慢性寰枢关节旋转固定或脱位的临床及影像学特征———52例病例资料分析

The menifestation and imaging characteristics of the chronic atlantoaxial rotatory fixation or dislocation

中文关键词:  寰枢椎  旋转固定  旋转半脱位  Grisel综合征

英文关键词:Atlantoaxial  Rotatory fixation  Rotatory subluxation  Grisel′s syndrome

中文摘要:

  【摘要】 目的：总结慢性寰枢关节旋转固定或脱位（atlantoaxial rotatory fixation/dislocation，AARF/AARD）患者的临床和影像学特征，探讨其诊治经验。方法：回顾性分析2004年9月～2017年2月在我院收治的52例慢性寰枢关节旋转固定或脱位患者的临床资料，男23例，女29例，发病年龄5～17岁，平均11.04±2.73岁；32例有明确发病诱因，其中18例有过颈部轻微外伤史；46例有明确记载从发病到我院就诊时间，为2～18个月，平均6.0±3.2个月；患者均有斜颈、颈部疼痛和活动受限等症状体征，3例有轻微神经损害。所有患者通过影像学测量寰齿前间隙（ADI）并观察寰枢侧块关节旋转和脱位的移位方向。根据影像学表现进行分类，探讨不同分类的治疗方法及效果。结果：根据影像学表现分为三种类型。A类：ADI<5mm，一侧寰椎侧块向前移位，另一侧后移位，共7例，称之为寰枢关节旋转固定（atlanto-axial rotatory fixation，AARF）；B类：ADI>5mm，寰椎侧块出现旋转移位，矢状位和水平位可见寰枢侧块关节面之间失去接触，共44例，称之为寰枢关节旋转脱位（atlanto-axial rotatory dislocation，AARD），其中11例一侧寰椎侧块向前脱位，另一侧原位（B1类），24例一侧寰椎侧块向前脱位，另一侧向后脱位（B2类），9例双侧寰椎侧块不对称性向前脱位，两侧轻重有别（B3类）；C类：ADI>5mm，寰枢关节旋转脱位合并寰枕关节反向旋转脱位，共1例，称之为枕寰枢关节旋转脱位（occipital-atlanto-axial rotatory dislocation，OAARD）。4例A类患者通过牵引治愈，3例A类患者经保守治疗失败后来我院行寰枢椎间植骨融合术，A类患者的病程在3个月左右。26例B类患者颅骨牵引复位后行后路寰椎侧块枢椎椎弓根螺钉钛板固定融合术；18例B类患者需要经口咽入路松解复位寰枢关节后行后路寰椎侧块枢椎椎弓根螺钉钛板固定融合术。B类患者的病程在6个月左右。1例C类患者病程4个月，经颅骨牵引复位失败，放弃治疗。手术患者术后随访均获骨性融合。结论：AARF/AARD多发生于儿童，无明显性别差异；颈部轻微创伤是常见诱因；A类患者病程短，保守治疗有治愈的可能性，B类患者病程长，需要手术复位和融合寰枢关节。目前还没有C类患者的治疗经验。本文观察到的影像学表现有助于更加全面地认识本病。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical and radiographic features of patients with chronic atlantoaxial rotatory fixation or dislocation(AARF/AARD), and to explore the diagnosis and treatment experience. Methods: A series of 52 cases were diagnosed and treated in our hospital from September 2004 to February 2017, including 23 males and 29 females, with the mean age of 11.04 years and the mean course of 6 month. The clinical materials and images of the patients were all reviewed. 32 patients had a clear cause, of which 18 had a history of minor trauma to the neck. All patients had torticollis, diminished range of the rotatory motion and neck pain. Only 3 patients had minor neurological deficit. The anterior atlantoid space(ADI) was measured on imaging materials in all patients, the rotation and dislocation directions of atlantoaxial mass joints were observed. According to the classification on the basis of imaging findings, different treatment methods and outcomes were explored. Results: According to ADI and atlantoaxial rotatory displacement on X ray and CT, imaging types were divided into three: the first was atlantoaxial rotatory fixation (AARF) with normal ADI and two sides of the lateral mass displacing to anterior and posterior respectively (Type A); the second was atlantoaxial rotatory dislocation(AARD) with abnormal ADI(more than 5mm) and two sides of the lateral mass displacing in different directions and degrees respectively(Type B); the third was occipital-atlanto-axial rotatory dislocation(OAARD) with abnormal ADI(Type C). There were 7 cases of AARF, 44 cases of AARD and 1 case of OAARD. Four cases with AARF healed by traction and collar; 3 cases with AARF were treated with halovest fixation combined with surgical fusion, the mean course of AARF was 3 months. All cases with AARD were treated with surgical internal fixation and fusion, the mean course of AARD was 6 months. One case with OAARD failed to reduction and gave up the treatment. Conclusions: AARF/AARD mostly occurred in children. Patients of type A has shorter course than patients of type B, and may healed by conservative therapy. Meanwhile, patients of type B need surgical reduction and fusion, but no therapeutic experience of OAARD was obtained. Moreover, the imaging characteristics in the study were more comprehensive than previous classification.