GrauerⅡ型齿状突骨折治疗方式选择及疗效分析

Treatment options for Grauer type II odontoid fractures and clinical outcome

目的探讨GrauerⅡ型（ⅡA、ⅡB、ⅡC型）齿状突骨折治疗方式的选择及临床疗效。方法本组共40例新鲜齿状突骨折患者，按照Grauer分型：ⅡA型7例，ⅡB型18例，ⅡC型15例；5例伴有不完全性脊髓损伤。7例ⅡA型患者先行枕颌带或颅骨牵引，后改用头颈胸石膏或支具外固定；15例ⅡB型患者行前路齿状突中空螺钉内固定；15例11C型、3例严重移位ⅡB型患者经后路行寰枢椎椎弓根钉棒系统内固定植骨融合术。结果40例患者随访6—24个月。7例ⅡA型患者经保守治疗3—6个月骨折愈合。15例ⅡB型患者螺钉位置良好，未出现脊髓损伤，其中14例术后3～6个月骨性愈合，愈合率93．3％；15例ⅡC型、3例严重移位ⅡB型患者术中未出现椎动脉和脊髓损伤，后路植骨3～6个月骨性融合；复查内置物位置良好，无变形、松动或断裂；5例伴有脊髓不全损伤患者术后脊髓神经功能均有不同程度改善。结论Grauer分型中ⅡA型齿状突骨折可以保守治疗，ⅡB型（无移位或经牵引复位）宜行前路齿状突中空螺钉内固定术，ⅡC型及严重移位ⅡIB型则应经后路行寰枢椎椎弓根钉棒系统内固定植骨融合术治疗。

Objective To explore the treatment options for fresh Grauer type Ⅱ odontoid fractures and discuss corresponding clinical outcome. Methods The study involved 40 patients with fresh odontoid fractures including seven with type li A fractures, 18 with type ⅡB and 15 with type Ⅱ C according to Grauer classification. There were five patients with incomplete cervical cord injuries. Type Ⅱ A fractures were treated by traction of occipital-jaw band or skull for 1-2 weeks and then fixed with head-neck-chest plaster or brace. Type Ⅱ B fractures were treated with anterior odontoid screw system fixation. Fifteen patients with type Ⅱ C fractures and three patients with type Ⅱ B fractures combined with severe fracture displacement were managed with posterior atlantoaxial pedicle screw fixation. Results All the patients were followed up for 6-24 months. Seven patients with type Ⅱ A fractures showed union after fixation with head-neck-chest plaster or brace for 3-6 months. Fifteen patients treated with odontoid screw fixation had good positions of screws, with no injury to the spinal cord, of which 14 patients obtained bone union, with union rate of 93.3%. Eighteen patients （ including 15 patients with type Ⅱ C fractures and three with type ⅡB fractures combined with severe displacement） managed with atlantoaxial pedicle screw system showed no injury to the vertebral artery and spinal cord. Solid bone fusion was achieved in 31 patients after 3 to 6 months. The X-ray and SCT scans verified proper fixation of the screws, with no deformation, loosening or breakage of the screws. Five patients with incomplete cervical cord injuries obtained neural function recovery at various degrees after surgery. Conclusions Conservative treatment can be alternative to type ⅡA fractures. Anterior odontoid hollow screw fixation is better for type liB fractures （non-displaced or reducible） and has advantages of minor trauma, fast postoperative recovery and high union rate. However, posterior atlantoaxialpedicle screw system fixation and fusion is suitable to type Ⅱ C and ⅡB fractures with severe displacement and has the advantages of stable three-dimension fixation, direct screw placement, intraoperative reduction, short-segment fixation and high fusion rate.