两种翻修术式治疗寰枢椎后路复位不足病例的临床疗效比较

Comparison of the clinical outcomes of two revision surgeries in cases of insufficient posterior atlantoaxial reduction

中文关键词:  翻修手术  寰枢关节脱位后入路手术  骨性脱位经口松解

英文关键词:Revision surgery  Posterior approach operation for atlantoaxial dislocation  Transoral release of bony dislocation

中文摘要:

  【摘要】 目的：研究难复性寰枢关节脱位（irreducible atlantoaxial dislocation，IAAD）患者因寰枢椎术后复位不足而进行翻修手术的临床效果。方法：回顾性分析2000年4月～2021年8月因寰枢椎复位不足产生神经压迫症状而接受翻修手术患者的临床资料，根据翻修术式不同分为两组：A组（经口齿状突切除术）和B组（“后前后”联合入路，即后路内固定拆除及植骨块截骨、前路经口咽寰枢松解复位、再次后路固定融合术）。研究本组病例手术前后的脊髓功能的变化、住院时间、手术时间及术中出血量，手术过程有无并发症及并发症的种类和数量，手术前后延脊髓角（cervicomedullary angle，CMA）的大小。其中脊髓功能采用日本骨科协会（Japanese Orthopaedic Association，JOA）评分评价，脊髓功能的改善率（JOA改善率）= [（治疗后评分-治疗前评分）/（17-治疗前评分）]×100%。寰枢关节脱位的影像学改善率用延脊髓角改善率[CMA改善率=（术后角度-术前角度）/术前角度×100%]表示，并在组间进行对比研究。结果：32例因寰枢椎复位不足行翻修术的IAAD患者术前均存在脊髓病，其中A组14例，B组18例。A组术前JOA评分13.00±1.96分，术后末次随访JOA评分15.54±1.08分，术前CMA 132.66°±9.36°，术后末次随访CMA 144.74°±11.18°，住院时间21.93±14.07d，手术时间211.43±92.64min，术中出血量279.29±345.17mL。B组术前脊髓功能JOA评分11.78±3.23分，术后末次随访JOA评分14.97±1.47分，术前CMA 126.28°±11.06°，术后末次随访CMA 154.71°±6.50°，住院时间35.83±26.19d，手术时间368.83±118.55min，出血量534.50±324.66mL。A组翻修手术并发症率为57.1%，JOA改善率为（68.00±15.16）%，CMA改善率为（9.23±6.23）%；B组翻修手术并发症率为33.3%，JOA改善率（63.59±10.89）%，延脊髓角改善率（23.21±9.83）%。A组的手术时间及术中出血量显著低于B组，而两组的住院时间无显著差异性。B组的CMA改善率显著优于A组，而两组的脊髓病改善率（JOA改善率）及翻修手术的并发症发生率无显著差异。结论：寰枢椎后路复位不足病例的翻修术并发症较高、临床疗效较差。后前后联合手术相对于经口齿状突切除术的CMA改善率较优，其最大的优势在于解除脊髓压迫的同时可完全恢复颈椎力线。初次手术应做到寰枢解剖复位，尽量避免在寰枢复位不足状态下实行固定融合术。

英文摘要:

  【Abstract】 Objectives: To study the clinical effects of patients with irreducible atlantoaxial dislocation(IAAD) undergoing revision surgery due to insufficient atlantoaxial reduction. Methods: The clinical data of patients who underwent revision surgery due to nerve compression symptoms caused by insufficient atlantoaxial reduction from April 2000 to August 2021 were retrospectively analyzed. The patients were divided into two groups according to different revision surgery types: group A(transoral odontoid resection) and group B(posterior internal fixation removal and bone graft osteotomy, then anterior transoral atlantoaxial release and reduction, followed by posterior fixation and fusion, namely the "posterior-anterior-posterior" combined approach operation). The changes of spinal cord functions after operation were studied, and length of hospital stay, operative time, intraoperative bleeding, and complications were recorded, as well as preoperative and postoperative cervicomedullary angles(CMA). Japanese Orthopaedic Association(JOA) score was used for evaluating spinal cord function, and the improvement rate of spinal cord function(JOA improvement rate)=[(After treatment JOA score-Before treatment JOA score)/(17-Before treatment JOA score)]×100%. CMA improvement rate was used to describe the imaging improvement of atlantoaxial dislocation[CMA improvement rate=(Postoperative CMA-Preoperative CMA)/Preoperative CMA×100%], and it was compared between the two groups. Results: All 32 IAAD patients who underwent revision surgery due to insufficient atlantoaxial reduction had myelopathy before surgery, including 14 cases in group A and 18 cases in group B. In group A, the preoperative JOA score was 13.00±1.96, which was 15.54±1.08 at the final follow-up; The preoperative CMA was 132.66°±9.36°, and the final follow-up CMA was 144.74°±11.18°; The length of hospital stay was 21.93±14.07d, the operative time was 211.43±92.64mins, and the intraoperative blood loss was 279.29±345.17mL. In group B, the preoperative JOA score was 11.78±3.23, the final follow-up JOA score was 14.97±1.47; The preoperative CMA was 126.28°±11.06°, the final follow-up CMA was 154.71°±6.50°; The length of hospital stay was 35.83±26.19d, and the operative time was 368.83±118.55mins, and the intraoperative blood loss was 534.50±324.66mL. The complication rate of revision surgery in group A was 57.1%, the JOA improvement rate was (68.00±15.16)%, and the CMA improvement rate was (9.23±6.23)%. The revision surgery complication rate in group B was 33.3%, the JOA improvement rate was (63.59±10.89)%, and the CMA improvement rate was (23.21±9.83)%. The operative time and intraoperative blood loss in group A were significantly less than those in group B, and there was no significant difference in length of hospital stays between the two groups. The improvement rate of CMA in group B was significantly better than that in group A, while there was no significant difference in the rate of improvement in myelopathy(JOA score improvement rate) and complication rate of revision surgery between the two groups. Conclusions: Cases with insufficient atlantoaxial reduction of IAAD have higher rate of revision surgery complications and poorer clinical outcomes. Compared with transoral odontoid resection, the CMA improvement rate of the "posterior-anterior-posterior" combined approach surgery is better, and its biggest advantage is that it can completely restore the cervical spine force line while relieving spinal cord compression. The initial operation should be done with atlantoaxial anatomical reduction, and fixed fusion should be avoided as much as possible in the state of insufficient atlantoaxial reduction.