后路寰枢椎固定非融合术与固定融合术治疗新鲜齿状突骨折的远期疗效比较

Comparison of long-term efficacy of posterior atlantoaxial fixation without fusion and posterior atlantoaxial fixation and fusion in the treatment of fresh odontoid fractures

中文关键词:  齿状突骨折  后路寰枢椎固定  单纯固定  固定融合

英文关键词:Odontoid fracture  Posterior atlantoaxial fixation  Single fixation  Fixation and fusion

中文摘要:

  【摘要】 目的：比较后路寰枢椎固定非融合术与固定融合术治疗新鲜齿状突骨折的远期疗效。方法：回顾性分析2006年6月~2015年6月在我院行手术治疗的新鲜齿状突骨折且随访5年以上的63例患者的临床资料，其中男性49例，女性14例，年龄18~72岁（42.9±13.7岁）。根据其手术方式将患者分为A、B两组：A组行后路寰枢椎固定非融合术（33例）；B组行后路寰枢椎固定融合术（30例）。两组患者性别、年龄、随访时间、受伤原因、受伤至手术时间、骨折移位程度、术前疼痛视觉模拟评分（visual analog scale，VAS）、颈椎功能障碍指数（neck disability index，NDI）、美国脊髓损伤协会（American Spinal Injury Association，ASIA）分级均无统计学差异（P>0.05）。记录并比较两组患者手术时间、术中出血量、术后临床疗效评价指标（VAS评分、NDI、ASIA分级）及手术相关并发症（供骨区疼痛、手术切口及供骨区感染、脑脊液漏等）发生情况。通过末次随访时的颈椎动力位X线片评估寰枢椎稳定性；多平面重建CT观察两组患者寰齿关节及寰枢侧块关节退变、寰枢椎自发融合及B组患者植骨融合情况。比较A组寰枢椎自发骨性融合患者与未骨性融合患者的年龄、性别、受伤原因、受伤至手术时间、骨折分型、骨折移位程度、固定方式及末次随访时的VAS评分和NDI，分析A组自发骨性融合的影响因素。结果：末次随访所有患者骨折均愈合。术前VAS评分A组6.5±1.2分，B组6.8±1.3分；NDI A组31.1±3.8分，B组32.5±4.3分；末次随访时VAS评分A组1.3±0.8分，B组1.5±0.9分，NDI A组4.2±1.3分，B组4.5±1.9分；术前ASIA分级A组C级1例、D级2例、E级30例，B组C级2例、D级3例、E级25例；末次随访时A组D级1例、E级32例，B组D级2例、E级28例。末次随访时VAS评分和NDI较术前降低（P＜0.05），末次随访时ASIA分级与术前无统计学差异（P＞0.05）。同时间点组间比较VAS评分、NDI、ASIA分级差异无统计学意义（P＞0.05）。A组患者手术时间及术中出血量明显少于B组患者（P＜0.05）。A组手术相关并发症发生率为9.1%（3/33），B组为30%（9/30），差异有统计学意义（P＜0.05）。末次随访时A、B两组均无寰枢椎不稳。两组寰齿及寰枢关节退变分级比较差异无统计学意义（P＞0.05）。A组寰枢椎自发纤维融合7例（21.2%），骨性融合23例（69.7%），B组寰枢椎骨性融合（自发融合及植骨融合）30例（100.0%）；两组骨性融合率比较差异有统计学意义（P＜0.05）。A组中自发骨性融合患者平均随访时间长于未自发骨性融合患者（P＜0.05），伴骨折明显移位（＞2mm）占比高于未自发融合者，但差异无统计学意义（47.8% vs 10%，P＞0.05）。结论：后路寰枢椎固定非融合术与固定融合术治疗新鲜齿状突骨折患者均可获得满意疗效，固定非融合术较固定融合术能有效缩短手术时间，减少术中出血。后路固定非融合术后的寰枢椎自发融合是维持寰枢椎稳定性和患者远期疗效的关键因素。骨折移位程度是术后寰枢椎自发骨性融合的影响因素。

英文摘要:

  【Abstract】 Objectives: To compare the long-term clinical efficacy of non-fusion posterior atlantoaxial fixation and posterior atlantoaxial fixation and fusion in the treatment of fresh odontoid fractures. Methods: The clinical data of 63 patients(49 males and 14 females, mean age 42.9±13.7 years) with fresh odontoid fractures who underwent posterior surgery and were followed up more than 5 years in our hospital from 2006 to 2015 were retrospectively analyzed. The patients were divided into group A and group B: 33 cases in group A were treated with posterior atlantoaxial fixation without fusion; 30 cases in group B were treated with posterior atlantoaxial fixation and fusion. Gender, age, cause of injury, time from trauma to surgery, fracture displacement, preoperative score of visual analogue scale(VAS), neck disability index(NDI) and American Spinal Injury Association(ASIA) were recorded and compared between the two groups, which showed no significant difference(P>0.05). The operation time, blood loss, clinical efficacy evaluation indexes(VAS score, NDI, ASIA) and complications (donor site pain, postoperative infection, cerebrospinal fluid leakage, etc.) were recorded and compared between the two groups. At the final follow-up, atlantoaxial stability was evaluated using dynamic X-ray; degeneration of atlantoodontoid joint and lateral atlantoaxial joints, spontaneous atlantoaxial fusion, and bone graft fusion in group B were observed by using multiplanar reconstruction CT. We further compared the age, gender, cause of injury, time from trauma to surgery, fracture type, fracture displacement, fixation method, VAS score, and NDI between the patients with atlantoaxial spontaneous bone fusion and patients without bone fusion in group A and analyzed the influencing factors of spontaneous bone fusion in group A. Results: At the final follow-up, all patients had fracture healing. The VAS scores were 6.5±1.2 in group A and 6.8±1.3 in group B before operation. And the NDI were 31.1±3.8 and 32.5±4.3 in group A and group B. At the final follow-up, the VAS score and NDI of groups A and B were 1.3±0.8 and 1.5±0.9, 4.2±1.3 and 4.5±1.9, respectively, which were significantly lower than those before operation(P<0.05). Preoperative ASIA grade: 1 case of grade C, 2 cases of grade D and 30 cases of grade E in group A, 2 cases of grade C, 3 cases of grade D and 25 cases of grade E in group B; At the final follow-up, there were 1 case of grade D and 32 cases of grade E in group A, 2 cases of grade D and 28 cases of grade E in group B. In both groups, there was no significant difference in ASIA grade between the final follow-up and before operation(P>0.05). There was no significant difference in VAS score, NDI and ASIA grade between the two groups at the final follow-up(P>0.05). The operation time and blood loss in group A were significantly less than those in group B(P<0.05). The incidence of operation related complications was 9.1%(3/33) in group A and 30%(9/30) in group B(P<0.05). At the final follow-up, there was no atlantoaxial instability in both groups; there was no significant difference in the degeneration grade of atlantoodontoid and atlantoaxial joints between the two groups(P>0.05). There were 7 cases(21.2%) of atlantoaxial spontaneous fibre fusion and 23 cases(69.7%) of atlantoaxial spontaneous bone fusion in group A, and 30 cases(100.0%) of atlantoaxial bone fusion in group B; there was a significant difference in the rate of atlantoaxial bone fusion between the two groups(P<0.05). In group A, the follow-up time of patients with spontaneous bone fusion was longer than that of patients without spontaneous bone fusion(P<0.05). Although the patients with spontaneous bone fusion had a higher rate of apparent displacement of fracture(>2mm) than that without spontaneous fusion, there was no significant difference(47.8% vs 10%, P>0.05). Conclusions: Both posterior atlantoaxial fixation without fusion and posterior atlantoaxial fixation and fusion are effective in managing fresh odontoid fractures. However, posterior atlantoaxial fixation without fusion can further shorten the operation time, reduce intraoperative blood loss. Spontaneous atlantoaxial fusion after posterior fixation without fusion is the crucial factor to maintain atlantoaxial stability and long-term curative effect. The fracture displacement is the influencing factor of postoperative spontaneous bone fusion.