类风湿性关节炎继发寰枢椎脱位的手术治疗

Surgical treatment for atlantoaxial dislocation in rheumatoid arthritis

中文关键词:  类风湿性关节炎  寰枢椎脱位  枕颈融合术  寰枢椎融合术  内固定  复位

英文关键词:Rheumatoid arthritis  Atlantoaxial dislocation  Atlantoaxial fusion  Occipitocervical fusion  Instrumentation  Reduction

中文摘要:

  【摘要】 目的：总结手术治疗类风湿性关节炎（rheumatoid arthritis，RA）继发寰枢椎脱位的临床疗效。方法：2010年1月~2018年12月收治57例RA继发寰枢椎脱位的患者，男14例，女43例；年龄46~79岁（61.8±12.4岁）。类风湿性关节炎病史2.5～36.8年（17.5±3.7年），诊断RA后出现上颈椎相关症状时间为1.5～19.4年（8.9±2.4年）。患者均有不同程度的枕颈部疼痛、颈部姿势异常和活动受限。术前神经功能ASIA分级：B级3例，C级12例，D级20例，E级22例；JOA评分4～14分（8.7±1.8分），VAS 4～10分（7.4±1.5分）。寰椎前向脱位44例，其中寰齿前间距（anterior atlantodental interval，AADI）>10mm者8例；寰椎后向脱位9例；寰椎前后向脱位4例。6例合并下颈椎不稳，10例合并枕颈部其他畸形。13例枕寰关节先天性融合及骨性融合无枕寰关节活动度者采用枕颈固定融合术治疗（A组）；44例有枕寰关节活动度的患者采用寰枢椎融合固定融合术治疗，其中16例寰枢椎脱位牵引不能复位的患者先行前路经下颌下寰枢椎关节松解术再一期后路行寰枢椎融合术治疗（B组），28例寰枢椎脱位牵引能复位的患者直接采用后路寰枢椎融合内固定术治疗（C组）。定期随访患者的临床症状和神经功能改善情况，影像学观察寰枢椎复位和植骨融合情况。结果：患者均顺利完成手术，A组手术时间100～130min（118.2±13.5min），术中出血量100～300ml（190.5±42.8ml）；B组手术时间180～240min（221.4±20.3min），术中出血量100～260ml（157.3±36.1ml）；C组手术时间100～130min（109.4±12.1min），术中出血量100～200ml（124.1±32.7ml）。术中均未发生椎动脉和脊髓损伤。所有患者随访期间复查颈椎CT及MRI显示寰枢椎序列重建满意，齿状突区域脑脊液线清晰，脊髓无压迫，术后AADI为2～3mm（2.4±0.4mm）。患者均获随访，随访时间12～84个月（34.4±10.3个月），术后12个月随访时，2例ASIA分级B级患者恢复至C级，C级患者6例恢复至D级、3例恢复至E级，9例D级患者恢复至E级，其余患者无变化；JOA评分改善至10～17分（14.6±3.5分），VAS评分降至1～5分（3.6±1.4分），与术前比较均有显著性差异（P<0.05）。1例患者植骨块发生自发性部分吸收，随访1年半时植骨块吸收停止并部分融合，未再次行植骨术；其余患者植骨均融合。随访期间均未发现螺钉松动、移位、断裂和寰枢椎再脱位、失稳现象。结论：RA累及上颈椎时会造成寰枢椎脱位导致脊髓受压，依据枕寰关节活动度情况采用寰枢椎融合术或枕颈融合术治疗可获得良好的临床效果。

英文摘要:

  【Abstract】 Objectives： To summarize the clinical outcomes of surgical treatment of atlantoaxial dislocation in rheumatoid arthritis(RA). Methods： We retrospectively analyzed the clinical and radiographic records of 57 patients(43 femals, 14 mals) with an average age of 61.8±12.4 years(46-79 years) between January 2010 and December 2018. The course of rheumatoid arthritis ranged from 2.5 to 36.8 years, with an average of 17.5±3.7 years. The time from first diagnosis of RA to symptoms of upper cervical spinal cord compression ranged from 1.5 to 19.4 years, with an average of 8.9±2.4 years. Posture abnormalities and movement disorders occurred frequently. The American Spine Injury Association(ASIA) impairment scale: 3 cases of B degree, 12 cases of C degree, 20 cases of D degree, 22 cases of E degree. The JOA score was 4 to 14 points, with an average of 8.7±1.8. The visual analogue scale(VAS) was 4 to 10 points, with an average of 7.4±1.5. There were 44 cases of anterior atlantodental interval(AADI>10mm, 8 cases), 9 cases of posterior atlantoaxial dislocation and 4 cases of instability. In them, 6 cases were with instability of the lower cervical spine, and 10 cases with other deformities of the craniovertebral junction. For the surgical treatment, 13 patients were treated with occipital cervical fusions(group A). The other 44 patients were treated with atlantoaxial fusion: 16 patients underwent anterior transpharyngeal decompression before posterior atlantoaxial fusion(group B), 28 patients were treated with posterior atlantoaxial fusion(group C). All patients were followed up regularly for clinical signs, symptoms and improvement of neurological function. The atlantoaxial reduction and bone graft fusion were also observed. Results： No intraoperative vertebral artery injury or spinal cord injury was founded． All 57 patients were followed up for an average of 34.4±10.3 months(range, 12-84 months). In group A, the operation time was 100-130min with an average of 118.2±13.5min, and the amount of blood loss was 100-300ml with an average of 190.5±42.8ml. In group B, the operation time was 180-240min with an average of 221.4±20.3min, and the amount of blood loss was 100-260ml with an average of 157.3±36.1ml. In group C, the operation time was 100-130min with an average of 109.4±12.1min, and the amount of blood loss was 100-200ml with an average of 124.1±32.7ml. Twelve months after surgery, all patients were improved, with 3 cases from B to C degree, 6 cases from C to D degree, 3 cases from C to E degree and 9 cases from D to E degree. JOA scores were improved to 10-17(mean, 14.6±3.5), and VAS scores were improved to 1-5(mean, 3.6±1.4). The postoperative AADI was reduced to 2-3mm(mean, 2.4±0.4mm). Solid bony fusion was achieved in 56 patients at 12 months after operation, but partial absorption of the bone graft occurred in one case． There was no screw loosening, displacement, instability or breakage. Postoperative cervical spine MRI showed that the sagittal cervical spine alignment was restored, cerebral spinal fluid line was clear in the odontoid process area and no spinal cord compression was found. Conclusions： Early surgical fusion is recommended for atlantoaxial dislocation with instability and cord compression in RA. Good clinical outcomes can be achieved by posterior atlantoaxial fusion or occipitocervical fusion according to the motion range of the occipito-atlantal joint.