腰椎后路椎间盘微创机器人刀头及工作通道的研究
|
摘要
腰椎间盘突出症是引起下腰痛的主要原因，是骨科的常见病、多发病，其治疗方法很多，总体上可划分为保守治疗和手术疗法两大类：前者如牵引、按摩、服药等，后者包括传统的开放手术以及一些微创技术(如化学溶核术、切吸术、激光气化减压术等经皮穿刺技术以及腰椎侧路、后路椎间盘镜等内镜辅助技术)。对于治疗方法的选择，通常的原则是保守治疗无效者采用手术疗法。手术疗法虽有其各自的优点，但还均存在一定的不足之处：如传统的开放手术创伤大、出血多、术后恢复时间较长，且可能发生神经损伤等并发症，不易为患者接受；各种经皮穿刺以及侧路椎间盘镜等微创技术虽然创伤小，但适用范围很窄，仅适合治疗单纯椎间盘突出，对合并椎间盘突出骨化及椎管狭窄时则无能为力。腰椎后路椎间盘镜适用范围宽，有创伤小、恢复快、疗效好等优点，但它仍有发生血管及神经损伤等并发症的可能，且培养熟练掌握MED技术的医生也并非一件易事，这在很大程度上阻碍了这项技术的推广。据文献报道，全国已有400多家医院购置了MED，但已有300余台处于闲置状态。因此，探索适用范围更宽，且安全高效、便于推广的新型微创治疗方法无疑已成为脊椎外科亟待解决的重要课题之一。
近几年来，遥操作手术机器人成为一个关注的热点，它不仅具有精确度高、重复性好、动作稳定等优点，且通过高级人机接口，不仅能在线采集并分析手术医生的操作信息，为实现手术过程“从技艺走向科学”提供有效手段，还能利用增强现实技术实现人的能力与外科手术任务之间的匹配，帮助术者恢复手术操作的灵活性，把失去了的“感觉”找回来，给术者提供更丰富、直观和易用的现埸信息及临埸感信息，从而提高手术的安全性和效率，减轻病人的痛苦以及医生的工作强度并能解决大量熟练医生培养难的问题。但迄今尚未见有关于腰椎后路椎间盘遥操作手术机器人的报道。
郑州大学硕士学位论文
腰椎后路椎间盘微创机器人的研究
本系列课题拟研制腰椎后路椎间盘微创机器人，它作为腰椎后路椎间盘遥
操作手术机器人的从手，无疑对整个腰椎后路椎间盘遥操作手术机器人是至关重
要的，而刀头和工作通道又对腰椎后路椎间盘微创机器人的工作方式和功能有重
大影响。有鉴于此，本课题首先从刀头和工作通道两个方面进行了研究:
一两类四种腰椎后路椎间盘微创机器人刀头的实验与临床对比研究:
目的选择适合腰椎后路椎间盘微创机器人的刀头，并根据刀头切除骨及韧
带等组织的情况确定该机器人将采取“连续”还是“间断”工作方式。方法设
计了两类刀头:①连续操作类刀头②间断操作类刀头，前者包括内刃口咬合式刀
头、外刃口咬合式刀头、内刃口剪切式刀头;后者包括椎板钳式刀头。通过手动
模拟动物及临床试验，从各种组织切除情况、“排屑”方式及时间、刀头内部
及外部清理情况以及提高效率的方式四个方面进行比较、综合评估。结果连
续操作类刀头:可切除各种组织，但不同组织情况不同。对于骨碎块，刀头连续
咬合3一10次后，空心管便被堵死，骨碎块不能再进入空心管;韧带等软组织
碎块均顺利进入刀头空心管，空心管不会被堵死;而碎屑不能顺利进入刀头空心
管，无法实现连续切除操作。空心管被骨碎块堵死或刀头外部粘有血液或
肌肉碎沫时影响视线须退出工作通道而不能连续操作。这类刀头提高效率
的方式主要是缩短“排屑”等无效操作时间，其中外刃口咬合式刀头稍优于内刃
口咬合式刀头及内刃口剪切式刀头。间断操作类刀头:适合各种组织切除，采用
每咬除一次骨、韧带等组织，进出一次工作通道并进行一次刀头内部及外部
清理及“排屑”的方式工作，“排屑”等无效操作时间较长，但不会因刀头外
部粘有血液或肌肉碎沫而影响视线和操作。提高效率的方式主要为咬除
超出刀头自身面积许多的骨及韧带等组织。结论连续操作类刀头有时不能实
现“连续”操作而变成“间断”操作，且“连续”变“间断”时有不可
预见性，达不到预期目标，而间断操作椎板钳式刀头适合各种组织的切除，“排
屑”等无效操作时间虽明显较长，但能够以超过其自身面积许多的方式咬除骨及
韧带组织而提高效率，并不比连续操作类刀头逊色，故将被选作本腰椎后路椎间
盘遥控微创机器人的刀头。
二.腰椎后路椎间盘微创机器人工作通道的研制及初步临床应用:
目的研制了一种腰椎后路椎间盘微创机器人工作通道，旨在基本不扩大手
郑州大学硕士学位论文
腰椎后路椎间盘微创机器人刀头及工作通道的研究
术范围的情况下实现经通道后路椎间融合，从而扩大该机器人的适用范围。方法
通过腰椎后路椎间盘镜模拟治疗23例退行性腰椎滑脱，初步证实其可行性。男13
例，女10例。年龄49一71岁，平均62.3岁。滑脱部位:L32例，L4 11例，51 10
例。I。滑脱13例，n”滑脱10例。结果1.手术情况:本微创机器人的工作
通道与腰椎后路椎间盘镜的工作通道相比，在基本不增加手术切口长度(l .scm
左右)的情况下，可容直径为14llun的椎间融合器通过。本组共置入螺纹状钦合金
Cage21例，方形钦合金Cagel例。1例Sl滑脱症患者因骸骨水平角过大(>70“)
无法置入椎间融合器仅施行单纯镜?
Lumbar disc protrusion is common disease in Orthopaedics , it is the main reason of the low back pain . There are many methods for its treatment . Generally , they can be categorized into two types : conservative and operative methods . The former includes traditional chirapsia and drug , etc ; the latter also can be divided into two types : traditional open operation and some minimally invasive techniques , for example : pertaneously chemical dissolve nucleus , resect and attract nucleus , nucleus gasification and decompression by laser , lateral-route MED (Micro-Endoscopic Discectomy) and posterior-route MED technique , etc .The remedial principle is that when the conservative treatment is proved to be inefficient then take operation . Although each type of operative method has its advantages , they also have insufficiencies : the conservative open operation may cause more trauma , blood loss , time for recovery , and the risk of complications like vessel or
nerve injury , the patient would not accept it. Those minimally invasive
techniques , like pertaneously chemical dissolve nucleus , resect and attract nucleus , nucleus gasification and decompression by laser , lateral-route MED (Micro-Endoscopic Discectomy) etc , can make minimal trauma , but the range of the applications of these techniques are very narrow . They only suit for the pure protrusion of the disc , when combined with disc ossification , stricture of the spinal tube or lareral crypt , they are proved to be inefficient . Lumbar posterior-route MED system have a comparatively wide application scope , but it also has the risk of vessel and nerve injury ; furthermore , it's not easy to cultivate a young surgeon to master the technique , which makes it hard to spread to great extent . Therefore , exploring a new method with wide applications , more safety , efficiency , and easily to be extended has become one of the most important tasks in the field of the spinal surgery . In recent years , the remote manipulation operative robot has become a hot spot and been paid close attention . Its has many advantages : higher degree of accuracy , good duplication , stable motion , etc ; and through senior man-machine interface,it can not only collect and analyze the surgeon's operative information on line , and offers important means to realize the operative procedure "from technique to science" , but match the human's capability with operative tasks by the utilization of the augmented reality technique , help the operator restore the flexibility of the operative procedure and offer more plentiful ,direct informations on
the spot and of the telepresence . Then increase the security and efficiency of the operation , eases the apprehensiveness and pain of the patients , and lessons the work intensity ; furthermore , resolve the cultivation problem of proficient surgeons . However , there has no operative robot applied for the treatment of the lumbar disc protrusion .
Our series of researchs are to develop the mini-invasively posterior route robot for lumbar disc disease . It acts as the subordinate arms of the remote-manipulation robot, and was of great importance . The blade and the working channel will decide the manner and function the robot will possess . So , we make the following research from two aspects in limited times.
1 . The experimental and clinical contrast and research of the four species of two sorts blades for the mini-invasively posterior-route robot.
Purpose : To select suitable blade for the mini-invasively posterior route robot , then determine the working manner of the robot according to the effect of the bone and soft tissue removal.
Method : Design the two sorts of reamer head , including continuous manipulation reamer head and discontinuous manipulation one . The former contains the occluding reamer head of inner and outer blade ,and cutting reamer head of inner blade . The latter is the blade of conservative laminal forceps . Thro
近几年来，遥操作手术机器人成为一个关注的热点，它不仅具有精确度高、重复性好、动作稳定等优点，且通过高级人机接口，不仅能在线采集并分析手术医生的操作信息，为实现手术过程“从技艺走向科学”提供有效手段，还能利用增强现实技术实现人的能力与外科手术任务之间的匹配，帮助术者恢复手术操作的灵活性，把失去了的“感觉”找回来，给术者提供更丰富、直观和易用的现埸信息及临埸感信息，从而提高手术的安全性和效率，减轻病人的痛苦以及医生的工作强度并能解决大量熟练医生培养难的问题。但迄今尚未见有关于腰椎后路椎间盘遥操作手术机器人的报道。
郑州大学硕士学位论文
腰椎后路椎间盘微创机器人的研究
本系列课题拟研制腰椎后路椎间盘微创机器人，它作为腰椎后路椎间盘遥
操作手术机器人的从手，无疑对整个腰椎后路椎间盘遥操作手术机器人是至关重
要的，而刀头和工作通道又对腰椎后路椎间盘微创机器人的工作方式和功能有重
大影响。有鉴于此，本课题首先从刀头和工作通道两个方面进行了研究:
一两类四种腰椎后路椎间盘微创机器人刀头的实验与临床对比研究:
目的选择适合腰椎后路椎间盘微创机器人的刀头，并根据刀头切除骨及韧
带等组织的情况确定该机器人将采取“连续”还是“间断”工作方式。方法设
计了两类刀头:①连续操作类刀头②间断操作类刀头，前者包括内刃口咬合式刀
头、外刃口咬合式刀头、内刃口剪切式刀头;后者包括椎板钳式刀头。通过手动
模拟动物及临床试验，从各种组织切除情况、“排屑”方式及时间、刀头内部
及外部清理情况以及提高效率的方式四个方面进行比较、综合评估。结果连
续操作类刀头:可切除各种组织，但不同组织情况不同。对于骨碎块，刀头连续
咬合3一10次后，空心管便被堵死，骨碎块不能再进入空心管;韧带等软组织
碎块均顺利进入刀头空心管，空心管不会被堵死;而碎屑不能顺利进入刀头空心
管，无法实现连续切除操作。空心管被骨碎块堵死或刀头外部粘有血液或
肌肉碎沫时影响视线须退出工作通道而不能连续操作。这类刀头提高效率
的方式主要是缩短“排屑”等无效操作时间，其中外刃口咬合式刀头稍优于内刃
口咬合式刀头及内刃口剪切式刀头。间断操作类刀头:适合各种组织切除，采用
每咬除一次骨、韧带等组织，进出一次工作通道并进行一次刀头内部及外部
清理及“排屑”的方式工作，“排屑”等无效操作时间较长，但不会因刀头外
部粘有血液或肌肉碎沫而影响视线和操作。提高效率的方式主要为咬除
超出刀头自身面积许多的骨及韧带等组织。结论连续操作类刀头有时不能实
现“连续”操作而变成“间断”操作，且“连续”变“间断”时有不可
预见性，达不到预期目标，而间断操作椎板钳式刀头适合各种组织的切除，“排
屑”等无效操作时间虽明显较长，但能够以超过其自身面积许多的方式咬除骨及
韧带组织而提高效率，并不比连续操作类刀头逊色，故将被选作本腰椎后路椎间
盘遥控微创机器人的刀头。
二.腰椎后路椎间盘微创机器人工作通道的研制及初步临床应用:
目的研制了一种腰椎后路椎间盘微创机器人工作通道，旨在基本不扩大手
郑州大学硕士学位论文
腰椎后路椎间盘微创机器人刀头及工作通道的研究
术范围的情况下实现经通道后路椎间融合，从而扩大该机器人的适用范围。方法
通过腰椎后路椎间盘镜模拟治疗23例退行性腰椎滑脱，初步证实其可行性。男13
例，女10例。年龄49一71岁，平均62.3岁。滑脱部位:L32例，L4 11例，51 10
例。I。滑脱13例，n”滑脱10例。结果1.手术情况:本微创机器人的工作
通道与腰椎后路椎间盘镜的工作通道相比，在基本不增加手术切口长度(l .scm
左右)的情况下，可容直径为14llun的椎间融合器通过。本组共置入螺纹状钦合金
Cage21例，方形钦合金Cagel例。1例Sl滑脱症患者因骸骨水平角过大(>70“)
无法置入椎间融合器仅施行单纯镜?
Lumbar disc protrusion is common disease in Orthopaedics , it is the main reason of the low back pain . There are many methods for its treatment . Generally , they can be categorized into two types : conservative and operative methods . The former includes traditional chirapsia and drug , etc ; the latter also can be divided into two types : traditional open operation and some minimally invasive techniques , for example : pertaneously chemical dissolve nucleus , resect and attract nucleus , nucleus gasification and decompression by laser , lateral-route MED (Micro-Endoscopic Discectomy) and posterior-route MED technique , etc .The remedial principle is that when the conservative treatment is proved to be inefficient then take operation . Although each type of operative method has its advantages , they also have insufficiencies : the conservative open operation may cause more trauma , blood loss , time for recovery , and the risk of complications like vessel or
nerve injury , the patient would not accept it. Those minimally invasive
techniques , like pertaneously chemical dissolve nucleus , resect and attract nucleus , nucleus gasification and decompression by laser , lateral-route MED (Micro-Endoscopic Discectomy) etc , can make minimal trauma , but the range of the applications of these techniques are very narrow . They only suit for the pure protrusion of the disc , when combined with disc ossification , stricture of the spinal tube or lareral crypt , they are proved to be inefficient . Lumbar posterior-route MED system have a comparatively wide application scope , but it also has the risk of vessel and nerve injury ; furthermore , it's not easy to cultivate a young surgeon to master the technique , which makes it hard to spread to great extent . Therefore , exploring a new method with wide applications , more safety , efficiency , and easily to be extended has become one of the most important tasks in the field of the spinal surgery . In recent years , the remote manipulation operative robot has become a hot spot and been paid close attention . Its has many advantages : higher degree of accuracy , good duplication , stable motion , etc ; and through senior man-machine interface,it can not only collect and analyze the surgeon's operative information on line , and offers important means to realize the operative procedure "from technique to science" , but match the human's capability with operative tasks by the utilization of the augmented reality technique , help the operator restore the flexibility of the operative procedure and offer more plentiful ,direct informations on
the spot and of the telepresence . Then increase the security and efficiency of the operation , eases the apprehensiveness and pain of the patients , and lessons the work intensity ; furthermore , resolve the cultivation problem of proficient surgeons . However , there has no operative robot applied for the treatment of the lumbar disc protrusion .
Our series of researchs are to develop the mini-invasively posterior route robot for lumbar disc disease . It acts as the subordinate arms of the remote-manipulation robot, and was of great importance . The blade and the working channel will decide the manner and function the robot will possess . So , we make the following research from two aspects in limited times.
1 . The experimental and clinical contrast and research of the four species of two sorts blades for the mini-invasively posterior-route robot.
Purpose : To select suitable blade for the mini-invasively posterior route robot , then determine the working manner of the robot according to the effect of the bone and soft tissue removal.
Method : Design the two sorts of reamer head , including continuous manipulation reamer head and discontinuous manipulation one . The former contains the occluding reamer head of inner and outer blade ,and cutting reamer head of inner blade . The latter is the blade of conservative laminal forceps . Thro
引文
(1) Biering-Sorenson F. Low back trouble in a general population of 30-40-50-and 60-year-old men and women. Dan Med Bull 1982;29:289
(2) Holbrook TL, Grazier K, Keksey JL Stauffer. RN. rhe socioeconomic impact of selected musculoskeletal disorders. Chicago: American Academy of OrthoOpaedic Surgeon, 1984;
(3) Rutkow IM. Orthopaedic operation in the United States 1979-1983. J Bone Joint surg 1986; 68A: 716;
(4) 胡有谷主编．腰椎间盘突出症的手术治疗．腰椎间盘突出症，北京：人民卫生出版社第二版，1996：247-296页；
(5) 滕皋军主编．经皮腰椎间盘摘除术，南京：江苏科学技术出版社2000．5：78-142 169-173页；
(6) 陈克银．后路椎间盘镜系统与脊柱微创手术2004，2(24)．湖南津市市风湿病科学研究所
(7) 唐天驷，郑召民．积极健康地发展我国的微创外科．中华脊柱脊髓杂志2003，13(2)：69-70
(8) 林良明，张江安，等．微创伤外科手术机器人的研制与发展．机电一体化，2000，5：12-16．
(9) 刘少强，黄惟一，王爱民，等．用于微创外科手术的遥控机器人系统研究现状及趋势．机器人，2002，5(24)，3
(10) Ballester P, Jain Y Haylett K R, et al. Comparison of task performance robotic camera holders Endoassisted and Aesop. In: International congress series, 2001,1230:1100-1103;
(11) 张春霖，唐恒涛，于远洋，等．腰椎后路椎间盘镜手术及疗效分析．中华骨科杂志，2002，2：84-87；
(12) 胡有谷，党耕町，唐天驷，等．BAR脊柱融合术．脊柱外科学，北京：人民卫生出版社 第二版；
(13) 徐震球，石瑛，等．腰椎间盘突出症三种非手术方法疗效分析．中医正骨，2003，8(15)，8：37-38
(14) Stephen D．kuslich吕厚山译 BAR椎间融合方法．脊柱内固定学 北京：人民卫生出版社；
(15) 郭世绂．临床骨科解剖学．天津科技出版社，1984，160：185-212；
(16) Tencer AF, Hampton D, Eddy S. Biomechanical properties of threaded inserts for lumbar interbody spinal fusion. Spine. 1995 Nov, 22:2408-14;
(17) 赵杰，王新伟，侯铁胜，斜向单枚BAK植入后路腰椎椎体间融合术的生物力学及临床研究．中国脊柱脊髓杂志，2000，4：208-211；
(18) Brodke DS, Dick JC, Kunz DN, et al. Posterior lumbar interbody fusion. A biomechanical comparison, including a new threaded cage. Spine. 1997 Jan, 1: 26-31;
(19) 胡有谷，党耕町，唐天驷，等．BAK脊柱融合术．脊柱外科学，北京：人民卫生出版社 第二版：
(2) Holbrook TL, Grazier K, Keksey JL Stauffer. RN. rhe socioeconomic impact of selected musculoskeletal disorders. Chicago: American Academy of OrthoOpaedic Surgeon, 1984;
(3) Rutkow IM. Orthopaedic operation in the United States 1979-1983. J Bone Joint surg 1986; 68A: 716;
(4) 胡有谷主编．腰椎间盘突出症的手术治疗．腰椎间盘突出症，北京：人民卫生出版社第二版，1996：247-296页；
(5) 滕皋军主编．经皮腰椎间盘摘除术，南京：江苏科学技术出版社2000．5：78-142 169-173页；
(6) 陈克银．后路椎间盘镜系统与脊柱微创手术2004，2(24)．湖南津市市风湿病科学研究所
(7) 唐天驷，郑召民．积极健康地发展我国的微创外科．中华脊柱脊髓杂志2003，13(2)：69-70
(8) 林良明，张江安，等．微创伤外科手术机器人的研制与发展．机电一体化，2000，5：12-16．
(9) 刘少强，黄惟一，王爱民，等．用于微创外科手术的遥控机器人系统研究现状及趋势．机器人，2002，5(24)，3
(10) Ballester P, Jain Y Haylett K R, et al. Comparison of task performance robotic camera holders Endoassisted and Aesop. In: International congress series, 2001,1230:1100-1103;
(11) 张春霖，唐恒涛，于远洋，等．腰椎后路椎间盘镜手术及疗效分析．中华骨科杂志，2002，2：84-87；
(12) 胡有谷，党耕町，唐天驷，等．BAR脊柱融合术．脊柱外科学，北京：人民卫生出版社 第二版；
(13) 徐震球，石瑛，等．腰椎间盘突出症三种非手术方法疗效分析．中医正骨，2003，8(15)，8：37-38
(14) Stephen D．kuslich吕厚山译 BAR椎间融合方法．脊柱内固定学 北京：人民卫生出版社；
(15) 郭世绂．临床骨科解剖学．天津科技出版社，1984，160：185-212；
(16) Tencer AF, Hampton D, Eddy S. Biomechanical properties of threaded inserts for lumbar interbody spinal fusion. Spine. 1995 Nov, 22:2408-14;
(17) 赵杰，王新伟，侯铁胜，斜向单枚BAK植入后路腰椎椎体间融合术的生物力学及临床研究．中国脊柱脊髓杂志，2000，4：208-211；
(18) Brodke DS, Dick JC, Kunz DN, et al. Posterior lumbar interbody fusion. A biomechanical comparison, including a new threaded cage. Spine. 1997 Jan, 1: 26-31;
(19) 胡有谷，党耕町，唐天驷，等．BAK脊柱融合术．脊柱外科学，北京：人民卫生出版社 第二版：
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |