彩色多普勒超声在置入外侧“in-out-in”枢椎椎弓根螺钉术中对椎动脉观察的价值

Values of color Doppler ultrasound in observing vertebral artery during lateral “in-out-in” axis pedicle screw placement

中文关键词:  彩色多普勒超声  枢椎椎弓根  螺钉  椎动脉  寰枢椎

英文关键词:Color Doppler ultrasound  Axis pedicle  Screw  Vertebral artery  Atlantoaxial

中文摘要:

  【摘要】 目的：探讨在寰枢椎脱位或不稳的枕颈后路手术中置入外侧“in-out-in”枢椎椎弓根螺钉前后，利用彩色多普勒超声对椎动脉观察并辅助螺钉置入的临床价值。方法：回顾性分析2016年1月~2022年1月，在枕颈后路手术中置入外侧“in-out-in”枢椎椎弓根螺钉内固定治疗的47例寰枢椎脱位或不稳的患者资料。其中，男30例，女17例，年龄21~68岁（42.2±18.9岁）；单侧枢椎椎弓根狭窄40例，双侧狭窄7例。观察组23例在显露完成后、钉道制备后、置入螺钉后3个时间点采用彩色多普勒超声观察椎动脉的形态并测量其直径，根据直径变化，决定最终置入螺钉长度；对照组24例基于钉道出血情况依据经验判断置入外侧“in-out-in”枢椎椎弓根螺钉。记录围手术期并发症，比较两组手术时间、术中出血量。患者均获得6~24个月（平均11个月）随访，术前及术后5d行X线、CTA和MRI检查，观察内固定及椎动脉情况；术后3、6、12个月行X线和CT检查，观察植骨融合情况；比较术前、术后5d及末次随访时的日本骨科协会（Japanese Orthopaedic Association，JOA）评分，评估患者的临床疗效。结果：两组患者手术顺利。观察组1例钉道制备后出现一侧椎动脉直径较显露完成时明显减小，使用短螺钉固定，余椎动脉直径在3个时间点分别为3.15±0.61mm、3.09±0.72mm、3.21±0.57mm，差异无统计学意义（P>0.05）。观察组、对照组手术时间分别为199.1±52.4（138~257）min、182.2±41.5（129~231）min；出血量分别为401.2±185.3（210~650）mL、415.3±201.7（230~660）mL，差异均无统计学意义（P>0.05）。术后CTA发现对照组1例出现一侧椎动脉被椎弓根螺钉压闭，无临床症状，无脊髓损伤等并发症。术后6个月CT检查示植骨融合，无内固定松动、移位。术后5d及末次随访时观察组JOA评分分别为13.1±2.1分、14.2±1.9分，与术前（7.8±1.9分）比较明显改善（P＜0.05）；对照组术后JOA评分分别为12.9±1.7分、13.8±2.2分，与术前（8.1±2.5分）比较明显改善（P＜0.05）；两组间比较JOA评分在各时间点差异均无统计学意义（P>0.05）。结论：在枕颈后路手术中置入外侧“in-out-in”枢椎椎弓根螺钉时利用彩色多普勒超声对椎动脉观察，可观察到椎动脉形态及直径，不增加手术时间和创伤。

英文摘要:

  【Abstract】 Objectives: To analyze the clinical effect of color Doppler ultrasound in observing vertebral artery before and after the placement of lateral "in-out-in" axis pedicle screw in posterior occipitocervical surgery for atlantoaxial dislocation or instability. Methods: The data of 47 patients with atlantoaxial dislocation or instability treated with lateral “in-out-in” axis pedicle screw fixation in posterior occipitocervical surgery from January 2016 to January 2022 were retrospectively analyzed. There were 30 males and 17 females, aged 21-68 years, with an average age of 42.2±18.9 years. Unilateral axis pedicle stenosis in 40 cases and bilateral stenosis in 7 cases. In the observation group, 23 cases underwent screw placement with color Doppler ultrasound monitoring the morphology of vertebral artery and measuring its diameter at 3 time points of after exposure, screw path preparation and screw placement, and the final screw placement length was determined according to the change of vertebral artery diameters. In the control group, 24 cases were implanted with lateral "in-out-in" axis pedicle screw according to bleeding and experience. Perioperative complications were recorded, and the operative time and intraoperative blood loss were compared between the two groups. All the patients were followed up for 6-24 months, with an average of 11 months. X-ray, CTA and MRI were performed before and at 5d after operation to observe the internal fixation and vertebral artery. X-ray and CT examinations were performed at 3, 6 and 12 months after operation to observe the bone graft fusion. The Japanese Orthopaedic Association(JOA) scores before operation, at 5d after operation and the last follow-up were compared to evaluate the clinical efficacy. Results: The operation of the two groups was successfully completed. In the observation group, the diameter of one side of the vertebral artery in 1 case was significantly reduced after the preparation of the screw path, and a short screw was used for fixation. The diameters of the remaining vertebral artery were 3.15±0.61mm, 3.09±0.72mm, 3.21±0.57mm at the three time points, respectively, with no significant difference(P>0.05). The operative time of the observation group and control group were 199.1±52.4(138-257)min and 182.2±41.5(129-231)min, respectively; The amount of bleeding in the observation group and control group were 401.2±185.3(210-650)mL and 415.3±201.7(230-660)mL, respectively, and there was no significant difference between the two groups(P>0.05). Postoperative CTA found that 1 case of the control group had one side of the vertebral artery compressed by pedicle screw without clinical symptoms and complications such as spinal cord injury. CT examination at 6 months after operation showed bone graft fusion and no internal fixation loosening or displacement. The JOA scores of the observation group at 5d after operation and the last follow-up were 13.1±2.1 and 14.2±1.9, respectively, which were significantly improved compared with before operation(7.8±1.9)(P<0.05). The JOA scores of the control group were 12.9±1.7 and 13.8±2.2, respectively, which were significantly improved compared with before operation(8.1±2.5)(P<0.05). There was no significant difference in JOA score between the two groups at each time point(P>0.05). Conclusions: The use of color Doppler ultrasound to observe the vertebral artery during the placement of lateral "in-out-in" axis pedicle screws in posterior occipitocervical surgery can observe the shape and diameter of vertebral artery without increasing surgical trauma.