枢椎骨折合并相邻节段不稳的分型和手术治疗选择

The classification and surgical management for axis fracture complicated with adjacent segment instability

中文关键词:  枢椎骨折  相邻节段不稳  分型  手术治疗

英文关键词:Axis Fractures  Adjacent section instability  Classification  Operative methods

中文摘要:

  【摘要】 目的：提出枢椎骨折合并相邻节段不稳的分型，探讨分型对于手术方式选择的指导意义。方法：2003年8月~2011年6月我院手术治疗枢椎骨折合并相邻节段不稳患者47例，其中男31例，女16例；年龄19~59岁，平均32岁。术前合并脊髓损伤11例，脊髓功能Frankel分级A级1例，B级2例，C级3例，D级5例。JOA评分为1~15（10.60±3.29）分。根据枢椎骨折的类型及其寰枢关节、C2/3关节的稳定情况分为3型：A型，枢椎骨折合并C1/2不稳，21例；B型，枢椎骨折合并C2/3不稳，17例；C型，枢椎骨折同时合并C1/2及C2/3不稳，9例。A型采用后路寰枢椎固定术，可联合齿状突螺钉固定；B型采用前路椎间盘切除、植骨融合、钢板固定术；C型采用后路C1~C3固定术。3例寰枢椎螺钉置入困难，采用枕颈融合术。均在固定骨折枢椎的同时，稳定C1/2和C2/3节段。术后3个月行JOA评分，术后随访X线片或CT片评价骨折愈合、植骨融合及颈椎稳定性情况。结果：47例均顺利完成手术，术中无椎动脉损伤、神经损伤、气管食管损伤等手术并发症。随访9~48个月，平均15个月。术后3个月JOA评分为2~17（13.83±3.93）分，与术前比较有统计学差异（P<0.05），JOA评分改善率为72.3%~90.8%，优良率为98%。术后6个月脊髓功能Frankel分级，1例B级无变化，10例Frankel分级改善1~2级。术后6~9个月复查X线片示骨折愈合良好，39例行植骨融合者在术后3~6个月（平均4.5个月）均获骨性融合。随访期间，颈椎序列良好，颈椎伸屈侧位X线片显示颈椎稳定，无内固定松动、脱出及断裂。结论：根据枢椎骨折合并相邻节段不稳的分型合理选择手术方案，在固定枢椎同时兼顾相邻节段的稳定性，能取得良好疗效。

英文摘要:

  【Ａbstract】 Objectives: To provide the classification of axis fracture complicated with adjacent segment instability and investigate its significance to surgical management. Methods: 47 patients(31 males and 16 females) with axis fractures from August 2003 to June 2011 with a mean age of 32 years(range, 19 to 59) were treated surgically and analyzed retrospectively. The Frankel scale was used to assesse neurofunction as following: 1 grade A, 2 grade B, 3 grade C and 5 grade D before surgery. The classification was determined according to the fracture type and stability of adjacent segment. Type A(21 cases): axis fracture with C1/2 instability; Type B(17 cases): axis fracture with C2/3 instability; Type C(9 cases): axis fracture with both C1/2 and C2/3 instability. Operations were performed as following: Type A, posterior atlantoaxial fixation plus anterior screw fixation for odontoid fracture; Type B, anterior discectomy, fusion, and cervical plate fixation; Type C, posterior C1-C3 fixation or occipitocervical fusion when C1-C2 fusion was unavailable. JOA score was applied to evaluate the therapeutic effect. The fracture healing, bone graft fusion and stability were observed on X-ray or CT scan. Results: All patients underwent surgery safely without spinal cord injury, cerebrospinal fluid leakage and vertebral artery injury. The average follow-up was 15 months(9-48 months). There was significant difference(P＜0.05) in JOA score between pre-operation(10.60±3.29) and post-operation(13.83±3.93), and the rate of improvement was 72.3%-90.8%, with the excellent to good rate of 98%. 1-2 degree improvement of neurofunction was achieved in all except 1 Frankel B. After operation, all patients were immobilized in a hard collar for 3 months. Fusion was achieved in 39 cases from 3 to 6 months(mean 4.5 months). X-ray verified no malposition of the screws. No instrument failure was noted during follow-up. Conclusions: Axis fracture complicated with adjacent segment instability should be treated individually based on fracture type and adjacent segment instability, and the classification can be used to guide the surgical management.