发育性寰椎管狭窄症的手术治疗

Surgical treatment for development spinal canal stenosis at atlas plane

中文关键词:  发育性寰椎管狭窄症  手术策略  分型

英文关键词:Development spinal canal stenosis at atlas plane  Surgical strategy  Classification

中文摘要:

  【摘要】 目的：探讨发育性寰椎管狭窄症的手术方法及疗效。方法：2014年1月~2018年5月我院共收治发育性寰椎管狭窄症患者15例，根据寰枢椎CT薄层扫描图像特征，将发育性寰椎管狭窄症分为4种类型，即Ⅰ型（小寰椎型）、Ⅱ型（寰椎后弓肥厚型）、Ⅲ型（寰椎后弓内陷型）和Ⅳ型（枢椎齿状突肥大型）。针对不同类型采用相应手术方法：①对不合并寰枢椎脱位或失稳的Ⅰ、Ⅲ、Ⅳ型患者实施单纯寰椎后弓切除术；②对Ⅱ型患者采用后弓磨薄回植术；③对合并有寰枢椎脱位或失稳的Ⅰ、Ⅱ、Ⅲ型患者，附加后路枕颈固定融合术；④对合并寰枢椎脱位的Ⅳ型患者采用经口咽前路枢椎齿状突打磨削薄+寰枢椎脱位内固定术的方法。术后复查颈椎MRI和CT，观察高位颈脊髓压迫改善情况；采用JOA评分评价手术前后脊髓功能的改善情况。结果：15例患者中，Ⅰ型7例，Ⅱ型2例，Ⅲ型2例，Ⅳ型4例。共实施寰椎后弓切除并后路枕颈固定融合术6例，单纯寰椎后弓切除术5例，寰枢椎后弓削薄回植术2例（其中1例因合并寰枢椎脱位同时实施枕颈固定融合手术），齿状突削薄寰枢椎前路复位内固定术2 例。手术顺利，未发生术中神经脊髓损伤、椎动脉损伤等严重并发症。术后复查MRI和CT显示寰椎平面的脊髓压迫解除。随访时间12~34个月（14±3个月），患者术后肢体麻木、无力、走路不稳等症状均有不同程度的改善，术前JOA评分10.60±0.96分，术后3个月恢复到14.10±0.37分，末次随访时为14.70±0.63分，改善率为64%。结论：发育性寰椎管狭窄症可分为4种类型，根据不同类型采用针对性的手术治疗可以获得满意的临床效果。

英文摘要:

  【Abstract】 Objectives: Investigate surgical strategies for development spinal cannal stenosis at atlas plane and their clinical results. Methods: We studied 15 cases diagnosed with development spinal cannal stenosis at atlas plane from January, 2014 to December, 2018 in our hospital. According to CT thin-layer scan images of atlantoaxial, they were divided into 4 subgroups: group Ⅰ (small size atlas), group Ⅱ(posterior arch incrassation), group Ⅲ(posterior arch incurvation) and group Ⅳ(odontoid hypertrophy). Different surgical procedures were applied to different types of patients: ①posterior arch osteomy(PAO) was performed on patients in group Ⅰ/Ⅲ/Ⅳ without atlantoaxial dislocation(AAD) or instability; ②posterior arch resect and replantation(PAR) was performed on patients in group Ⅱ; ③besides previous mentioned surgical methods, occipital cervical fixation(OCF) and fusion was also performed on patients associated with atlantoaxial dislocation or instability; ④a novel method of odontoid remodeling and atlantoaxial fixation by transoral anterior reduction plate(ORTARP) were performed on patients associated with AAD in group Ⅳ. All patients underwent MRI and CT examination on cervical vertebrae after operation to evaluate the improvement of spinal medulla compression in C1 plane, and the spinal function recovery was evaluated by JOA scores. Results: Of the 15 patients, 7 in group Ⅰ, 2 in group Ⅱ, 2 in group Ⅲ, and 4 in group Ⅳ. All cases underwent surgery successfully, which included OCF+PAO 6 cases, PAO 5 cases, PAR 2 cases (1 case with atlantoaxial dislocation also underwent occipital cervical fixation and fusion) and ORTARP 2 case. There were no severe complications such as spinal cord damage and vertebrae artery injury in the 15 cases. All patients show different levels of improvement in the symptoms such as limber numbs, weak, claudication. The JOA scores improved from preoperative 10.60±0.96 to 14.10±0.37 at 3 months follow up, and 14.70±0.63 at the last follow up. The improvement rate of cervical spinal function was 64%. Conclusions: Development spinal stenosis at atlas plane could be diagnosed into 4 types, and satisfactory clinical results could be obtained if treated with appropriate surgery for each type.