寰椎骨折合并不连续下颈椎骨折脱位的外科治疗

Surgical treatment for atlas fractures combined with noncontiguous lower cervical fracture-dislocation

中文关键词:  寰椎  骨折  骨折固定术  下颈椎  外科治疗

英文关键词:Atlas  Fracture  Fracture fixation  Lower cervical spine  Surgical treatment

中文摘要:

  【摘要】 目的：探讨寰椎骨折合并不连续下颈椎骨折脱位的治疗方法及效果。方法：回顾性分析2005年10月～2011年5月收治的20例寰椎骨折合并不连续下颈椎骨折脱位患者的一期手术治疗效果。男13例，女7例，平均年龄36岁。5例寰椎粉碎性骨折合并有寰椎侧块内侧骨性结构附着处横韧带撕裂（DickmanⅡ型），3例双侧前弓骨折（前1/2 Jefferson骨折），5例单侧前后弓双骨折（半环Jefferson骨折），2例前3/4 Jefferson骨折 （前弓二处、后弓一处骨折），5例后3/4 Jefferson骨折 （前弓一处、后弓二处骨折）。其中并存下颈椎骨折脱位按Allen分型：屈曲压缩型5例，牵张压缩型3例，垂直压缩型8例，屈曲牵张型2例，伸展牵张型2例。20例患者均行上、下颈椎一期手术治疗：5例行后路C1-C2固定融合术，7例行口咽入路钢板内固定术，8例行单纯C1后路螺钉固定术；9例并发脊髓不完全损伤来自于下颈椎骨折脱位者，先行下颈椎融合固定，无脊髓损伤11例患者，先固定相对不稳定节段。随访观察治疗效果。结果：平均手术时间200min（180～240min）；平均失血量760ml（500～1600ml）。2例因电刀灼伤C1-C2间血管静脉丛导致出血，行止血纱布、脑棉片填塞止血，未出现颅脑缺血症状；其他病例未出现与手术直接相关并发症及长期卧床所导致的并发症。患者均于术后3d颈托固定后下地行走。随访8～42个月，平均26个月。9例合并脊髓不完全损伤者术后神经功能Frankel分级均有1个级别恢复。复查X线片和CT，未发现患者颈椎失稳或复位丢失，螺钉位置良好，无松动、断钉，寰椎骨折及下颈椎骨折脱位均获骨性愈合。结论：手术治疗寰椎骨折合并不连续下颈椎骨折脱位利于患者早期下床活动，减少长期卧床并发症，可获得较好疗效。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical features and surgical treatment of atlas fractures combined with noncontiguous lower cervical fracture-dislocation. Methods: A retrospective study was performed on 20 patients with atlas fractures combined with noncontiguous lower cervical fracture-dislocation treated by one-stage operation from October 2005 to May 2011. Five patients suffered from comminuted fracture of the lateral mass associated with bony avulsion of the medial tubercle and transverse ligament (Dickman transverse ligament type II injury), three from bilateral fractures of anterior arch (pre-half Jefferson fractures), five from anterior arc fracture associated with unilateral posterior arc fracture(half-ring Jefferson fracture), two from anterior 3/4 Jefferson fracture(two fracture lines in anterior arch, one fracture line in posterior arch), five from posterior 3/4 Jefferson fracture(one fracture line in anterior arch, two fracture lines in posterior arch). Five cases underwent C1-C2 fusion, seven cases underwent transoral osteosynthesis of the atlas, five cases were performed posterior osteosynthesis of the atlas. For the lower cervical fracture-dislocation, according to Allen classification: five cases had compression-flexion, three cases had compression-extension, eight cases had vertical-compression, two cases had distraction-flexion, two cases had distraction-extension. There were 13 males and 7 females with the mean age of 36 years. All of the 20 cases underwent surgery on both sites simultaneously. Lower cervical fracture-dislocation responsible for neurological deficit was stabilized firstly in 4 cases. For the other 16 cases without neurological involvement, stabilization was performed in atlas alone. Results: All patients were followed up for an average of 26 months(range, 8 to 42 months). According to Frankel grade, there were 1 grade B, 3 grade C, 5 grade D, 11 grade E before operation, and 1 grade C, 3 grade D, 16 grade E after operation respectively. Four cases with neurological defect had neurofunction improved 1 Frankel scale. The operative time ranged from 180 to 240 min with an average of 200min． The intra- operative blood loss ranged from 500 to 1600ml with an average of 760ml． No surgery-related complications were noted. Two cases had venous plexus ruptured due to the use of electrocautery, which ceased by using hemostatic sponge and cotton piece without causing cerebral hemodynamic deficit． No screw looseness or breakage occurred． All cases obtained solid fusion at both atlas fractures and lower cervical fracture-dislocation. Conclusions: Atlas fractures combined with noncontiguous lower cervical fracture-dislocation often lead to the utmost instability of the cervical spine. Surgery at early stage can decrease the rate of complication as well as ensure recovery．