不稳性寰椎骨折的外科治疗策略

Surgical treatment selection for unstable atlas fractures

目的探讨枕颈或寰枢椎内固定融合技术治疗不稳性寰椎骨折的临床疗效和应用价值。方法对2004年10月-2009年3月收治的不稳性寰椎骨折38例进行回顾性分析，其中6例寰椎爆裂性骨折合并寰枕关节不稳（5例行C0～C2固定融合术，其中1例同时合并有C7椎体压缩性骨折行C0～C3固定融合术），7例典型的Jefferson骨折，3例半环骨折，8例寰椎骨折合并Ⅱ型齿状突骨折，3例寰椎骨折合并Hangman骨折（其中2例Levine—EdwardsⅢ型行C0～C3固定融合术，1例Ⅱ型行C1～C2固定融合术），3例寰椎骨折合并下颈椎损伤，6例寰椎横韧带断裂（Dick—manI型）伴寰枢关节不稳，2例寰椎粉碎性骨折合并寰椎侧块内侧骨性结构附着处横韧带撕裂（DickmanⅡ型）。5例行C0～C2固定融合术，3例行C0～C3固定融合术，30例行C1～C2固定术并行自体髂骨植骨融合。结果所有患者术后均获得随访，平均随访时间为28个月（12～46个月）。临床症状均得到不同程度的改善。平均手术时间135min（80～190min），平均失血量460ml（200—3300ml），平均透视时间60s。38例患者术中均未发生神经、椎动脉和其他手术相关并发症。全部患者均于术后3d颈托固定后下地行走；术后脊髓损伤症状无加重。3例因电刀灼伤C1-C2间血管静脉丛导致出血，行止血纱布、脑棉片填塞止血，未出现颅脑缺血症状。复查X线片和CT未发现上颈椎失稳或复位丢失，螺钉位置良好，无松动、断钉，寰枢椎或枕颈部均获骨性融合。在晚期随访中，4例（11％）有颈部疼痛和僵硬感，1例枕神经痛。结论对具有不稳定性寰椎骨折或合并寰椎横韧带损伤的患者，采用枕颈或寰枢椎内固定融合技术及短期外固定对于重建上颈椎永久稳定性是较好的手术方式，并且能阻止神经和脊髓功能的进一步损伤。

Objective To evaluate the clinical effect and safety of the occiput-cervicle or C1 -C2 internal fixation and bone graft fusion in treatment of the unstable atlas fracture. Methods A retrospective study was performed in 38 patients with unstable atlas fractures treated by the occiput-cervicle or C1 -C2 internal fixation and bone graft fusion from October 2004 to March 2009. Six patients with comminuted atlas fracture combined with instability of the occipito-atlantoid articulations were treated with oc- eiput-C2 fusion （five patients） and with occiput-C3 fusion （one patient）. There were seven patients with typical Jefferson fractures, three with semiring fractures, eight with atlas fractures combined with Anderson type Ⅱ odontoid process fractures, three with atlas fractures combined with Hangman＇ s fractures （two patients with Levine and Edwards type Ⅲ Hangman＇ s fractures were treated with occiput-C3 fusion and one patient Levine and Edwards type Ⅱ Hangman＇s fracture was treated with C1-C2 fusion）, three with atlas fracture combined with lower cervicle injury, six with rupture of transverse ligament combined with instability of atlanto-axial joint （Dickman transverse ligament type I injury） and two with comminuted fracture of the lateral mass associated with bony avulsion of the medial tubercle and transverse ligament （Dickman transverse ligament type II injury）. Of all, five patients were treated with occiput-C2 fusion, three treated with occiput-C3 fusion and 30 treated with C1-C2 fusion. Results All the patients were followed up for a range of 12-46 months （ average 28 months）, which showed improvement of clinical symptoms in some extent postoperatively. The operation time ranged from 80 to 190 min ares （average 135 min ares）, with intraoperative blood loss for 200-3 300 ml （average 460 ml） and average fluoroscopic time for 60 seconds. There were no neurological deficits, vertebral artery related complications or other complications in all the patients during the surgieal operation. No neurological deficit was aggravated after the patient＇ s mobilization with brace three days after operation. The enous plexus of blood vessel at C1-C2 rupture induced by the use of eleetrocautery was found in three patients who showed no cerebral hemodynamic deficit after hemostasis with hemostatic sponge and cotton piece. The follow-up X-ray and CT manifested osseous fusion in all the patients, with no looseness or breakage of the screws. The late follow-ap showed pain associated with nlovement and limited range of motion in four patients （ 11% ） and occipital neuralgia in one. Conclusions An occiput-cervicle fixation fusion or a C1-C2 fixation fusion combined with short external fixation can reestablish the upper cervical stability and prevent further injury of the spinal cord and nerve function and hence is an ideal option for C1 burst fracture with or without rupture of the transverse ligament.