寰枢椎不稳后路固定方式的选择

Surgical strategy of the posterior approach for atlantoaxial instability

目的探讨寰枢椎不稳后路手术治疗的方式.方法 2001年10月～2004年10月根据患者不同的病情采用不同的方式手术治疗寰枢椎不稳78例.齿突骨折49例,其中AndersonⅡ型35例(陈旧骨折14例,新鲜骨折21例),Ⅲ型14例(陈旧骨折6例,新鲜骨折8例);寰枢横韧带断裂7例;C1,2联合骨折9例(Jeffson骨折联合Hangman 骨折合并C12不稳);颅底陷入症4例;枢椎齿状突畸形2例;Chiari Ⅰ型畸形1例;寰椎爆裂型骨折合并枕颈不稳6例.采用Apofix联合Magerl技术治疗AndersonⅡ型28例,Apofix治疗Ⅲ型和寰枢横韧带断裂9例,Axis或VertexC1,2侧块固定AndersonⅡ型和Ⅲ型骨折15例,Axis枕颈固定26例.结果本组患者术后随访6～40个月,植骨全部融合,无一例假关节形成.术后并发感染3例,经清创后愈合,无一例因感染而取除内固定器.1例术中损伤硬脊膜,术后经保守治疗而愈合.1例术后伴枕颈部麻木,3个月后缓解.椎动脉损伤1例,术中采用填塞止血,术后无脑缺血等症状.1例采用Apofix固定者3个月后出现内固定松动而采取了二次手术.所有患者无脊髓损伤、舌下神经麻痹或内固定断裂.有2例患者主诉旋转活动部分受限(约42°),为正常的70%,主要为陈旧性骨折没能完全复位所致.结论对于寰枢椎不稳的后路手术治疗,应根据不同的骨折和不稳类型采取不同的手术方式.

Objective To study surgical strategy of the posterior approach for atlantoaxial instability. Methods Seventy-eight patients of atlantoaxial instability were treated by different surgical approaches. Of the 78 cases, there were 35 cases of type Ⅱ odontoid fractures,14 cases of type Ⅲ, 2 cases of odontoid deformity, 7 cases of transverse ligament breaking, 6 cases of Jefferson fractures, 9 cases of Hangman’s combined Jefferson’s fractures, and 5 cases of congenital defects of occipitocervical instability. 28 cases of type Ⅱ odontoid fractures were treated by combined use of Magerl and Apofix systems, 9 cases of type Ⅲ and transverse ligament breaking by Apofix system, 15 cases of type Ⅱand Ⅲ by C 1 and C 2 pedicle screw system, and the other 26 cases by posterior occipitocervical reconstruction. Results All patients underwent a follow-up for 6-40 months. In this series, vertebral artery injury was seen in 1 case, and no spinal cord injury was experienced clinically. There was 1 case of neurological symptom after surgery related to the procedure. Three patients experienced a deep wound infection, which responded to surgical debridement and intravenous antibiotics. There were 1 case with revision because of failed fixation by Apofix system. There was no case of implant failure. At final follow-up, all patients demonstrated evidence of solid fusion on radiographs. Conclusion To maximize stability and improve fusion rates, posterior different surgical approaches for atlantoaxial instability should be taken depending on different fracture types.