后路寰枢椎侧块关节cage植骨融合内固定术治疗难复性寰枢椎脱位疗效初探

Preliminary observation of the clinical efficacy of posterior atlantoaxial lateral mass joint cage graft fusion and internal fixation in the treatment of irreducible atlantoaxial dislocation

中文关键词:  寰枢椎脱位  后路  侧块关节  植骨融合  融合器

英文关键词:Atlantoaxial dislocation  Posterior approach  Lateral mass joint  Graft fusion  Cage

中文摘要:

  【摘要】 目的：探讨后路寰枢椎侧块关节cage植骨融合内固定术治疗难复性寰枢椎脱位的临床疗效，并与经口咽松解后路复位固定融合术进行疗效对比。方法：回顾性分析2018年1月～2022年8月我科采用后路寰枢椎侧块关节cage植骨融合内固定术（23例，cage组）与经口咽松解后路复位固定融合术（25例，对照组）治疗的难复性寰枢椎脱位患者的临床资料，cage组男8例，女15例，年龄9～79岁（48.35±14.38岁）；对照组男6例，女19例，年龄21～69岁（47.84±13.51岁）。记录两组患者手术时间、术中出血量、住院时间及并发症情况，术前、术后及末次随访时使用JOA评分评估患者神经功能状态，测量术前、术后及末次随访时的寰齿间距（atlantodental interval，ADI）、齿状突顶点距离Chamberlain线的垂直距离（vertical distance from odon to idprocess to Chamberlain′s line，DOCL）、延髓颈髓角（cervicomedullary angle，CMA）、斜坡枢椎角（clivus-axial angle，CAA），评估寰枢椎复位情况。评估侧块关节cage及后方植骨融合情况。结果：所有患者内固定位置良好，减压充分复位满意，症状均明显缓解，未出现椎动脉损伤和脊髓损伤加重。cage组手术时间133.04±34.04min、术中出血量119.13±54.77mL、住院时间14.74±6.10d，均明显短于或少于对照组（253.20±53.98min、181.20±45.40mL、23.96±5.47d）。cage组术前JOA、ADI、DOCL、CMA、CAA分别为6.33±1.13分、7.31±3.05mm、9.47±3.32mm、122.89°±12.58°、122.02°±12.50°，术后分别为13.04±2.17分、2.18±0.67mm、0.89±1.00mm、148.81°±5.43°、146.70°±9.32°，末次随访时分别为14.89±1.17分、2.09±0.69mm、0.83±0.86mm、149.10°±5.11°、146.89°±8.95°；对照组术前JOA、ADI、DOCL、CMA、CAA分别为6.76±1.21分、7.70±0.97mm、10.56±1.99mm、121.53°±4.87°、123.77°±8.95°，术后分别为13.26±1.32分、1.89±0.50mm、1.13±1.08mm、151.40°±6.15°、149.86°±5.58°，末次随访时分别为15.02±0.88分、1.87±0.44mm、0.87±1.39mm、149.48°±4.06°、149.94°±6.61°，两组术后及末次随访JOA、ADI、DOCL、CMA及CAA均较术前明显改善（P<0.05），术后JOA评分与末次随访相比存在统计学差异（P<0.05），但ADI、DOCL、CMA及CAA无统计学差异（P>0.05）。cage组仅1例切口感染；对照组3例切口感染（口咽2例，后路1例），1例脑脊液漏。两组随访期间内固定在位稳定，末次随访植骨均达到骨性融合，cage组关节间隙高度无丢失。结论：难复性寰枢椎脱位采用后路寰枢椎侧块关节cage植骨融合内固定术与经口咽松解后路复位固定融合术相比疗效相当，但增加了植骨融合位点，能更有效融合，避免了经口手术，减少了手术时间、术中出血量、住院时间及并发症的发生。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical efficacy of posterior atlantoaxial lateral mass joint cage graft fusion and internal fixation for the treatment of irreducible atlantoaxial dislocation(IAAD) through comparing with the transoral pharyngeal release and posterior reduction, fixation and fusion procedure. Methods: The clinical data of patients with IAAD treated with posterior atlantoaxial lateral mass joint cage graft fusion and internal fixation(23 cases, cage group) and transoral pharyngeal release and posterior reduction, fixation and fusion(25 cases, control group) in our department from January 2018 to August 2022 were retrospectively analyzed. There were 8 males and 15 females in the cage group, aged 9-79(48.35±14.38) years old, while 6 males and 19 females were in the control group, who aged 21-69(47.84±13.51) years old. The operative time, intraoperative bleeding, length of hospital stay and complications were recorded. Japanese Orthopaedic Association(JOA) score was used to evaluate nerve functions, and atlantodental interval(ADI), vertical distance from odontoid process to Chamberlain′s line(DOCL), cervicomedullary angle(CMA), and clivus-axial angle(CAA) were measured to evaluate the reduction of atlantoaxial dislocation preoperatively, postoperatively and at final follow-up. The conditions of lateral mass joint cage and posterior bone graft fusion were also assessed. Results: All the patients had good positions of internal fixation, adequate decompressions and satisfactory reductions, and all symptoms were significantly relieved without vertebral artery injury and aggravation of spinal cord injury. The operative time, intraoperative bleeding and length of hospital stay in the cage group were 133.04±34.04min, 119.13±54.77mL and 14.74±6.10d, which were significantly less or shorter than those in the control group(253.20±53.98min, 181.20±45.40mL, 23.96±5.47d), respectively. The preoperative JOA, ADI, DOCL, CMA, CAA of the cage group were 6.33±1.13 points, 7.31±3.05mm, 9.47±3.32mm, 122.89°±12.58°, 122.02°±12.50° respectively, which were 13.04±2.17 points, 2.18±0.67mm, 0.89±1.00mm, 148.81°±5.43°, 146.70°±9.32° postoperatively, and 14.89±1.17 points, 2.09±0.69mm, 0.83±0.86mm, 149.10°±5.11°, 146.89°±8.95° at final follow-up. The preoperative JOA, ADI, DOCL, CMA, CAA of the control group were 6.76±1.21 points, 7.70±0.97mm, 10.56±1.99mm, 121.53°±4.87°, 123.77°±8.95° respectively, which were 13.26±1.32 points, 1.89±0.50mm, 1.13±1.08mm, 151.40°±6.15°, 149.86°±5.58° postoperatively, and 15.02±0.88 points, 1.87±0.44mm, 0.87±1.39mm, 149.48°±4.06°, 149.94°±6.61° at final follow-up. The JOA, ADI, DOCL, CMA and CAA of postoperative and final follow-up were significantly improved in both groups compared with those before operation(P<0.05), and the postoperative JOA score was statistically different from that at final follow-up in both groups(P<0.05), but there was no significantly statistical difference in ADI, DOCL, CMA and CAA between postoperative and final follow-up in both groups(P>0.05). 1 case of incision infections occurred in the cage group; 3 cases of incision infections(2 oropharyngeal, 1 posterior) and 1 case of cerebrospinal leakage occurred in the control group. The internal fixations were all stable in positions during follow-up, and osseous fusion was achieved at final follow-up in both groups, besides, there was no loss of joint space height in the cage group. Conclusions: Posterior atlantoaxial lateral mass joint cage graft fusion and internal fixation has similar efficacy for treating IAAD compared with transoral pharyngeal release and posterior reduction, fixation and fusion, but with the addition of implant fusion sites, which can be more effectively fused, and apart from avoiding transoral surgery, it can reduce the operative time, intraoperative bleeding, hospitalization time and complications.