寰枢椎脱位手术后翻修的原因及策略

Causes and therapeutic strategies for atlantoaxial dislocation revision surgery

中文关键词:  寰枢椎脱位  翻修手术  原因分析  治疗策略

英文关键词:Atlantoaxial dislocation  Revision surgery  Cause analysis  Therapeutic strategies

中文摘要:

  【摘要】 目的：分析寰枢椎脱位手术后翻修的原因，探讨其策略。方法：回顾性分析15例寰枢椎脱位手术后翻修患者，男11例，女4例，翻修时年龄15~68岁（46.60±14.95岁）；两次手术相隔2～120个月（28.73±38.59个月）。根据影像资料及手术探查情况分析翻修原因。翻修手术中均行8~10kg颅骨牵引及后方松解；后方结构完整患者行后路固定，根据松解后复位情况决定是否选择前路松解术；1例后路减压患者行前路松解复位固定术。导航模板辅助置入寰枢椎螺钉；自体髂骨松质骨颗粒植骨。随访观察寰枢椎复位、螺钉位置、植骨融合及手术疗效。结果：翻修原因，减压或复位不足10例，内固定失败3例，植骨未融合3例（含植骨未融合致内固定失败1例）。15例翻修手术中，14例为后路固定手术，1例为前路固定手术。通过术中颅骨牵引及充分松解，13例获得解剖复位；2例因广泛骨性融合，无法牵引复位，切除齿状突后彻底减压。导航模板辅助下共置入寰枢椎螺钉42枚，均一次性置入；置钉准确率97.6%。随访3~36个月（16.0±4.2个月），所有病例骨性融合，融合时间为3~6个月（3.7±0.5个月）；末次随访JOA评分为13.8±3.1分（11~16分），较术前评分8.1±2.3分（6~11分）明显提高，改善率为（64.0±21.2）%（45.4%~88.8%）。结论：寰枢椎脱位手术后翻修的原因为减压或复位不足、内固定失败以及植骨未融合。充分的术中松解、8~10kg的颅骨牵引、恰当的骨质切除减压有利于翻修术中寰枢椎的复位，导航模板辅助有利于提高置钉准确性。

英文摘要:

  【Abstract】 Objectives: To analyze the causes of postoperative revision surgery of atlantoaxial dislocation, and to discuss the therapeutic strategies. Methods: 15 patients with atlantoaxial dislocation revision surgeries(11 male, 4 female; 15-68 years, mean 46.60±14.95 years) were analyzed in this retrospective study. The intervals of two operations ranged from 2 to 120 months(28.73±38.59 months). The reasons were analyzed for revision surgery according to the image data and intraoperative findings. All patients received 8-10kg high dose skull traction and posterior release during revision surgery. For patients with integral posterior structure, the option of anterior release depended on the degree of reduction. After decompression and reduction, all patients received posterior internal fixation. One patient who received posterior decompression in the primary operation was performed with anterior decompression and fixation. Assisted atlantoaxial screw placement under 3D navigation template was performed; autogenous iliac cancellous bone was placed. The atlantoaxial reduction, screw position, bone graft fusion and surgical efficacy were evaluated at follow-up. Results: Reasons for revision were as following: 10 cases of insufficient decompression/reduction, 3 cases of failed internal fixation, 3 cases of unfused bone graft(including 1 case of internal fixation failure caused by unfused bone graft ). Among all the 15 revision surgeries, 14 cases received posterior fixation surgery, 1 case received anterior fixation surgery. By intraoperative skull traction and full release, 13 cases achieved anatomical reduction, the other 2 cases did not reach anatomical reduction due to extensive bony fusion and were fully decompressed after odontoidectomy. 42 atlantoaxial screws were implanted with 3D template-assisted navigation, the accuracy of screw implantation was 97.6%. The follow-up time ranged from 3 to 36 months(16.0±4.2 months). All patients got bone fusion, the fusion time ranged from 3-6 months(3.7±0.5 months). The final JOA score ranged from 11 to 16( mean, 13.8±3.1), which improved compared with the preoperative(range form 6 to 11, mean 8.1±2.3), the improvement rate was (64.0±21.2)%(45.4%-88.8%). Conclusions: Inadequate decompression/reduction, failed internal fixation, and unfused bone graft are the common reasons of C1-2 dislocation needing revision surgery. Intraoperative full release, 8-10kg skull traction, and proper bony structure resection are leading to the reduction of atlantoaxial dislocation, 3D navigation template is beneficial to the accuracy of screw placement.