结核性寰枢椎脱位的个体化治疗——附12例病例报道

Individualized treatment of tuberculous atlantoaxial dislocation: 12 cases reports

中文关键词:  寰枢椎脱位  脊柱结核  手术治疗  JOA评分  NDI评分

英文关键词:Atlantoaxial dislocation  Spinal tuberculosis  Surgical treatment  JOA score  NDI score

中文摘要:

  【摘要】 目的：探讨个体化手术方案治疗结核性寰枢椎脱位的可行性及有效性。方法：回顾性分析2018年1月～2023年11月我院收治的12例结核性寰枢椎脱位患者的临床资料。男7例，女5例，年龄27～79岁；Frankel分级C级2例、D级7例、E级3例；所有患者接受术前2周和术后18个月四联抗结核药物治疗。根据患者神经功能、影像学检查情况选择个体化手术方式，寰枢椎椎弓根和侧块破坏严重时选择单纯前路手术；寰枢椎前方软组织破坏严重而寰枢椎结构较完整时选择前后路联合手术；前方软组织破坏轻微且寰枢椎结构相对完整时选择单纯后路手术。通过对比术前及末次随访时的Frankel分级、日本骨科协会（Japanese Orthopaedic Association，JOA）评分和颈部功能障碍指数（neck disability index，NDI）评分进行临床疗效评估；通过寰齿前间隙（atlanto-dental interval，ADI）和延髓颈髓角（cervicomedullary angle，CMA）影像学评估进行颈椎稳定性和脊髓受压风险评估。结果：术后患者神经功能显著改善，Frankel分级2例C级恢复至D级，7例D级恢复至E级；JOA评分从术前平均11.5分提升至15.5分（P<0.05）；NDI评分从37.8分降至9.2分（P<0.05）。CMA从134.7°增至157.7°（P<0.05）；ADI从术前平均5.1mm降低至术后1.7mm（P＜0.05）。并发症包括1例吞咽困难和1例取骨区疼痛。随访期间无结核病灶复发和再脱位，内固定无松动移位，所有患者术中植骨在术后3～9个月内完全融合。结论：个体化手术方案可有效清除结核病灶、重建寰枢椎序列稳定并显著改善神经功能，是治疗结核性寰枢椎脱位的可靠策略。

英文摘要:

  【Abstract】 Objectives: To explore the feasibility and effectiveness of individualized surgical approach for tuberculous atlantoaxial dislocation. Methods: A retrospective analysis was performed on the clinical data of 12 patients with tuberculous atlantoaxial dislocation who were treated at our hospital between January 2018 and November 2023. The cohort consisted of 7 males and 5 females, aged 27 to 79 years. Preoperative neurological status according to the Frankel grading system was grade C in 2 cases, grade D in 7 cases, and grade E in 3 cases. All patients received a four-drug antituberculosis regimen for 2 weeks preoperatively and 18 months postoperatively. The surgical approach was individualized based on neurological function and imaging findings, as follows: (1) a standalone anterior approach was adopted when severe destruction of the pedicles and lateral masses of the atlas and axis was present; (2) a combined anterior-posterior approach was employed when anterior soft tissue destruction was extensive while the osseous structures of the atlas and axis remained relatively intact; and (3) a standalone posterior approach was selected when anterior soft tissue destruction was mild and the atlantoaxial osseous structures were relatively well preserved. Clinical outcomes were assessed using the Frankel grade, Japanese Orthopaedic Association(JOA) score, and neck disability index(NDI) before operation and at final follow-up. Radiological evaluation for cervical stability and spinal cord compression was performed using the atlanto-dental interval(ADI) and the cervicomedullary angle(CMA). Results: Neurological function improved significantly after surgery. According to the Frankel grading system, 2 cases improved from grade C to D, and 7 cases improved from grade D to E. The mean JOA score increased from 11.5 preoperatively to 15.5 postoperatively(P<0.05), while the mean NDI score decreased from 37.8 to 9.2(P<0.05). Radiologically, the mean CMA increased from 134.7° to 157.7°(P<0.05), and the mean ADI decreased from 5.1mm preoperatively to 1.7mm postoperatively(P<0.05). Complications included dysphagia in one case and donor site pain in one case. During follow-up, no recurrence of tuberculous lesions, redislocation, or loosening or displacement of internal fixation was observed. Successful bone graft fusion was achieved in all patients within 3 to 9 months after surgery. Conclusions: Individualized surgical strategy effectively clears tuberculous lesions, restores atlantoaxial alignment and stability, and leads to significant improvement in neurological function. It therefore represents a reliable treatment option for tuberculous atlantoaxial dislocation.