颈椎后路“组合式”内固定治疗寰枢关节不稳或脱位的临床疗效

Clinical effect of posterior hybrid cervical fixations in the treatment of atlantoaxial instability or dislocation

中文关键词:  寰枢关节不稳  寰枢关节脱位  组合式内固定  枢椎椎板螺钉  椎弓根螺钉  棘突螺钉

英文关键词:Atlantoaxial instability  Atlantoaxial dislocation  Hybrid fixations  C2 laminar screw  Pedicle screw  Spinous process screw

中文摘要:

  【摘要】 目的：评价颈椎后路“组合式”内固定治疗寰枢关节不稳或脱位的临床效果。方法：回顾分析因颅椎区骨发育畸形、血管变异或者常规固定方式失败而实施寰枢椎后路“组合式”内固定术患者共58例，其中男性24例，女性34例；年龄7~75岁，平均47.8±14.7岁。术前诊断寰枢关节不稳33例，寰枢关节脱位25例。合并颈脊髓功能损害者32例（JOA 8~16分，平均13.2±1.8分）。采用的内固定方式包括寰枢椎弓根螺钉、经寰枢侧块关节螺钉（Magerl技术）、枢椎椎板螺钉、下颈椎侧块螺钉及下颈椎棘突螺钉。58例“组合式固定”患者中，45例应用2种内固定方式组合，9例应用3种方式组合，4例应用4种方式组合。使用“组合式固定”的原因包括：枢椎段椎动脉高跨、枢椎椎弓根细小或椎体发育不良、颈椎椎弓根变薄（颈椎融合畸形患者）、枢椎椎弓根骨质疏松明显以及医源性枢椎椎弓骨折等。观察手术融合率及并发症，并比较手术前后的脊髓功能。结果：全部病例术中均未出现脊髓及血管损伤。随访时间24~72个月，平均36.8±10.5个月。57例（98.3%）未出现内固定松动或断裂并获得骨性融合，1例发生内固定松动造成未融合。术前合并颈脊髓功能损害者32例，术后脊髓功能均获得不同程度改善（术后JOA 11~17分，平均15.2±1.5分）。6例患者出现了并发症，包括伤口感染延迟愈合、脑脊液漏以及内固定松动。结论：针对合并颅椎区骨发育畸形、血管变异或者常规固定方式失败的寰枢椎不稳或脱位患者，合理选择“组合式”内固定治疗是安全、有效的。

英文摘要:

  【Abstract】 Objectives: To evaluate the clinical result of posterior hybrid cervical fixations for atlantoaxial instability or dislocation. Methods: Fifty eight cases were retrospectively studied, including twenty four male and thirty four female, with the mean age of 47.8±14.7. Thirty three cases were diagnosed as atlantoaxial instability, while twenty five cases as atlantoaxial dislocation. Among the fifty eight cases, thirty two had cervical myelopathy and their JOA scores ranged from 8 to 16(mean 13.2±1.8). The hybrid fixation techniques included C1-C2 pedicle screw, C1-2 transarticular screw, C2 laminar screw, cervical lateral mass screw and spinious process screw. Forty five cases underwent posterior cervical fixation using two hybriid techniques, nine cases using three techniques, and four using four techniques. The reasons for hybrid fixations included: vertebral artery high-riding in C2, C2 vertebral body dysplasia, pedicle hypogenesis in Klippel-Feil syndrome, severe osteoporosis of C2 pedicle and iatrogenic C2 pedicle fracture. Atlantoaxial fixation was performed in twenty two cases, while occiput-cervical fixation used in thirty six cases. The fusion rate and complications were observed, and the spinal cord function before and after the operation was compared. Results: No spinal cord injury or vertebral artery injury occurred. The mean follow-up was 36.8±10.5 months. Fifty seven cases(98.3%) achieved solid osseous fusion without hardware failure. All thirty two cases with preoperative myelopathy had postoperative improvement and their JOA scores ranged from 11 to 17, with the mean of 15.2±1.5. Six cases suffered with complications, including delayed wound healing, CSF leakage, and fixation loosening followed by revision. Conclusions: For atlantoaxial instability or dislocation concomitant with osseous and vascular deformity, or technical failure in typical procedure , posterior hybrid cervical fixations can safely achieve good clinical results.