下颈椎陈旧性脱位的手术治疗

Surgical management for old dislocation of the subaxial spine

中文关键词:  下颈椎  陈旧性脱位  手术治疗

英文关键词:Low cervical spine  Old dislocation  Operation

中文摘要:

  【摘要】 目的：探讨下颈椎陈旧性脱位的手术治疗方法及近期疗效。方法：2004年6月~2008年2月收治下颈椎陈旧性脱位患者23例，脱位椎体为C4 4例，C5 5例，C6 10例，C7 4例，均为前脱位。神经功能按ASIA分级，A级2例，B级1例，C级5例，D级8例，E级7例。入院后均行颅骨牵引。根据术前测量的颈椎中矢状位CT二维重建图像上脱位节段最小椎管矢状径与椎体前后径比值（C/V比值）及关节突关节的绞锁情况制定手术方案，15例0.5≤C/V比值＜0.9的患者中，6例无关节绞锁患者直接行前路松解、复位植骨融合术，9例合并关节绞锁患者先行全身麻醉后透视下颅骨牵引复位术，3例复位成功后行前路植骨融合术，余6例闭合复位失败（仍存在关节绞锁）的患者先行后路复位固定再行前路植骨融合术；5例合并关节绞锁且0.3＜C/V比值<0.5的患者先行前路松解、减压，再行后路复位固定，最后行前路植骨融合术；3例合并关节绞锁且C/V比值≤0.3的患者，先前路松解，再行后路全椎板切除减压、复位，最后行前路减压、植骨融合术。采用颈椎功能残障指数（NDI）、VAS评分及ASIA分级评价颈部功能、疼痛程度及神经功能。结果：平均手术时间105min，术中平均出血量280ml，术中无脊髓、血管、神经损伤，平均住院时间15.7d。术后并发切口脂肪液化1例，内固定松动1例。20例患者随访15~48个月，平均28个月，脱位节段的C/V比值由术前0.56±0.27增至术后0.86±0.07（P<0.05），术后6个月为0.88±0.06，与术后比较无显著性差异（P>0.05）；术后3、6、12个月NDI、VAS评分分别较术前平均下降24%、2.4分，26%、2.8分，35%、3.3分；术后6个月所有患者植骨均融合；术后12个月时10例患者的神经功能至少改善1个ASIA评分等级，余3例（A级、B级和D级各1例）无明显改善。结论：根据术前测量的颈椎中矢状位CT二维重建图像上脱位节段椎管最狭窄处的C/V比值及关节突关节的绞锁情况制定手术方案，治疗下颈椎陈旧性脱位能够恢复脱位节段的椎管容积，重建下颈椎的稳定性，近期疗效满意。

英文摘要:

  【Abstract】 Objective：To investigate surgical strategy and short-term clinical outcome for old dislocation of the subaxial spine.Method：Twenty-three patients with old dislocation of subaxial spine were treated surgically from June 2004 to February 2008.Dislocation vertebrae were C4 in 4 patients，C5 in 5，C6 in 10 and C7 in 4.According to ASIA criterion，neurological status was grade A in 2 patients，grade B in 1，grade C in 5，grade D in 8 and grade E in 7.All 23 patients were performed skull traction prior to surgery.The canal-vertebrae（C/V） ratio at narrowest site of involved segment was measured from CT scan images of sagittal reconstruction.The surgical procedure was determined based on the ratio and the status of facets interlocking.Of 15 patients with C/V ratio over 0.5，6 with no facets interlocking underwent anterior reduction and fusion，9 with facet interlocking were managed as follows：3 cases with bilateral facets interlocking experienced closed reduction by skull traction under general anesthesia followed by anterior fusion，and the other 6 patients irresponsible to skull traction experienced posterioer realignment and fusion followed by anterior fusion and instrumentation.Five cases with C/V ratio less than 0.5 were managed with anterior release and decompression，then posterior reduction and fixation，after that anterior fusion was performed afterwise.Three cases with C/V ratio less than 0.3 underwent anterior release，followed by posterior laminectomy and reduction，finally anterior decompression and fusion was performed.Neck disability index（NDI） and visual analog scale（VAS） was used to evaluate neck function and pain.Additionally ASIA criterion was used for neurological assessment.Result：The average surgical time was 105min，no intra-operative complications were noted.The average blood loss was 280ml，and the average hospital stay was 15.7 days.Post-operative complications were seen in 2 cases，one developed fat liquefaction at skin incision which was cured by changing dressing，the other had one screw loosing which was resolved by removal of anterior implant.20 patients were followed up for an average of 28 months（range，15-48 months）.The C/V ratio improved significantly from preoperative 0.56±0.27 to postoperative 0.86±0.07（P<0.05） and 0.88±0.06 at 6 months follow-up.NDI and VAS score at 3，6，12 months after operation decreased 24% for 2.4，26% for 2.8 and 35% for 3.3 respectively.Successful interbody fusion occurred in all 20 patients at 6 months.10 patients had neurologic function improved，however 3 cases remained unchanged（1 grade A，1 grade B and 1 grade D） at 12 months.Conclusion：The surgical strategy for old subaxial dislocation should be referred to the canal-vertebrae（C/V） ratio and status of facets interlocking at narrowest site of involved segment from CT scan images of sagittal reconstruction，which can reconstruct subaxial spine stability and ensure a good early outcome.