对颅骨牵引结合后路枕颈融合术治疗枕颈部畸形所致寰枢椎脱位的疗效评价

Clinical outcomes of skull traction and posterior occipitocervical fusion for craniovertebral anomalies combined with atlantoaxial dislocation

目的：探讨颅骨牵引结合后路枕颈融合术治疗枕颈部畸形所致寰枢椎脱位的临床疗效。方法：回顾性分析2004年1月~2011年6月收治的28例枕颈部畸形所致寰枢椎脱位患者，男18例，女10例；年龄13~56岁，平均31.1±14.2岁。颅底凹陷（扁平）畸形16例，其中8例伴寰椎枕骨化畸形，6例伴寰枢椎椎弓发育畸形，2例伴上述两种畸形；单纯寰椎枕骨化畸形6例；齿状突发育不良4例；单纯寰枢椎椎弓发育畸形2例。MRI示所有病例脊髓均有不同程度受压，术前JOA评分5~9分，平均7.2±1.4分。术前均行颅骨牵引，牵引重量4~7kg，平均5.2±0.7kg；牵引时间7~14d，平均10.1±2.1d；复查X线片，22例患者脱位部分复位，6例患者脱位完全复位。均行枕颈融合术，术中枢椎尽量置椎弓根螺钉（根据枢椎畸形程度，20例患者枢椎双侧置入椎弓根螺钉，6例单侧置钉，2例未能置钉），余固定节段（固定至畸形椎体下2~3个节段）置侧块螺钉。结果：全部病例手术均安全完成，手术时间3~5h，平均3.5h；术中出血量180~400ml，平均250ml；无脊髓、血管损伤及其他严重并发症。术后第1天JOA评分8~13分，平均10.6±1.5分，较术前明显改善（P〈0.05）。术后复查X线片和MRI，21例患者脱位完全复位，7例患者脱位较术前明显改善，脊髓受压完全解除。随访6~48个月，平均20.3±9.7个月，所有病例术后3~6个月（平均4.3±0.9个月）获得骨性融合。末次随访时，JOA评分11~16分，平均14.6±1.7分，较术前及术后第1天均有改善（P〈0.05）。随访期间内固定无松动、断裂。结论：颅骨牵引结合后路枕颈融合术治疗部分枕颈部畸形所致寰枢椎脱位近期疗效确切，安全可靠。

Objectives： To investigate the clinical outcomes of skull traction and posterior occipitocervical fusion for craniovertebral anomalies combined with atlantoaxial dislocation. Methods： From January 2004 to June 2011, 28 patients（18 males and 10 females） with a mean age of 31.1±14.2 years（range, 13-56 years） suffering from craniovertebral anomalies combined with atlantoaxial dislocation were reviewed. 16 patients had basilar invagination （8 os odontoidem, 6 pedicle malformation of C1-C2, 2 with both anormalities）. All patients had different degree of spinal cord compression in MRI, and the preoperative JOA score was 5-9（mean, 7.2±1.4）. Preoperative skull traction was performed with a mean weight of 5.2±0.7kg（range, 4-7kg） and a mean traction time of 10.1±2.1d（range, 7-14d）. Preoperative X-ray showed no complete reduction in 22 patients and complete reduction in 6 patients. Posterior occipitocervical fusion surgery was then taken, and during the operation, C2 pedicle screws were implanted based on the C2 morphology（bilateral placement in 20 cases and unilateral placement in 6 cases, while no screw placement in 2 cases）, and lateral mass screws were placed in other segments（2-3 segments below）. Results： All patients underwent the skull traction and occipitocervical fusion successfully without any neurological deficit or vascular injury. The average operation time was 3.5 hours（range, 3-5 hours） with an average blood loss of 250ml（range, 180-400ml）. No severe complications were noted. JOA score of the first day after operation was 10.6±1.5（range, 8-13）, which showed significant improvement compared with preoperative ones（P〈0.05）. X-ray and MRI after operation showed complete reduction in 21 patients and partial reduction in 7 cases, all patients reached decompression of spinal cords completely. The follow-up was 6-48 months, with an average time of 20.3±9.7 months, and all cases had solid bony fusion with an average of 4.3±0.9 months（range, 3-6 months）. At final follow-up, the JOA score was 11-16（mean, 14.6±1.7）, which improved significantly than preoperation and 1 day after operation（P〈0.05）. During the follow-up, no instrument failure was noted. Conclusions： The skull traction and posterior occipitocervical fusion is effective, reliable and safe for craniovertebral anomalies combined with atlantoaxial dislocation.