后路松解复位侧块关节植骨融合枕颈内固定术治疗颅底凹陷合并难复性寰枢椎脱位的疗效分析

Clinical efficacy of posterior approach release and reduction of lateral mass joint followed by bone grafting and occipital-cervical internal fixation for basilar invagination with irreducible atlantoaxial dislocation

中文关键词:  颅底凹陷症  难复性寰枢椎脱位  椎间融合器  侧块关节植骨融合

英文关键词:Basilar invagination  Irreducible atlantoaxial dislocation  Interbody fusion cage  Lateral mass joint bone graft and fusion

中文摘要:

  【摘要】 目的：探讨后路松解复位侧块关节植骨融合枕颈内固定术治疗颅底凹陷症合并难复性寰枢椎脱位的临床疗效。方法：回顾性分析2010年1月~2020年1月于我院行后路松解复位侧块关节植骨融合枕颈内固定术治疗颅底凹陷症合并难复性寰枢椎脱位患者的资料，其中男11例，女8例，年龄37.4±13.9岁（13~69岁），随访时间为54.7±29.4个月（25～131个月）。术前、术后1周、术后6个月、末次随访时分别通过视觉模拟（visual analogue scale，VAS）评分和日本骨科协会（Japanese Orthopaedic Association，JOA）评分评估患者的疼痛和神经功能情况。术前、术后1周、术后6个月、末次随访时在颈椎正中矢状位CT上测量寰齿前间距（atlantodental interval，ADI）、齿突尖至Chamberlain线的距离（distance of the top of odontoid to Chamberlain′s line，DOCL），在颈椎MRI上测量延髓脊髓角（cervico-medullary angle，CMA）。通过CT评估植骨融合情况，记录术后并发症。结果：所有患者手术顺利，手术时间136.1±29.0min（95～210min），出血量为189.7±85.0mL（100～455mL）。术前、术后1周、术后6个月及末次随访时VAS评分分别为6.06±1.21分、2.35±0.76分、1.24±0.81分、1.12±0.90分，JOA评分分别为9.26±2.24分、14.05±2.01分、15.05±1.57、15.16±1.42分；与术前相比，患者术后1周、术后6个月和末次随访时的VAS评分和JOA评分均显著改善（P<0.05）。影像学方面，术前、术后1周、术后6个月及末次随访时ADI分别为9.63±1.93mm、1.21±1.10mm、1.16±1.09mm、1.26±1.02mm，DOCL分别为11.47±3.93mm、2.53±3.30mm、2.32±3.20mm、2.26±2.73mm，CMA分别为114.31°±11.00°、144.16°±9.33°、145.31°±8.83、143.42°±9.12°；与术前相比，患者术后1周、术后6个月和末次随访时的ADI、DOCL和CMA均显著性改善（F=41.05，P＜0.001）。所有患者均实现骨性融合，融合时间为10.3±2.7个月（5～15个月）。术后发生并发症2例（脑脊液漏1例，切口深部组织感染1例），给予对症支持治疗后均治愈。结论：后路松解复位侧块关节植骨融合枕颈内固定术是治疗颅底凹陷症合并难复性寰枢椎脱位安全有效的手术方式。

英文摘要:

  【Abstract】 Objectives: To evaluate the clinical outcomes for the treatment of basilar invagination(BI) with irreducible atlantoaxial dislocation(irAAD) through posterior approach release and reduction of lateral mass joint followed by bone grafting and occipital-cervical internal fixation. Methods: The clinical data of patients of BI-irAAD undergone posterior approach release and reduction of lateral mass joint followed by bone grafting and occipital-cervical internal fixation at our institution between January 2010 and January 2020 were retrospectively analyzed. A total of 19 patients were enrolled, including 11 males and 8 females. The average age of the patients was 37.4±13.9 years(range 13-69 years), and the follow-up period was 54.7±29.4 months(25-131 months). Visual analogue scale(VAS) and Japanese Orthopaedic Association(JOA) scores before operation, at postoperative 1 week, six month and final follow-up were recorded to evaluate the relief of neck pain and the recovery of neurological functions, respectively. The atlantodental interval(ADI), distance of the top of odontoid to Chamberlain′s line(DOCL), and cervico-medullary angle(CMA) before operation, at postoperative 1 week and final follow-up were measured on cervical midsagittal CT and MRI. The bony fusion condition was evaluated on CT and complications were also recorded. Results: The operative time was 136.1±29.0min(range 95-210min) and blood loss was 189.7±85.0mL(range 100-455mL). For functional scores, the VAS was 6.06±1.21 points preoperatively, 2.35±0.76 points at one week postoperatively, 1.24±0.81 points at six months of follow-up, and 1.12±0.90 points at the final follow-up. The JOA was 9.26±2.24 points preoperatively, 14.05±2.01 points at one week postoperatively, 15.05±1.57 points at six months of follow-up, and 15.16±1.42 points at the final follow-up. The VAS and JOA at one week postoperatively, six months of follow-up, and final follow-up significantly improved than those before operation(P<0.05). Regarding dislocation, the ADI was 9.63±1.93mm preoperatively, 1.21±1.10 mm at one week postoperatively, 1.16±1.09mm at six months of follow-up, and 1.26±1.02mm at the final follow-up. The DOCL was 11.47±3.93mm preoperatively, 2.53±3.30mm at one week postoperatively, 2.32±3.20mm at six months of follow-up, and 2.26±2.73 mm at the final follow-up. The CMA was 114.31°±11.00° preoperatively, 144.16°±9.33° at one week postoperatively, 145.31°±8.83° at six months of follow-up, and 143.42°±9.12° at the final follow-up(P<0.05). The ADI, DOCL and CMA at one week postoperatively, six months of follow-up, and final follow-up significantly improved than those before operation(P<0.05). Bony fusion was achieved in all patients, the fusion duration was 10.3±2.7 months(range 5-15 months). Of these patients, one developed wound infection and one developed cerebrospinal fluid leakage. The two patients were cured through corresponding management. No patient developed implant failure or re-dislocation. Conclusions: Posterior approach release and reduction of lateral mass joint followed by bone grafting and occipital-cervical internal fixation is a safe and efficient surgical strategy for the treatment of BI-irrAAD.