儿童寰枢椎旋转脱位的治疗策略

Treatment strategy of rotatory dislocation of atlantoaxial articulation in children

目的探讨儿童寰枢椎旋转脱位的治疗方法。方法自2005年3月至2009年2月共收治寰枢椎旋转脱位患儿36例。其中男性25例，女性11例；年龄3-14岁，平均7．8岁。按Fielding-Hawkins分型：Ⅰ型24例、Ⅱ型8例、Ⅲ型2例、Ⅳ型2例。常规行颈椎X线片、MRI和cT三维重建检查评估寰枢椎旋转脱位情况及有无上颈椎畸形。对牵引后能复位、无外观畸形、无神经症状的32例患儿采用保守治疗。对牵引后难以复位、伴有游离齿状突畸形的4例患儿行颈后路寰枢椎融合内固定术。结果35例患儿治疗前寰椎旋转角度为5°-26°，平均16．0°±4．4°，治疗后寰椎旋转角度为0°-8°，平均4．5°±1．5°，治疗前后寰椎旋转角度比较差异有统计学意义（t=14．75，P〈0．05）。1例患儿治疗前寰椎旋转45°，治疗后为4°。所有病例均获随访，时间14-38个月，平均18个月。保守治疗的32例患儿斜颈消失，颈椎正位X线片示寰椎两侧块对称，颈部活动良好。4例手术患儿寰枢椎脱位复位、神经症状缓解，植骨均融合。结论大部分寰枢椎旋转脱位的儿童可以通过保守治疗获得满意疗效，但对于难复性或伴有游离齿状突畸形的患者宜行手术治疗。

Objective To analyze appropriate strategy about treatment of rotatory dislocation of atlantoaxial articulation in children. Methods From March 2005 to February 2009,36 patients with rotatory dislocation of atlantoaxial articulation were retrospectively analyzed,including 25 males and 11 females, with the average age of 7.8 years （ranged 3-14 years）. According to Fielding-Hawkins clinical classification, type Ⅰ24 cases, type Ⅱ8 cases, type Ⅲ 2 cases, type Ⅳ 2 cases. All of the patients were assessed rotatory dislocation of atlantoaxial articulation and whether or not upper cervical spine malformation by X-ray, MRI and CT scan and three-dimensional reconstruction. Thirty-two cases received onservational treatments which were reduction after cervical traction, without appearance of the deformity, without neurological symptoms. And another 4 serious cases（ irreducible atlantoaxial dislocation or with os odontoideum） received posterior atlantoaxial fixed autograft fusion. Results Rotation of atlas decreased from 16. 0° ± 4.4° （ range ,5 °to 26° ） pre-therapy to 4. 5° ± 1.5° （ range, 0° to 8°） post-therapy in 35 cases, rotation of atlas had significant difference between pre-therapy and post-therapy（ t = 14. 75, P 〈 0. 05 ）. One patient pre-therapy rotation of atlas was 45°,post-therapy was 4°. All patients were followed up for 14-38 months （mean, 18 months）, 32 cases who received cervical traction and external fixation resulted in satisfactory outcome in which all the ankylodeire were disappear, bilateral masses were symmetrical on anterior-posterior and good functional activities of cervical. All the 4 cases surgically treated obtained reduction, sound bony fusion and neural symptoms were improved obviously after operation. Conclusions Conservative treatment has been proved to be very effective in most of rotatory dislocation of atlantoaxial articulation in children. However, operative treatment should be considered in the following situations ： irreducible atlantoaxial dislocation or patients with os odontoideum.