基于多模态图像配准融合的腰椎椎间孔穿刺无辐射可视化手术导航系统研究

Lumbar disc herniation(LDH) is a common and frequently encountered disease.Percutaneous transforaminal endoscopic lumbar discectomy（PTED）has become one of the most important surgical approaches treating LDH.Transforaminal puncture is the key step during the procedure of PTED.However, current guiding methods such as X-ray and ultrasound shared certain drawbacks including radiation exposure and diminished accuracy.We found in previous study that registration of real-time ultrasonic images and 3D CT images could be applied in transforaminal puncture but suggested several problems such as poor identification of lumbar structures and unsatisfying accuracy of image registration. We also noticed that low frequency ultrasound with broadband longitudinal wave could show clear images of bone tissues with different depth. By investigating the parameters involving optimized lumbar structures display with ultrasound as well as the best registration algorithm of lumbar ultrasonography and CT scan images, this study aims to develop a highly precised, non-radiative, visualized surgical navigation system for transforaminal puncture，and to verify its feasibility via cadaveric and clinical studies. This novel navigation system would shorten the learning curve and reduce the difficulty of PTED procedure, hence has a broad application prospect.

腰椎间盘突出症（LDH）是一种常见病和多发病，严重威胁人民群众健康。经皮椎间孔入路内镜下椎间盘切除术（PTED）已经成为治疗LDH的重要手术方式。椎间孔穿刺是PTED手术最为关键和复杂的环节，现有的X线或单纯超声引导椎间孔穿刺存在放射暴露或精准度低等缺点。课题组前期研究发现：实时超声图像与三维CT图像配准融合的容积导航技术可以引导椎间孔穿刺，但存在普通超声对腰椎结构辨识度不高、图像配准精度不高等问题；课题组前期还发现低频纵波宽带超声能对不同深度骨组织清晰显像。本课题拟通过超声信号对腰椎结构最佳显像效果相关参数研究，以及结合IMLOP算法的腰椎超声图像和三维CT图像多重配准方法研究，研发适合椎间孔穿刺的高精度、无辐射、可视化手术导航系统，并通过尸体及临床试验验证其可行性。新型手术导航系统的研发将大大提高椎间孔穿刺的精准度，避免放射暴露，缩短PTED手术的学习曲线，临床应用前景广泛。

超声容积导航技术（UVN）利用超声实时图像与先前收集的CT或MRI等数据进行配准融合，使用电磁场跟踪系统，能协助医生更快、更精准的识别和确认靶点部位，从而进行相关诊疗操作。本课题探究无超声相关经验的脊柱外科医生在UVN引导下行脊柱椎体周围靶点穿刺的穿刺时间、穿刺精度及学习曲线等问题。发现超声医师辅助下，脊柱外科医生在UVN引导下行脊柱椎体周围的靶点穿刺，其穿刺时间和穿刺精度明显优于无超声医师辅助；并且其学习曲线较为平坦。比较常规徒手穿刺“试错法”、同心圆穿刺定位器法及UVN辅助下椎间孔穿刺3种方法之间的优劣势，明确UVN技术在经皮内镜经椎间孔入路椎间盘切除术（PTED）手术中的应用价值；比较3种穿刺引导方法在L4/5及L5S1不同手术节段的围手术期指标，明确UVN技术在引导L5S1节段椎间孔穿刺中的优势。UVN辅助PTED手术椎间孔穿刺与传统徒手“试错法”相比，明显减少了穿刺时间、透视次数、射线暴露及手术时间。UVN应用于PTED手术椎间孔穿刺安全、有效，值得推广。与常规徒手穿刺“试错法”比较，明确UVN技术在PVP或PKP手术中的应用价值。UVN引导PVP和PKP手术的椎弓根穿刺安全、可行，与传统射线引导下徒手椎弓根穿刺相比，能取得一样的疗效和优良率，但显著降低了穿刺时间、透视次数及辐射暴露。比较常规徒手穿刺“试错法”经皮螺钉置入术与自制皮内定位器辅助下经皮椎弓根螺钉置入术及UVN辅助下经皮椎弓根螺钉置入术，三种方法之间的优劣势，明确UVN在腰椎经皮螺钉置入手术中的临床价值。UVN引导下经皮椎弓根螺钉置入法与传统射线引导下“试错法”及皮内定位器辅助法相比，其明显缩短了置钉时间，减少透视次数及射线暴露

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