内窥镜辅助下前路经寰枢关节螺钉固定植骨融合术治疗上颈椎不稳

Endoscopy-assisted anterior transarticular screw fixation and bone grafting for upper cervical instability

中文关键词:  上颈椎不稳  经寰枢关节螺钉固定  脊柱融合术  内窥镜  微创

英文关键词:Upper cervical instability  Transarticular screw fixation  Spinal fusion  Endoscopy  Minimal invasive

中文摘要:

  【摘要】 目的：探讨内窥镜辅助下前路经寰枢关节螺钉固定植骨融合术治疗上颈椎不稳的临床可行性及其疗效。方法：2006年1月至2009年12月采用内窥镜辅助下前路经寰枢关节螺钉固定植骨融合术治疗上颈椎不稳患者13例，男8例，女5例；年龄17~65岁，平均46.8岁。Jefferson Ⅱ型骨折6例，Jefferson Ⅲ型骨折1例，寰枢椎脱位3例，陈旧性齿状突骨折3例。患者均有枕颈部不适和活动受限，术前VAS评分为3.2～4.1分，平均3.8分；2例伴有不同程度脊髓功能损害者，按Frankel分级C级1例，D级1例。随访患者临床症状改善和植骨融合情况。结果：均在内镜辅助下顺利完成手术，13例患者共置入26枚螺钉；手术时间60～130min，平均80min；术中出血110~290ml，平均190ml。术中无脊髓、椎动脉损伤等并发症。术后复查CT显示1枚螺钉位置欠佳，螺钉外斜角偏小且上斜角偏大，螺钉部分进入椎管，但未损伤脊髓，未做处理；25枚位置良好。寰枢关节基本复位，固定可靠。术后随访12~60个月，平均18个月，末次随访时VAS评分降至1.0～2.0分，平均1.3分，与术前比较有统计学差异（P＜0.05）。2例伴颈髓损伤患者的症状均有改善，Frankel分级C级者恢复到D级，D级者恢复到E级。12例患者术后3个月开始出现植骨融合，末次随访时寰枢关节间隙植骨均达到融合；1例患者未见明显植骨融合，但寰枢关节稳定性良好，未出现断钉等并发症。结论：内窥镜辅助下前路经寰枢关节螺钉固定植骨融合术治疗上颈椎不稳是可行的，能取得较好的治疗效果，且在一定程度上克服了传统手术显露困难的缺点，从而减少手术并发症。

英文摘要:

  【Abstract】 Objectives: To evaluate the operation method and clinical outcome of atlantoaxial joint fusion using endoscopy-assisted anterior transarticular screw fixation and bone grafting for upper cervical instability. Methods: 13 cases with upper cervical instability who underwent anterior release with endoscopic aide and subsequently reduction, anterior transarticular screw fixation and morselized autologous bone grafts from January 2006 to December 2009 were retrospectively analyzed． There were 8 males and 5 females, with an average age of 46.8 years(range 17-65 years). There were 6 cases of Jefferson fracture(type Ⅱ), 1 case of fracture of C1 anterior arch(type Ⅲ), 3 cases of atlantoaxial joint dislocation, 3 cases of chronic odontoid fracture. All patients showed neck pain and activity limitation. The preoperative visual analogue scale(VAS) scores of neck pain were 3.2 to 4.1(average 3.8). According to the Frankel classifiaction of disability, 1 case was grade C and 1 case grade D. Evaluation parameters included VAS scores of neck pain, neurological function and bony fusion. Results: All patients were performed successfully by endoscopy-assisted anterior tansarticular screw fixation and bone grafting. 26 screws were implanted in 13 cases. The average operation time was 80min(range, 60 to 130min), and the mean estimated blood loss was 190ml(range, 110 to 290ml). No patient had the injury of spinal cord and vertebral artery. According to the postoperative computed tomography, 25 screws were appropriately placed except that a part of one screw was implant into spinal canal but without neurological deficit. All cases restored anatomic position and stability. The patients were all followed up for an average of 18 months(12-60 months). The average VAS was 1.3(1.0-2.0) at final follow-up. There was significant difference in VAS between preoperation and postoperation(P＜0.05). Neurological functions improved by one grade in both 2 patients according to Frankel grading criteria． All cases occurred bone fusion at 3 months postoperatively and got bony fusion at final follow-up except 1 case. Postoperative final follow-up radiographs demonstrated that all cases almost restored to anatomic position. There was no screw failure complication. Conclusions: Endoscopy-assisted anterior transarticular screw fixation and bone grafting can achieve satisfactory clinical outcomes in patients with instability of the upper cervical spine． This operation procedure for upper cervical instability has the advantage of simplicity, less trauma and minimized bleeding.