據84
表4-10 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜側向彎曲P值， (*)表示p < 0.05在統計學上有顯著差異86
表4-11 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜態軸向扭轉數據88
表4-12 未植入、植入小面關節墊片、小面關節骨釘、椎弓骨釘與脊突間固定器靜軸向扭轉P值， (*)表示p < 0.05在統計學上有顯著差異90
表4-13 未植入與植入小面關節墊片神經孔面積91

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