后路内固定融合手术治疗类风湿性寰枢椎不稳

Posterior fixation and fusion for atlantoaxial instability caused by rheumatoid arthritis

中文关键词:  类风湿性关节炎  寰枢椎脱位  寰枢椎融合  枕颈融合

英文关键词:Rheumatoid arthritis  Atlantoaxial subluxation  Atlantoaxial fixation  Occipital cervical fusion

中文摘要:

  【摘要】 目的：评估后路内固定融合节段对治疗类风湿性寰枢椎不稳临床疗效的影响。方法：2008年1月~2015年3月收治类风湿性寰枢椎不稳患者24 例，其中女15例，男9例；年龄37~64岁（50.8±4.3岁）。21例患者入院前已经诊断为类风湿性关节炎（RA），病程2~30年（15.6±7.8年）；3例患者本次入院确诊为RA并且伴有寰枢椎不稳。侧位X线片示寰枢椎脱位（AAS）13例；寰枢椎垂直脱位（VS）5例；AAS+VS 2例；AAS+下颈椎半脱位（SAS）1例；后路钢丝固定术后3年钢丝断裂合并下颈椎SAS 1例；寰枢关节破坏无脱位表现2例。均行后路固定融合手术，13例AAS患者10例行后路寰枢椎（C1-2）融合内固定术，2例因C2椎弓根细小行C1-C3固定融合，1例因寰椎后弓细小及骨质疏松行枕颈融合术（O-C2）；7例VS/AAS+VS患者及2例严重枕颈部疼痛的患者行枕颈融合术，O-C2融合3例，O-C3融合6例，其中1例行寰椎后弓切除减压；2例合并SAS的患者行枕颈椎/胸椎（O-C7 1例，O-T1 1例）固定融合，包括1例翻修手术。比较患者术前、术后及末次随访时的Ranawat神经功能分级、VAS和JOA评分。结果：24例患者手术均顺利完成，无术中并发症；术后伤口浅表感染2例，经换药和使用敏感抗菌素治愈。24例患者均获得随访，随访时间12~45个月（24.1±10.3个月）。VAS评分由术前的6.6±1.2分下降到术后的2.6±0.9分，末次随访时1.8±0.7分（P＜0.05）。JOA评分由术前的平均11.5±1.9分增加到术后的平均13.6±2.0分，末次随访时14.5±1.1分（P＜0.05）。Ranawat神经损伤分级：3例术前Ⅰ级无恢复；5例Ⅱ级者4例恢复至Ⅰ级，1例无恢复；15例Ⅲa级恢复至Ⅰ级13例，Ⅱ级2例；1例Ⅲb级恢复至 Ⅲa级。术后3个月植骨融合率为29%（7例），术后6个月为79%（19例），术后12个月为100%（24例）。术后继发SAS 3例，脱位部位：C3/4 2例，C4/5 1例。结论：类风湿性寰枢椎不稳患者行后路内固定融合手术治疗效果满意，应根据病变累及范围、脱位类型、骨密度和钉道情况选择固定融合范围。

英文摘要:

  【Abstract】 Objectives: To assessed the effect of fixation and fusion segment on clinical effects for atlanto-axial instability caused by rheumatoid arthritisand. Methods: 24 patients diagnosed as atlantoaxial instability in RA and operated in Southwest Medical University during January 2005 to March 2015 were reviewed, including 15 males and 9 females, with an average age of 50.8±4.3 years. 21 patents were diagnosed as RA prior to hospitalization with course of disease 2-30 years, 3 patients were diagnosed after admission. Among them, 13 patients were atlantoaxial dislocation(AAS) in lateral X ray, 5 patients were vertical dislocation(VS), 2 patients had both AAS and VS, 1 patient had both AAS and subaxial subluxation(SAS), 1 patient had wire breaking after 3 years of posterior fixation with SAS, 2 patients showed destruction of atlantoaxial joint without any dislocation. All patients underwent posterior fixation and fusion surgery, including atlanto-axial fixation and fusion in 10 cases, C1-3 fixation and fusion in 2 cases due to abnormality of C2 vertebra, occipitocervical fusion in 1 case due to abnormality of C1 vertebra and severe osteoporosis. 7 cases with VS/AAS+VS and 2 cases with severe neck pain underwent occipitocervical/thoracic fusion, including 1 case underwent revision surgery. The Ranawat grade, visual analogue scale(VAS), Japanese Orthopaedic Association(JOA) score were assessed preoperatively, postoperatively and at the final follow-up. Results: All the 24 cases were operated successfully, 2 cases encountered superficial incision infection which cured by changing the dressing and anti-infective therapy. All patients had completed follow-ups of 12-45 months(average, 24.1±10.3 months). VAS score was decreased from the average 6.6±1.2 preoperatively to the average 2.6±0.9 postoperatively, and to 1.8±0.7 at final follow-up(P＜0.05); JOA score was increased from the average 11.5±1.9 preoperatively to the average 13.6±2.0 postoperatively, and to 14.5±1.1 at final follow-up(P＜0.05); Ranawat grade showed that 3 cases with Ranawat class Ⅰ preoperatively remainned class Ⅰ postoperatively, 5 cases with Ranawat class Ⅱ improved to class Ⅰ in 4 cases and remainned class Ⅱ in 1 case, 15 cases with Ranawat class Ⅲa improved to class Ⅰ in 13 cases and class Ⅱ in 2 cases; 1 case with Ranawat class Ⅲb improved to Ⅲa. The fusion rate was 29%(7 patients) in 3 months after operation, and 79%(19 patients) in 6 months after operation, and 100%(24 patients) at final follow-up. 3 patients occurred SAS postoperatively, including 2 patients at C3/4, 1 patient at C4/5. Conclusions: Satisfactory surgical outcomes are achieved by posterior fixation and fusion for atlantoaxial instability caused by rheumatoid arthritis. The segment of posterior fixation and fusion should be chose according to the scope of lesions, dislocation type, bone mineral density and screw pathway condition.