寰枢椎不稳的后路手术恢复脊柱稳定性策略

Strategy of posterior surgical approach for atlantoaxial instability in the recovery of spinal stabilization

目的:寰枢椎不稳使高位脊髓损伤患者处于危险状态,观察后路手术治疗寰枢椎不稳恢复脊柱稳定性的远期效果。方法:选择2001-10/2004-02宁波市第六医院骨科根据不同的病损采用不同的手术治疗寰枢椎不稳患者38例。齿突骨折26例,其中AndersonⅡ型19例(陈旧骨折9例,新鲜骨折10例),Ⅲ型7例(陈旧骨折6例,新鲜骨折1例);齿突游离小骨2例;寰枢横韧带断裂2例;Jefferson骨折4例;Ⅱ型Hangman骨折+Jefferson骨折4例。采用Apofix联合Magerl技术治疗AndersonⅡ型17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型骨折5例,Axis枕颈固定7例。随访6个月,观察患者术后骨愈合情况、内固定有无松动及不良事件和副反应。结果:38例患者均进入结果分析。①骨愈合和脊柱稳定性情况:随访6个月,植骨全部融合,无一例假关节形成。②不良事件及副反应:本组患者术后并发感染3例,经清创后愈合,无一例因感染而取除内固定。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,但术后无脑缺血等症状。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%,主要为陈旧骨折,没有完全复位所致。结论:对于寰枢椎不稳的后路手术治疗,根据不同的骨折和不稳类型采取不同的手术方式可达到长期稳定的目的。

AIM： Atlantoaxial instability makes the patients with injury of elevated spinal cord in danger. The paper observed the long-term effect of posterior surgical approach for operation on the recovery of spinal stabilization. METHODS： Thirty-eight patients with atlantoaxial instability were treated by different surgical approaches according to different damage in the Department of Orthopaedics, Ningbo Sixth People＇s Hospital between October 2001 and February 2004. Of the 38 patients, there were 26 cases of odontoid fracture, including 19 of type Ⅱ Anderson odontoid fractures （9 had old fracture and 10 had new fracture） and 7 cases of type m （6 had old fracture and 1 had new fracture）, 2 cases of odontoid deform, 2 cases of atlantoaxial transverse ligament broking, 4 cases of Jefferson fractures and 4 cases of Hangman fracture＋Jefferson fracture. The Apofix together with Magerl techniques were used to treat 17 cases of type Ⅱ Anderson odontoid fractures, Apofix was used to treat 9 cases of type Ⅲ Anderson odontoid fractures and atlantoaxial transverse ligament broking, Axis or VertexC1, 2 fixation was used in 5 cases of type Ⅱ Anderson fracture, Axis occipital.cervical fixation was used in 7 cases. The patients were followed up for 6 months, the postoperative bone healing, whether there was looseness of internal fixation, adverse events and side effects were observed. RESULTS： All the 38 patients were involved in the analysis of results. ① Bone healing and spinal stabilization： During the 6-month follow-up, all the grafted bones fused, no pseudoarticulation formation was observed. ② Adverse events and side effects： In the group, 3 cases were complicated with infection, and healed after debridement, the internal fixation was taken out in none because of infection; The dura mtaer of spinal cord was damaged in 1 case during the surgery, and it healed after postoperative conservative treatment; 1 case was accompanied by occipitalcervical numbness, which was relieved after 3 months; Vertebral artery was injured in 1 case, and the bleeding was stopped by packing during the surgery, but no postoperative symptom of cerebral ischemia was observed. No spinal cord injury, paralysis of hypoglossal nerve or breakage of internal fixation occurred in any patients. Two patients had chief complaint that rotation activity was partly restricted, about 42°, which was 70% of the normal one, it was old fracture caused by incomplete reduction. CONCLUSION： To maximize the stability and improve fusion rates, posterior different surgical approach for atlantoaxial instability should be taken depending on different fracture type.