寰枢椎脱位翻修手术的临床疗效观察

Clinical outcome of revision surgery for atlantoaxial dislocation

中文关键词:  寰枢椎脱位  翻修手术  经口咽入路  后路复位  内固定

英文关键词:Atlantoaxial dislocation  Revision surgery  Transoral approach  Posterior reduction  Fixation

中文摘要:

  【摘要】 目的：探讨一期前路经口咽松解并后路复位固定融合术对寰枢椎脱位手术治疗失败病例翻修的手术要点及疗效。方法：2001年10月~2011年10月对29例寰枢椎脱位手术治疗失败病例行翻修手术，其中26例获得随访，男12例，女14例。初次手术时年龄4~56岁，平均33.5岁，齿状突骨折不愈合6例，齿状突发育畸形6例，横韧带断裂2例，先天性寰枕融合12例。翻修手术时年龄12~60岁，平均37.2岁。两次手术相隔11~158个月，平均44.2个月。8例初次手术后未复位，18例复位后因内固定失败再次脱位，脑干脊髓角平均101.8°。患者均有枕颈部持续性疼痛，其中19例伴脊髓神经功能障碍，JOA评分平均8.5分。均行一期前路经口咽松解、后路复位减压、寰枢椎或枕颈固定融合术，其中12例行C1-C2融合，6例C0-C2融合，3例C0-C3融合，3例C0-C4融合，2例C1-C4融合。随访患者临床疗效并进行影像学评估。结果：手术均顺利完成，手术时间210~340min，平均290min；失血量500~1100ml，平均700ml。术中未发生血管、神经和脊髓等损伤，术后无咽壁和椎管内感染发生。19例（73.1%）获得完全复位，7例不完全复位；脑干脊髓角恢复至平均143.0°，其中11例达到正常，15例小于正常。随访18～90个月，平均 45个月，随访期间未见内固定松动表现，植骨均获得骨性融合；临床症状明显改善，19例伴有脊髓神经功能障碍患者末次随访时JOA评分平均12.6分。按Macnab疗效评估标准评定：优10例，良6例，无改善3例。结论：一期前路经口咽松解、后路复位减压、寰枢或枕颈固定融合术是一种具有较好临床疗效的寰枢椎脱位翻修术式。

英文摘要:

  【Abstract】 Objectives: To investigate the key point and clinical outcome of revision anterior release and posterior reduction and fusion for the failed atlantoaxial dislocation. Methods: A total of 29 cases suffering from atlantoaxial dislocation and neurological deficit due to failed surgery between October 2001 and October 2011 underwent revision surgery, of them, 26 were followed up. There were 12 males and 14 females with the age at primary surgery averaged at 33.5 years(range, 4-56 years), and averaged at 37.2 years at the time of revision surgery, with the average interval of 44.2 months(range, 11-158 months). The result of the revision surgery included no reduction in 8 cases and recurrent dislocation after instrumentation in 18 cases. The average preoperative cervicalmedullary angle(CMA) was 101.8°. All patients presented with continuous neck pain and 19 cases suffered from neurological deficit, with the average JOA score of 8.5. All cases underwent one-stage anterior transoral atlantoaxial release and posterior reduction and decompression, atlantoaxial or occipitocervical fusion.The protocol included 12 C1-C2 fusion, 6 C0-C2 fusion, 3 C0-C3 fusion, 3 C0-C4 and 2 C1-C4 fusion. JOA(17 points) score and radiograph were used to evaluate the surgical outcome during follow-up. Results: The average surgical time was 290min(range, 210-340min) and the average blood loss of 700ml(range, 500-1100ml). No neurovascular injury or deep infection was noted. 19 cases(73.1%) got complete reduction finally, while 7 cases got incomplete reduction. The CMA increased from preoperative 101.8° to postoperative 143.0°(11 normal and 15 less than normal). All patients were followed up for an average of 45 months(range, 18-90 months). No instrument failure was noted in any case. 19 cases with neurological deficit had preoperative JOA score of 8.5 increasing to 12.6 at final follow-up. Based on Macnab criteria, there were 10 excellence, 6 good, and 3 fair. Conclusions: One-stage anterior transoral atlantoaxial release and decompression by posterior reduction and fusion is reliable, less invasive and effective for atlantoaxial dislocation.