寰枢椎侧块关节内碎骨植骨融合术治疗寰枢椎不稳的临床疗效

Clinical efficacy of intra-articular bone grafting of atlantoaxial lateral mass for treating atlantoaxial instability

中文关键词:  寰枢椎后路融合术  寰枢椎侧块关节内碎骨植骨  后路结构性植骨  寰枢椎侧块关节间隙高度

英文关键词:Atlantoaxial instability  Posterior fusion  Intra-articular bone grafting of the atlantoaxial lateral mass  Posterior structural bone grafting  Height of atlantoaxial lateral mass space

中文摘要:

  【摘要】 目的：探讨寰枢椎侧块关节内碎骨植骨融合术治疗寰枢椎不稳的临床疗效。方法：对2016年1月~2019年12月在海军军医大学附属长征医院骨科行寰枢椎后路螺钉内固定植骨融合术的49例寰枢椎不稳患者进行回顾性分析。其中男性17例，女性32例；年龄8~72岁（45.2±17.1岁）。所有病例均采用寰枢椎后路椎弓根钉棒内固定技术，根据所行植骨方式不同将患者分为两组：2016年1月~2018年12月期间行寰椎后弓与枢椎椎板间结构性植骨融合术的28例患者纳入A组，男9例，女19例，年龄42.1±20.2岁；2018年1月~2019年12月期间行寰枢椎侧块关节内碎骨植骨融合术的21例患者纳入B组，男8例，女13例，年龄49.3±19.8岁。记录两手术时间、术中出血量和随访时间，比较两组患者术前和末次随访时的日本骨科协会评分（Japanese Orthopaedic Association，JOA）、颈部残疾指数（neck disability index，NDI）和颈部疼痛视觉模拟评分（visual analogue scale，VAS），术前、术后和末次随访时在冠状位CT上测量寰枢椎侧块关节间隙的高度，观察植骨融合情况。结果：两组患者年龄、性别、疾病种类无统计学差异（P>0.05），具可比性。两组患者均顺利完成手术，术中无椎动脉和神经损伤。A组术中出血量显著性低于B组（210.2±26.6mL vs 230.5±6.2mL，P＜0.05），两组手术时间和随访时间无统计学差异（P>0.05）。两组患者末次随访时的JOA评分、NDI和VAS评分与术前比较均明显改善（P＜0.05），两组间同时间点比较均无统计学差异（P>0.05）。术前两组患者的寰枢侧块关节间隙高度无显著性差异（P>0.05）；术后即刻B组侧块关节间隙高度显著性高于A组（P＜0.05）；末次随访时，两组侧块关节间隙高度均有不同程度的下降，但B组侧块关节间隙高度仍显著性高于A组（P＜0.05）。所有患者植骨均融合，两组植骨融合时间无统计学差异（P>0.05）。随访期间未出现螺钉松动、移位、断裂等并发症。结论：寰枢椎后路钉棒固定融合术中采用寰枢椎侧块关节内碎骨植骨能够实现良好的骨融合，可应用于后弓缺失等不能行寰椎后弓与枢椎椎板植骨术的患者，避免取自体髂骨植骨供骨区疼痛、感染等并发症，且能够在一定程度上维持寰枢椎的关节间隙高度，增强其稳定性。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical efficacy of intra-articular bone graft fusion within atlantoaxial lateral mass for the treatment of atlantoaxial instability. Methods: A retrospective analysis was conducted on 49 patients with atlantoaxial instability who underwent posterior atlantoaxial fusion with screw fixation and bone grafting at the Department of Orthopedics, Changzheng Hospital, Naval Medical University from January 2016 to December 2019. There were 17 males and 32 females, aged from 8 to 72 years(45.2±17.1 years). All the patients were treated with posterior atlantoaxial fixation with pedicle screw-rod system, and were divided into two groups based on the bone grafting method: group A comprised 28 patients who underwent posterior structural bone grafting between the posterior arch of atlas and the lamina of axis from January 2016 to December 2018, including 9 males and 19 females, with a mean age of 42.1±20.2 years; group B consisted of 21 patients who underwent intra-articular bone grafting in the atlantoaxial lateral mass from January 2018 to December 2019, comprising 8 males and 13 females, with a mean age of 49.3±19.8 years. The operative time, intraoperative blood loss were collected, and Japanese Orthopaedic Association(JOA) score, neck disability index(NDI) and visual analogue scale(VAS) of neck pain were compared between the two groups before operation and at the last follow-up. The height of the atlantoaxial lateral mass space was measured on the coronal CT before operation, right after operation, and at the last follow-up, and the fusion status of bone graft was observed. Results: There were no statistically significant differences in age, gender, and types of diseases between the two groups of patients(P>0.05), indicating comparability. Both groups of patients successfully completed the surgery without any injury to the vertebral artery or nerves. The intraoperative blood loss in group A was significantly less than that in group B(210.2±26.6mL vs 230.5±6.2mL, P<0.05). There were no statistically significant differences between the two groups in terms of operative time and follow-up duration(P>0.05). The JOA scores, NDI, and VAS scores of both groups showed significant improvement compared to preoperative values at the last follow-up, respectively(P<0.05), while no statistical differences were observed between the two groups at the same time point(P>0.05). The space height of atlantoaxial lateral mass of group A wasn′t significantly different from that of group B before surgery(P>0.05), it was significantly lower than that of group B immediately after surgery(P<005), which was still lower than that of group B at the last follow-up, although both groups experienced varying degrees of collapse(P<005). All the patients achieved bone fusion, and there was no statistically significant difference in the fusion time between the two groups(P>0.05). During the follow-up period, no complications such as screw loosening, displacement, or fracture were observed. Conclusions: In posterior atlantoaxial screw-rod fixation surgery, utilizing intra-articular bone grafting of the atlantoaxial lateral mass can achieve favorable bone fusion, which can be employed in patients with conditions such as posterior arch defects where traditional atlantoaxial structural bone graft fusion surgery is not feasible. Intra-articular bone grafting of the atlantoaxial lateral mass helps to avoid complications associated with harvesting autologous iliac bone grafts, such as pain and infection; Furthermore, it can maintain the height of the atlantoaxial facet joint space to a certain extent, thereby enhancing stability.