经口咽前路寰枢椎复位钛板手术在寰枢椎内固定翻修手术中的应用

Transoral atlantoaxial reduction plate in revision of atlantoaxial internal fixation

目的探讨经口咽前路寰枢椎复位钛板（transoral atlantoaxial reduction plate，TARP）手术在寰枢椎内固定翻修手术中的应用价值。方法2005年4月～2007年5月采用自行设计的TARP治疗10例寰枢椎初次手术失败需要再次手术的患者。其中包括寰枢椎脱位，行后路Apofix内固定术后再脱位3例；颅底凹陷症伴寰枢椎脱位，行后路减压枕颈内固定术后寰枢关节仍呈脱位状态且症状加重2例；先天性齿突不连伴寰枢关节脱位，行后路Brooks钛缆寰枢椎内固定术后再脱位且症状加重2例；先天性齿突发育不良伴寰枢关节脱位，行颈前路C。Axis钛板内固定术后未复位且症状加重1例；陈旧性齿突骨折伴寰枢关节脱位行TARP手术后再脱位1例；颅底畸形、C。脱位、四肢瘫痪伴呼吸困难，行TARP手术后再脱位1例。10例翻修手术分别为：7例先行后路取出枕颈内固定器及寰枢内固定器，同期行TARP手术；1例行经口前路取出C。Axis钛板，同时行TARP手术；2例行经口前路取出松动的TARP，其中1例更换成比之前小1个型号的TARP和直径比之前粗0．5mm的翻修螺钉予以重新固定，另1例行C2次全切除，更换特制的加长TARP固定于C1侧块和C3椎体。观察翻修术前、术后即时复位及随访时症状、体征、影像学及神经功能恢复情况。结果随访时间为2～25个月，平均18个月。10例寰枢关节脱位均获得解剖复位或接近解剖复位。TARP固定良好，无松动。9例获得骨性融合，1例随访时间偏短，暂无法确定融合情况。MRI示：寰枢节段椎管矢径恢复正常，颈髓获得充分减压，脊髓减压改善率达85％～100％（平均96％），但有3例寰枢节段脊髓明显萎缩，呈高信号改变。7例患者的神经功能获得不同程度的恢复。1例恢复自主呼吸，四肢运动无明显恢复。本组无神经血管损伤和术后再脱位并发症。结论TARP手术对于寰枢椎前后路内固定手术失败的翻修是一个理想的选择。

Objective To explore the clinical value of TARP in revision of atlantoaxial internal fixation. Method Ten cases of failed upper cervical operation followed by TARP revision from April 2005 to May 2007 were reviewed. There were 3 cases of redislocation after atlantoaxial internal fixation with Apofix, 2 cases of nonreduction after occipitocervical internal fixa- tion, 2 cases of redislocation after atlantoaxial internal fixation with Brooks titanic cable, 2 cases of redislocation after atlanto- axial internal fixation with TARP and one case of nonreduction after C1-3 internal fixation with Axis lateral mass plate. These cases all received revision surgery with TARP or modified TARP to reconstruct atlantoaxial stability. The occipitocervical and atlantoaxial internal fixation devices were dislodged through posterior approach in 7 cases followed by TARP operation. One axis titanic plates in C1-3 was dislodged followed by TARP operation through transoral approach. Failed TARP fixation was dislodged and replaced with smaller size in 1 case. And 1 patient underwent C2 subtotal vertebrectomy fixed with lengthened TARP from C1 to C3. Results All cases were followed up from 5 months to 25 months, average 18 months. Anatomy reduction were achieved in all 10 cases, 9 had bony fusion. MRI showed that radius vectors of atlantoaxial vertebral canals returned tonormal level, and cervical cords were decompressed effectively, which had an improvement rate ranging from 85 % to 100 % ,average 96%. However, spinal cord atrophia were seen in 3 cases. Nerves functions were partially recovered in 7 cases, one of which had spontaneously breathing but no quadruped locomotion. In all cases, no neurovascular injury or redislocation were documented. Conclusion TARP is an idegl choice for atlantoaxial internal fixation revision operation.