颈前路内窥镜下松解复位后路内固定治疗难复性寰枢关节垂直脱位

Endoscopic transcervical anterior release and posterior fixation in the treatment of irreducible vertical atlantoaxial dislocation

中文关键词:  寰枢关节  脱位  颅底凹陷症  内窥镜

英文关键词:Atlantoaxial joint  Dislocation  Basilar invagination  Endoscopy

中文摘要:

  【摘要】 目的：探讨颈前路内窥镜下松解复位后路内固定治疗难复性寰枢关节垂直脱位的效果。方法：5例难复性寰枢关节垂直脱位患者接受一期前路经颈内镜松解复位后路内固定治疗，其中类风湿关节炎2例，原发性颅底凹陷症3例。所有患者均有神经功能受损的症状和体征，术前行颅骨牵引后摄片证实复位失败，采用颈前路内窥镜下松解复位后路内固定术治疗，观察临床症状改善情况，评价术前术后影像学资料及神经功能情况，随访术后并发症及植骨融合情况。结果：平均随访时间为25.8个月（12～40个月），所有患者均取得显著的脊髓功能改善，无并发症发生。前路术中内窥镜视野下可见寰齿关节韧带挛缩及疤痕组织增生，经松解后所有患者均取得寰枢关节解剖复位，患者术前齿状突最高点高于McRae线5.02～7.02mm，平均5.79±0.75mm，术后为-9.89～1.53mm，平均-3.18±4.19mm（P<0.05）；术前颈髓延髓角105°～139°，平均127.2°±11.58°，术后恢复至141°～164°，平均152.8°±9.60°（P<0.05）；术前VAS评分4～7分，平均5.4±1.1分，术后改善至1～2分，平均1.6±0.5分（P<0.05）；术前JOA评分7～12分，平均9.2±2.3分，术后提高至13～17分，平均15.2±1.6分（P<0.05），改善率为80.5%；术前ASIA分级B级1例、C级3例、D级1例，术后较术前提高1～2级；所有患者均获骨性融合且无并发症发生。结论：颈前路内窥镜下松解复位后路内固定是一种安全有效的治疗难复性寰枢关节垂直脱位的治疗手段。

英文摘要:

  【Abstract】 Objectives: To describe the effect of endoscopic transcervical anterior release and posterior fixation in treating patients with irreducible vertical atlantoaxial dislocation. Methods: Five consecutive patients with vertical atlantoaxial dislocation and upper cervical spinal cord compression underwent endoscopic transcervical anterior release and posterior fixation. The pathologies were rheumatoid arthritis(2 patients) and primary basilar invagination(3 patients). The McRae line was chosen to evaluate the reduction, the cervicomedullary angle(CMA) was measured to evaluate the degree of upper cervical spinal cord compression, and the JOA score and VAS were used to evaluate the pre- and post-operative neurological function. Results: All patients had an uneventful recovery with significant improvement in neurological function and radiographic parameters with an averange 25.8-month follow-up. No complications were seen. In all cases, anatomic reduction was achieved, the mean value of distance between odontoid process and the McRae was 5.79mm preoperatively(range: 5.02-7.02mm), and -3.18mm postoperatively(range: -9.89-1.53mm). The CMA was improved from average 127.2°(range: 105°-139°) to 152.8°(range: 141°-164°) averagely. The average preoperative and postoperative JOA score was 9.2(range: 7-12) and 15.3(range: 13-17) with an 80.5% overall improvement rate. The mean VAS improved from 5.4(preoperative, range: 4-7) to 1.6(postoperative, range: 1-2) in average. Conclusions: Endoscopic transcervical anterior release and posterior fixation appears to be a viable and interesting alternative for the treatment of vertical atlantoaxial dislocation in properly selected individuals.