齿状突骨折的外科手术方式探讨

Surgical treatment strategies of odontoid fractures

[目的]综合考虑齿状突骨折及其相邻节段特点,探讨齿状突骨折的外科手术方式及其疗效。[方法]回顾性分析2005年1月~2012年6月本院手术治疗的37例齿状突骨折患者的临床资料,其中男26例,女11例;年龄21~65岁,平均36岁。骨折情况:单纯齿状突骨折25例,其中Ⅱ型20例,浅Ⅲ型5例;合并相邻节段不稳12例:齿状突骨折合并寰枢椎不稳6例,齿状突骨折合并C2、3不稳4例,齿状突骨折合并C1、2及C2、3同时不稳2例。神经损伤12例,Frankel分级A级1例,B级2例,C级3例,D级6例。手术在稳定齿状突的同时,兼顾相邻节段不稳情况,选择个性化的固定方式。术前、术后3个月进行JOA评分,有脊髓损伤者采用Frankel评分标准,术后随访X线或CT片评价骨折愈合、植骨融合及颈椎稳定性情况。[结果]37例均顺利完成手术,术中无明显椎动脉损伤、神经损伤、气管食管损伤等手术并发症。随访12~48个月,平均18个月。术前JOA评分(12.11±2.09)分,术后3个月(15.36±3.17)分,两者有统计学差异(t=13.464,P=0.000);临床JOA改善率(90.8±11.6)%,优良率98%。术后6个月Frankel分级,除1例B级无恢复外,其余Frankel分级平均提高1~2级。术后佩戴颈托3个月。9个月内X线片复查示骨折愈合良好,植骨融合者在6个月内均获骨性融合(平均4.5个月);颈椎序列良好,颈椎伸屈侧位X线片显示颈椎稳定;无内固定松动、脱出及断裂。[结论]根据齿状突骨折本身特点结合有无合并相邻节段不稳情况,选择合理的手术方案,在稳定齿状突同时将相邻不稳的节段固定,能取得良好的疗效。

[Objective] Considering the characteristics of both odontoid fractures and adjacent section instability,to explore its surgical treatment strategies and curative effect of odontoid fractures.[Methods] Thirty- seven patients(including 26males and 11 females) with odontoid fractures who were treated from January 2005 to June 2012 with mean age of 36 years(ranging from 21 to 65) were analysed retrospectively.There were 25 cases of simple odontoid fractures with type Ⅱ in 20 cases and low type Ⅲ in 5 cases.There were 12 cases of odontoid fractures with adjacent section instability with C1、2instability(6 cases),C2、3instability(4 cases),both C1、2and C2、3instability(2 cases).The Frankel scale was used for assessment of nerve function among 12 patients.One cases were rated as Grade A,2 as Grade B,3 as Grade C,and 6 as Grade D before surgery.Treatment included anterior and / or posterior pedicle screw fixation.The order was to fix the fracture and make the upper cervical stable.JOA evaluating standards were applied to evaluate the therapeutic effect.According to Frankel grade,nerve functional restoration of spinal cord injury were described.The fracture healing,bone graft fusion and stability of the spine were observed by X ray or CT scan.[Results] All patients underwent surgery safely without severe complications occurring.The average following up time was 18 months(12 ~ 48 months).There was significant difference(t=13.464,P=0.000) in JOA score between pre- operation(12.11±2.09) and post- operation(15.36±3.17),and the rate of improvement was(90.8±11.6) %,with98% of'excellent'or'good'results.1 ~ 2 degree recovery of neural function were achieved in all except 1 cases with Frankel B damaged.Postoperatively,all patients were immobilized in a hard collar for 3 months.Fusion occurred in all cases(mean 4.5months).X ray verified the proper position of the screws after operation.There were no such complications occurred as loosening,displacement or breakage of internal fixations.[Conclusion] We should choose the proper surgical method according to the characteristics of both odontoid fractures and adjacent section instability to fix the fracture and make the upper cervical stable.Advisable and active treatment conduces to better effect.