齿状突骨折伴寰枢椎不稳的手术治疗

Surgical treatment of odontoid fracture with atlantoaxial instability

中文关键词:  齿状突骨折  寰枢椎不稳  前路  后路  齿状突螺钉固定  C1/2椎弓根螺钉固定

英文关键词:Odontoid fracture  Atlantoaxial instability  Anterior approach  Posterior approach  Odontoid screw fixation  C1-2 pedicle screw fixation

中文摘要:

  【摘要】 目的：探讨齿状突骨折伴寰枢椎不稳的治疗方案及疗效。方法：2005年4月~2014年2月共手术治疗Ⅱ、Ⅲ型齿状突骨折患者48例，男33例，女15例，年龄21~74岁，平均43.3±29.0岁。新鲜骨折43例，陈旧骨折5例。按Grauer分型：Ⅱa型12例，Ⅱb型13例，Ⅱc型11例，浅Ⅲ型12例。术前均有外伤史，伴有颈部疼痛和活动受限。术前常规行颅骨牵引，牵引后骨折均有不同程度的复位。根据患者骨折类型、年龄、牵引复位情况、骨质情况、全身条件选择手术方式，22例采用前路单枚中空齿状突螺钉固定，其中1例因C6椎体骨折同时行C6椎体次全切除钛网支撑植骨钢板固定。24例采用经后路寰枢椎椎弓根螺钉固定取髂骨植骨融合，其中1例行一期后路C1/2椎弓根螺钉植骨融合+前路C5椎体次全切除钛网置入钢板内固定术，4例因椎动脉骑跨采用枢椎椎板螺钉固定。2例高龄患者因体质差合并骨质疏松，不能耐受全麻手术，行Halo-vest架固定。随访观察患者骨折融合率、颈椎活动度及神经功能恢复情况。结果：患者均顺利完成手术。前路手术患者中2例在术后1周复查CT时发现骨折移位，1例行翻修手术，取出内固定后重新置钉，再次复查CT示骨折复位满意，6个月后骨折愈合；1例改为后路C1/2椎弓根螺钉内固定植骨融合术，术后4个月植骨融合；2例发生喉上神经损伤，出现饮水呛咳，经对症处理后症状缓解。后路手术患者1例术中出现椎动脉破裂，置入螺钉后出血停止，未特殊处理；1例枢椎椎弓根螺钉进入椎管，无神经损伤症状，未特殊处理。所有患者均未发生脑脊液漏和脊髓损伤。随访12~120个月，平均25±72个月，骨折均达到骨性愈合。前路手术组颈椎屈伸和旋转功能正常，后路手术组颈椎旋转功能有不同程度受限。结论：对于齿状突骨折伴寰枢椎不稳的患者，根据骨折类型、患者年龄、牵引复位情况、骨质情况、全身条件综合考虑，制定个体化的手术方案，可获得良好的治疗效果。

英文摘要:

  【Abstract】 Objectives: To explore the appropriate surgical strategy of odontoid fracture complicated with atlantoaxial instability. Methods: From April 2005 to February 2014, 48 cases with type Ⅱ and shallow type Ⅲ odontoid fracture were surgically treated in our hospital, including 33 males and 15 females with an average age of 44.3±29.0 years old (ranging from 21 to 74 years old). Among them, there were 43 fresh fractures and 5 old fractures. According to Grauer type classification, 12 cases were type Ⅱa, 13 cases were Ⅱb, 11 cases were Ⅱc and 12 cases were shallow type Ⅲ. They all had trauma history, suffering from cervical pain and limited neck movement. All cases had received skull traction. Anterior odontoid screw fixation, posterior cervical instrumented fusion and Halo-vest external fixation were used in our series. 22 cases underwent anterior odontoid screw fixation. 24 cases underwent posterior cervical instrumented fusion, and the other 2 patients underwent Halo-vest external fixation because of old age and bad general condition. Among the anterior odontoid screw fixation cases, 1 patient complicated with C6 fracture received C6 subtotal resection and plate internal fixation. Among the cervical instrumented fusion cases, 4 cases underwent C2 lamina screw because of vertebral artery straddle. The fusion of fracture and the movement of neck were evaluated. Results: All the patients underwent the operation successfully. Two patients who underwent anterior surgery showed unsatisfactory reduction, one of them received a revision surgery by replacing a thick screw with solid fusion in later CT examination, the other one was treated with posterior cervical instrumented fusion and showed solid fusion after 4 months. Two patients suffered from superior laryngeal nerve injury but the symptom improved in 1 month. One case suffered from vertebal artery injury after insertion of the screw but the blooding stopped without clinical symptom. In the other one case, the pedicle screw invaded into the spinal canal, but no clinical symptom was observed. No CSF leakage or spinal cord injury was noted. All 48 patients were followed up for an average of 25 months (ranging from 12 to 120 months). Bony fusion was achieved in all the patients. Cervical movement in the group of anterior cannulated odontoid screw fixation recovered to normal, while the group of posterior C1-C2 screw-rod fixation had some degree of limitation in rotation. Conclusions: For Grauer type Ⅱ and shallow type Ⅲ odontoid fracture, surgical strategy should be based on the fracture type, reduction of skull traction, age and the general condition. Good therapeutic results can be achieved by choosing individualized surgical plan.