两种不同手术方式治疗不稳定性Hangman骨折的疗效对比

The comparison of two different surgical methods in clinical efficacy for unstable Hangman′s fractures

中文关键词:  Hangman骨折  前后路联合手术  后路手术  疗效  颈椎矢状面平衡

英文关键词:Hangman′s fractures  Combined anterior and posterior surgery  Posterior surgery  Efficacy  Cervical sagittal balance

中文摘要:

  【摘要】 目的：比较后路C2/3融合内固定术与前路颈椎间盘切除融合术联合后路C2椎弓根螺钉内固定术两种不同术式治疗不稳定性Hangman骨折的疗效。方法：回顾性分析2010年3月～2017年8月行不同手术方式治疗的34例不稳定性Hangman骨折患者。20例患者接受后路C2/3融合内固定术（P组），14例患者接受前路颈椎间盘切除融合术联合后路C2椎弓根螺钉内固定术（AP组）。记录并比较两组患者术前和末次随访的脊髓损伤分级（ASIA）、视觉疼痛模拟评分（VAS）、颈椎功能障碍指数（NDI）、患者满意度评价（Odom分级）；以及入院时、术前和末次随访时的颈椎矢状面平衡影像学相关参数：枕颈角、C2/3 Cobb角、颈椎前凸角（cervical lordosis，CL）、颈椎矢状面轴向垂直距离（C2～C7 sagittal vertical axis，cSVA），并进行组间比较。结果：两组患者末次随访时颈痛及颈部活动受限等症状均较术前明显改善。P组手术时间（105.7±13.8min）较AP组（177.9±14.7min）短（P＜0.05），P组共3例ASIA D级患者恢复至E级，AP组共 2例ASIA D级患者恢复至E级。两组末次随访的VAS、NDI评分均较术前明显改善，差异具有统计学意义（P＜0.001）。两组术前及末次随访时的各指标组间比较均无统计学差异（P＞0.05）；末次随访与术前的VAS、NDI变化量的组间比较无统计学差异（P＞0.05）。末次随访的Odom分级示P组有17例评价优良，优良率为85.0%; AP组有13例评价优良，优良率为92.9%，两组比较无统计学差异（P＞0.05）。两组术前枕颈角、C2/3 Cobb角、CL、cSVA差异无统计学意义（P＞0.05）。末次随访时，两组枕颈角与cSVA均较术前减小，差异具有统计学意义（P＜0.001）；而末次随访的C2/3 Cobb角与CL均较术前增大，差异具有统计学意义（P＜0.001）。对手术前后各影像学参数的变化量进行组间比较，AP组改变程度均较P组显著，且差异具有统计学意义（P＜0.05）。结论：后路C2/3融合内固定术与ACDF联合后路C2椎弓根螺钉内固定术治疗不稳定性Hangman骨折均可获得满意疗效，然而前后路联合术式更加有利于恢复颈椎矢状位曲度。

英文摘要:

  【Abstract】 Objectives: To compare the clinical outcomes between posterior C2/3 fixation and fusion (PFF) and anteroposterior surgery [combined anterior cervical discectomy and fusion (ACDF) and posterior compressive C2 pedicle screw fixation] for unstable Hangman′s fractures. Methods: A total of 34 patients with unstable Hangman′s fractures who underwent two different surgeries from March 2010 to August 2017 were retrospectively reviewed. 20 cases were treated with PFF(group P), and 14 cases were treated with anteroposterior surgery(group AP). Clinical data as American Spinal Injury Association(ASIA) scale, visual analogue scale (VAS), neck disability index(NDI) and Odom criteria were recorded before surgery and at the final follow-up. Radiographic parameters related to cervical sagittal balance as occiput-C2 angel, C2/3 Cobb angle, cervical lordosis(CL) and C2-C7 sagittal vertical axis(cSVA) were also recorded on admission, before surgery and at final follow-up. All clinical and radiological data were compared between the two groups. Results: At final follow-up, all patients had significant improvement in neck pain and neck mobility. The operation time(group P vs group AP; 105.7±13.8min vs 177.9±14.7min) had significant difference(P＜0.05). 3 patients in group P and 2 in group AP recovered from grade D to grade E. At final follow-up, both groups showed significant VAS and NDI scores compared to those before surgery(P＜0.001); and there was no significant difference of the scores between preoperation and final follow-up in the two groups(P＞0.05); and there was no significant difference of the changes of VAS and NDI between preoperation and final follow-up in the two groups(P＞0.05). Numbers of patients evaluated their level of satisfaction as good or excellent were 17 in group P(the satisfactory rate was 85.0%) and 13 in group AP(the satisfactory rate was 92.9%), and there was no statistical difference between the two groups(P＞0.05). There was no statistical difference of occiput-C2 angel, C2/3 Cobb angle, CL and cSVA(P＞0.05). A statistically significant decrease of occiput-C2 angel and cSVA was found between preoperation and final follow-up, and C2/3 Cobb angle and CL increased(P＜0.001). The changes of radiological parameters between preoperation and final follow-up were more significant statistically in group AP(P＜0.05). Conclusions: Both PFF and combined ACDF and posterior compressive C2 pedicle screw fixation can achieve satisfactory clinical efficacy for unstable Hangman′s fractures. Furthermore, anteroposterior surgery has an advantage in maintaining cervical sagittal balance.