应用枕骨螺钉-棒-多轴螺钉枕颈固定融合术治疗“三明治”畸形伴寰枢关节脱位的疗效分析

Efficacy of occipitocervical fusion with the occipital screw-rod-multiaxial screw internal fixation system in the treatment of "sandwich" deformity with atlantoaxial dislocation

中文关键词:  寰枢关节脱位  “三明治”畸形  枕骨板-棒-多轴螺钉内固定系统  枕骨螺钉-棒-多轴螺钉内固定系统  植骨融合面积

英文关键词:Atlantoaxial dislocation  "Sandwich" deformity  Occipital plate-rod-multiaxial screw system  Occipital screw-rod-multiaxial screw system  Bone graft fusion area

中文摘要:

  【摘要】 目的：探讨应用枕骨螺钉-棒-多轴螺钉内固定系统行枕颈固定融合术治疗“三明治”畸形伴寰枢关节脱位的临床效果。方法：回顾性分析2017年1月~2023年1月于我院因“三明治”畸形伴寰枢关节脱位行后路复位、植骨融合、枕颈内固定术的62例患者，其中男性19例，女性43例，年龄51.1±23.5岁（29~72岁）。根据内固定系统枕骨端螺钉固定方式不同将患者分为两组：A组（38例）采用枕骨螺钉-棒-多轴螺钉内固定系统，男12例，女26例，年龄50.9±24.8岁（29~72岁），影像学表现脑干或颈髓受压30例、脊髓空洞6例、Chiari畸形2例；B组（24例）采用枕骨板-棒-多轴螺钉内固定系统，男7例，女17例，年龄51.4±22.4岁（32~69岁），影像学表现脑干或颈髓受压16例，脊髓空洞6例，Chiari畸形2例。A组随访时间36.5±11.8个月，B组随访时间36.1±9.8个月。两组患者年龄、性别、随访时间、影像表现无统计学差异（P＞0.05）。收集并比较两组的术中出血量、手术时间、并发症发生率。术前及末次随访时进行颈部疼痛视觉模拟量表（visual analog scale，VAS）评分、颈椎功能障碍指数（neck disability index，NDI）、日本骨科协会（Japanese Orthopaedic Association，JOA）评分，术后1周及末次随访时测量两组患者CT植骨融合部横断面及矢状面骨性融合面积，术前、术后1周及末次随访时测量两组患者寰齿前间隙（atlantodental interval，ADI）、脊髓可用空间（space available for cord，SAC）、斜坡-椎管角（clivus canal angle，CCA）、延髓-脊髓角（cervico-medullary angle，CMA）。结果：A组术中出血量362.4±89.1mL、手术时间144.8±35.6min，B组术中出血量345.1±93.7mL、手术时间143.7±36.2min，两组间无统计学差异（P＞0.05）。随访期间两组均无脊髓损伤、脑脊液漏等严重并发症发生，B组有2例患者出现连接棒断裂，3例患者出现复位丢失。两组术前NDI、VAS评分、JOA评分与末次随访比较有显著性差异（P＜0.05），两组同时间点比较均无统计学差异（P＞0.05）。两组术前ADI、SAC、CCA、CMA与术后1周及末次随访比较有显著性差异（P＜0.05），两组同时间点比较均无统计学差异（P＞0.05）。A组术后1周植骨融合部横断面面积、植骨融合部矢状面面积分别为385.44±84.51mm2、290.28±110.41mm2，末次随访时分别为267.06±66.13mm2、204.54±83.85mm2；B组术后1周分别为442.61±76.85mm2、267.21±104.63mm2，末次随访时分别为172.43±37.37mm2、124.87±48.10mm2，两组术后1周植骨融合部横断面面积和植骨融合部矢状面面积比较无统计学差异（P＞0.05），末次随访时有显著性差异（P＜0.05）。结论：应用枕骨螺钉-棒-多轴螺钉内固定系统枕颈固定融合术治疗“三明治”畸形伴寰枢关节脱位同枕骨板-多轴螺钉内固定系统相比疗效相当，但术后植骨融合效果更好，能达到可靠的枕颈固定。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical efficacy of occipitocervical fusion with the occipital screw-rod-multiaxial screw internal fixation system in treating "sandwich" deformity with atlantoaxial dislocation. Methods: A retrospective analysis was conducted on 62 patients who underwent posterior reduction, bone graft fusion, and occipitocervical internal fixation for "sandwich" deformity with atlantoaxial dislocation from January 2017 to January 2023. There were 19 males and 43 females, aged 51.1±23.5 years(29-72 years). The patients were divided into two groups based on the different fixation methods of the occipital screws used in the two types of occipitocervical internal fixation systems: group A of 38 patients utilized the occipital screw-rod-multiaxial screw system, consisting of 12 males and 26 females, aged 50.9±24.8 years(29-72 years), and the imaging findings revealed brainstem or cervical spinal cord compression in 30 cases, syringomyelia in 6 cases, and Chiari malformation in 2 cases; And group B of 24 cases utilized the occipital plate-rod-multiaxial screw system, consisting of 7 males and 17 females, aged 51.4±22.4 years(32-69 years), and the imaging findings revealed brainstem or cervical spinal cord compression in 16 cases, syringomyelia in 6 cases, and Chiari malformation in 2 cases. Group A was followed up for 36.5±11.8 months and Group B was followed up for 36.1±9.8 months. No statistically significant differences were observed between the two groups in terms of age, sex, imaging findings, or surgery style(P>0.05). A comparison was performed between the groups regarding intraoperative blood loss, operative time, follow-up period, and complication rates. Clinical outcomes were evaluated preoperatively and at the final follow-up using the neck pain visual analog scale(VAS) score, neck disability index(NDI), and Japanese Orthopaedic Association(JOA) score. The cross-sectional and sagittal bone fusion area of the graft site, atlantodental interval(ADI), space available for cord(SAC), clivus canal angle(CCA), and cervico-medullary angle (CMA) were measured preoperatively, 1 week postoperatively, and at the final follow-up in both groups. Results： Group A and group B weren′t significantly different in intraoperative blood loss(362.4±89.1mL vs 345.1±93.8mL, P>0.05) and operative time(144.8±35.6min vs 143.7±36.2min, P>0.05). In group B, rod fractures occurred in 2 cases and loss of reduction was observed in 3 cases, whereas the remaining patients maintained stable screw-rod fixation. Neither group experienced severe complications such as spinal cord injury or cerebrospinal fluid leakage. Both groups demonstrated statistically significant differences between preoperative NDI, VAS, JOA scores and those measured at the final follow-up(P<0.05), while no statistically significant differences existed between the two groups at the same time points(P>0.05). Statistically significant differences were observed between preoperative and postoperative(1-week and final follow-up) measurements for ADI, SAC, CCA and CMA in both groups(P<0.05), while no significant intergroup differences were found at corresponding time points(P>0.05). In group A, the cross-sectional area and the sagittal area of the graft site were 385.44±84.51mm2 and 290.28±110.41mm2 in postoperative 1 week, and 267.06±66.13mm2 and 204.54±83.85mm2 at the final follow-up; which in group B were 442.61±76.85mm2 and 267.21±104.63mm2 in postoperative 1 week, and 172.43±37.37mm2 and 124.87±48.10mm2 at final follow-up. Comparisons between groups revealed no statistically significant differences in either cross-sectional or sagittal graft areas at 1 week postoperatively(P>0.05), however, significant differences were observed at the final follow-up(P<0.05) for both parameters between the two groups. Conclusions: The occipital screw-rod-multiaxial screw internal fixation system presents comparable restoration effects to the occipital plate-rod-multiaxial screw system in treating "sandwich" deformity with atlantoaxial dislocation. It exhibits satisfactory implant fusion postoperatively and achieves reliable occipitocervical fixation.