颈后路椎弓根螺钉内固定术治疗寰枢椎不稳及脱位

TRANSPEDICLE SCREW FIXATION IN UPPER CERVICAL SPINE FOR TREATING ATLANTOAXIAL INSTABILITY AND DISLOCATION

目的探讨颈后路椎弓根螺钉内固定术治疗寰枢椎不稳及脱位的手术可行性及临床疗效。方法2007年1月-2009年6月,采用颈后路椎弓根螺钉内固定术治疗寰枢椎不稳及脱位16例,男13例,女3例;年龄24～61岁,平均42岁。其中AndersonⅡ型齿状突陈旧性骨折4例、Ⅲ型1例,新鲜骨折4例,寰椎横韧带断裂4例,先天性齿状突不连伴寰枢椎不稳3例。患者均有不同程度颈部疼痛、颈部活动受限等临床症状;10例伴不同程度四肢感觉和运动障碍,术前日本骨科协会(JOA)评分5～13分,平均8.5分。影像学检查均有寰枢椎不稳或脱位表现。术中对陈旧性骨折及横韧带断裂引起的脱位患者取自体髂嵴松质骨行后路植骨,植骨量20～30g。结果手术时间1.2～2.5h,平均1.6h;术中出血量50～200mL,平均100mL。术后切口均Ⅰ期愈合。16例均获随访,随访时间3～18个月,平均11.5个月。患者均无椎动脉损伤、硬膜破裂、神经症状加重、伤口感染及断钉等并发症发生。术后X线片及CT示1枚螺钉进入椎管内,但未出现神经症状,未行特殊处理;余患者螺钉植入位置和复位均满意。寰枢椎植骨于术后6～18个月达骨性融合。术后3个月JOA评分12～17分,平均14.2分。所有患者颈部运动功能恢复良好,但轴向旋转活动部分丧失。结论应用颈后路椎弓根螺钉内固定术治疗寰枢椎不稳及脱位安全可靠,疗效满意。

Objective To explore the surgical feasibility and clinical outcome of transpedicle screw fixation in treatment of atlantoaxial instability and dislocation.Methods From January 2007 to June 2009,16 patients with atlantoaxial instability and dislocation were treated with transpedicle screw fixation.There were 13 males and 3 females,with a mean age of 42 years（range,24-61 years）.The transpedicle screw fixation was employed in 5 patients with old odontoid fracture（4 of Anderson type II and 1 of type III）,in 4 patients with fresh odontoid fracture,in 4 patients with traumatic disruption of transverse atlantal ligament,and in 3 patients with congenital odontoid disconnection for atlantoaxial instability.All patients had symptoms of cervical pain and limition of cervical motion,10 patients complicated by dyscinesia and hypoesthesia of extremities.The Japanese Orthopaedic Association（JOA）score before operation was from 5 to 13,with an average of 8.5.The image examination showed atlantoaxial instability or dislocation in all patients.Granulated autogenous ilium（20-30 g）was placed onto the surface of the posterior arches of both atlas and axis in some patients with old fracture of odontoid process or disruption of transverse atlantal ligament.Results The mean operative time and bleeding amount were 1.6 hours（1.2-2.5 hours）and 100 mL（50-200 mL）,respectively.All the incision healed by first intension.All patients were followed up for 3-18 months,with an average of 11.5 months.The JOA score 3 months after operation was from 12 to 17,with an average of 14.2.All screws were successfully placed in atlas and axis.No postoperative complications such as vertebral artery injury,dural rupture,exacerbation of neurological symptoms,wound infection,and broken srews were observed in 16 cases.Postoperative radiograph and CT showed that only one screw penetrated into vertebral canal,but there was no neurological symptoms.Bony fusion was observed after 6 to 18 months of operation,and atlantoaxial rotational function in all patients restored satisfactorily,but axial rotation was partially lost.Conclusion Transpedicle screw fixation in upper cervical spine for treatment of atlantoaxial instability and dislocation is safe and reliable.