大重量颅骨牵引结合两种手术治疗下颈椎骨折脱位伴关节突交锁

Treatment for subaxial cervical fracture-dislocation with locked-facet by high weight skull traction combined with two operations

[目的]根据大重量颅骨牵引复位成功与失败分别行前路和一期后前路联合手术治疗下颈椎骨折脱位伴侧关节突交锁,探讨其可行性及临床效果。[方法]回顾性分析本院自2000年1月～2010年3月间收治下颈椎骨折脱位伴侧关节突绞锁68例,其中单侧关节突交锁23例,双侧关节突交锁45例。治疗方法:所有患者先行大重量持续闭合颅骨牵引复位,若复位成功则择期行前路手术(A组),若失败则择期一期后前路联合手术(B组)。[结果]A组37例,B组31例,复位成功率54.4%。颅骨牵引单侧关节交锁复位成功率为22.2%,双侧关节交锁复位成功率为75.6%,统计学有显著性差异(P<0.05)。术后患者无脊髓损伤加重,5例完全瘫痪者无任何恢复。美国脊髓损伤协会等级标准平均提高1～2级,牵引后AISA感觉评分增加,术后随访ASIA感觉、运动评分日本骨科协会颈髓评分均显著增加,两组间评分比较无显著性差异(P>0.05),除3例前路手术内固定失败外,其余患者术后5 d,3、6、9、12个月定期X线检查示椎体序列及椎间高度良好,植骨正常融合,无内置物松动、断裂等并发症。[结论]双侧关节突交锁同单侧关节交锁相比,大重量颅骨牵引效果更好。牵引后可改善ASIA感觉评分但对运动评分不显著。下颈椎脱位伴关节交锁,应根据不同的伤情采取合理的手术方式,都可以取得不错的临床效果。

[Objective]To investigate the clinical effectiveness and feasibility of anterior approach in patients who had obtained successful high weight close reduction with skull traction and one-stage posterior-anterior approach in those who failed in closed reduction in the treatment of subaxial cervical fracture-dislocation with locked-facet. [Method]From Jan.2000 to Mar.2010,retrospective analysis was done on 68 cases of lower cercical fracture-dislocation with locked-faced who were managed in our institution.Closed reduction was attempted in all patients using high weight Gardner-wells traction.If reduction was accomplished successfully,only anterior cervical fixation was performed（group A）,if reduction failed,one-stage posterior-anterior approach was performed（group B）.[Result]Thirty-seven patient were included in Group A and the Group B,31 patients.Successful rate of closed reduction in all paitients was 54.4%,patients with bilateral cervical locked facets was 75.6%,patients with unilateral cervical locked facet was 22.2%,these were statistical difference between bilateral and unilateral group（P0.05）.No one with spinal cord injury were aggravated after operation.The neurologica fuction of five patients with complete spinal cord inury（SCI） not improved at all.The average American Spinal Cord Injury Association（ASIA） neurological function scale was improved by 1-2 levels.The average score of ASIA sense and motor,Japanese Orthopaedics Association（JOA） were apperantly improved,respectively,at final follow-up.There was no statistical difference between group A and group B in the recovery rate（P〉0.05）.X-ray films were examined disconnectedly in 5 days,and 1,3,6,9,12 months after operation which displayed that these measurements of kyphosis（Cobb angle）,vertebral body translation,vertebral body height and interbody fusion were mostly normal and no looseness or breakage was found in the fixation system for all but three patients developed prolapse of plate and screw and vertebral body displacement. [Conclusion]Our study demonstrated that for reduction of bilateral cervical locked facets dislocation by high weight skull traction is more effective in comparison with unilateral cervical locked facet dislocation.Reasonably ASIA sensor score was increased after traction but motor score of no avail.All active and reasonable surgical strategy according to different severity of injury can get a practical and effective clinical results for subaxial cervical fracture-dislocation with locked-facet.