不稳定性Hangman骨折手术入路选择

Option of anterior or posterior approach for unstable Hangman fracture

目的：探讨前路或后路手术治疗不稳定性Hangman骨折的影响因素及临床疗效。方法：回顾性分析我院2004年5月~2011年5月收治的65例不稳定性Hangman骨折患者，术前采用颅骨牵引C型臂X线机透视观察椎间盘和韧带损伤程度，X线片、CT和MRI观察合并存在的骨折和畸形情况。对椎间隙增宽、C2关节突间部粉碎、C2关节突间部发育细小、C2椎动脉高切迹、C3椎弓根发育细小或无髓腔、C3椎体骨折者采用前路手术；对椎间隙无增宽、C2-C3关节突交锁牵引不能复位、C3椎弓根骨折者采用后路手术。通过临床和影像随访观察两组患者临床疗效。结果：本组患者除C2关节突间部骨折伴C2/C3不稳定外，合并存在的严重损伤和畸形包括：椎间隙增宽9例、C2椎弓根发育细小1例、C2椎动脉高切迹2例、C2关节突间部粉碎骨折3例、C2-C3关节突脱位6例、C3椎体骨折3例、C3椎弓根骨折3例、C3椎弓根细小2例、C3椎弓根无髓腔2例。前路手术15例：椎间隙増宽3例、伴C2关节突间部粉碎骨折2例、C3椎体骨折＋C3椎弓根细小1例、C3椎体骨折＋C2-C3后方关节突交锁牵引复位1例、C2椎动脉高切迹1例；椎间隙未增宽也需行前路手术者包括C2椎弓根发育细小1例、C3椎体骨折＋C2-C3关节突交锁牵引复位1例、C2-C3关节突交锁牵引复位又不能判断C2/3椎间盘和韧带复合体损伤程度1例、C3椎弓根无髓腔2例、C2椎动脉高切迹＋C3椎弓根细小1例、关节突间部粉碎骨折＋C2-C3关节突交锁复位1例。后路手术50例：其中椎间隙增宽1例、C2-C3关节突脱位交锁牵引不能复位2例、C3椎弓根骨折3例。前、后路手术分别出现并发症7例次（47%）和8例次（16%），手术并发症发生率前路高于后路。结论：根据不稳定Hangman骨折合并C2/3椎间盘韧带结构损伤程度、合并存在的骨折和畸形情况选择前后路手术有利于提高临床疗效。

Objectives： To investigate the risk factors and clinical outcome of anterior or posterior approaches for unstable hangman fracture. Methods： 65 patients with hangman fracture from May 2004 to May 2011 in our hospital were reviewed retrospectively. Preoperative and intraoperative skull traction was applied and C-arm fluroscopy was used to evaluate the condition of C2-C3 disc and paravertebral ligaments. The fracture morphology of the involved cervical vertebrae was evaluated by X-rays, computed tomography and magnetic resonance images. Patients with the following conditions underwent anterior approach： C2-C3 disc space increase, comminuted fracture of pars interarticularis of C2, narrowed C2 pedicle, high notch of vertebral arteries of C2, C3 body fracture and C3 pedicle deformity. Patients without C2-C3 disc space increase or irreducible interlocking of posterior facets of C2-C3, or pedicle fracture of C3 underwent posterior approach. The clinical outcomes and rediograph results were reviewed. Results： Except for C2 pars fracture combined with C2/3 instability, severe injury and deformity included： completely rupture of C2-C3 intervertebral discs and ligamentous structure in 9 cases, narrowed C2 pedicle in 1 case, high notch of vertebral arteries of C2 in 2 cases, comminuted fracture of pars interarticularis of C2 in 3 cases, C3 body fracture in 3 cases, C3 pedicle fracture in 3 cases, C3 pedicle narrowing in 2 cases, and C3 pedicle sclerosis in 2 cases. Fifteen patients underwent anterior surgery, which included intervertebral disc space increase in 3 cases, fracture of C2 pars interarticularis in 2 cases, C3 body fracture and C3 pedicle narrowing in 1 case, C3 body fracture and reduced interlocking of posterior facets of C2-C3 in 1 case, C2 high notch of vertebral arteries in 1 case. Seven other cases without C2-C3 disc space increase also underwent anterior surgery, which included narrowing of C2 pedicle in 1 case, fracture of C3 body and reduced interlocking of posterior facets in 1 case, uncertain injuries of C2-C3 intervertebral discs and ligamentous structure in 1 case, C3 pedicle sclerosis in 2 cases, C2 high notch of vertebral arteries and C3 pedicle narrowing in 1 case, comminuted fracture of C2 pars interarticularis and irreducible facets interlocking in 1 case. Fifty patients received posterior surgery： no disc space increase in 44 cases, disc increase in 1 case, failure of reduction of C2-C3 in 2 cases, fracture of C3 pedicle in 3 cases. Anterior and posterior approach was noted 7 and 8 complications respectively. Conclusions： Unstable Hangman fracture complicated with C2/3 dislocation, injury to disc-ligament complex, complicated fracture and deformity can be used to guide the surgical approach.