Goel技术治疗颅底凹陷及寰枢椎脱位

Goel's technique for the treatment of atlantoaxial dislocation with basilar invagination

目的探讨应用寰椎侧块螺钉、枢椎椎弓峡部螺钉棒内固定术治疗颅底凹陷合并寰枢椎脱位的可行性及临床疗效。方法回顾分析76例颅底凹陷合并寰枢椎关节脱位患者临床诊断与治疗经过,其中合并寰椎枕骨化畸形的寰枢椎脱位50例,未合并寰椎枕骨化畸形的寰枢椎失稳和脱位26例(齿状突不连性或发育不良性寰枢椎脱位14例、未合并脱位的颅底凹陷经前路切除齿状突减压所致医源性寰枢椎不稳12例)。全部病例均采用寰椎侧块螺钉和枢椎椎弓峡部螺钉棒或下关节突螺钉棒系统进行复位固定,髂后上嵴松质骨颗粒植骨。结果 74例获得满意临床治疗效果,出院时日本骨科协会(JOA)评分(17分法)由术前的9.43±3.16提高至13.80±2.07(t=4.063,P=0.037),Odom评级优19例、良49例、可7例、差1例。未合并寰枕融合者经后路固定手术均获得解剖学复位;50例伴寰枕融合患者中15例完全复位、35例部分复位;其中26例经口腔入路施行减压。共50例获3个月以上随访,JOA评分由术前的8.90±1.22提高至14.72±1.57(t=4.914,P=0.015),Odom评级优18例、良30例、可2例、差0例。随访期间未出现断钉、断板现象,内固定稳固、植骨完全融合。1例术后清醒拔管12h突发呼吸、心跳停止,复苏成功后深度昏迷,家属放弃治疗出院;1例术后第6天发生全身凝血机制障碍,随后出现四肢完全瘫痪,目前仍然在康复治疗中,肌力恢复至3级;2例术后发生呼吸衰竭;2例出现切口延迟愈合。无一例发生感染和后组脑神经损伤并发症。结论应用Goel内固定技术行寰枢椎关节复位、固定及植骨融合治疗畸形寰枢椎脱位安全可行,疗效满意。

Objective To explore the surgical feasibility and clinical outcome of translateral mass and pars screws fixation （GoeFs technique） in the treatment of atlantoaxial instability and dislocation. Methods Seventy-six patients were diagnosed as atlantoaxial dislocation, including 50 cases combined with occipitalization, and 26 patients with os odontoideum. Fifty- seven patients presented signs and symptoms of myelopathy or spinal cord injury. All of the patients underwent posterior operation of open reduction and arthrodesis with C1,2 joint fixation with rods and screws in the lateral masses and pars articulars of the atlas and axis. Results Seventy-four cases obtained good outcome. The main Japanese Orthopaedic Association （JOA） scale increased from 9.43± 3.16 preoperation to 13.80 ±2.07 postoperation （t = 4.063, P = 0.037）. According to Odom＇s scoring system, 19 patients were assessed as excellent, 49 good, 7 fair and 1 poor. A complete reduction was achieved in 15 cases, 35 patients obtained partial reduction. Twenty- six patients underwent transoral anterior decompression. One patient occurred respiratory and cardiac arrest at 12 h after operation. One patient subjected disturbances of blood coagulation tetraplegia and recovered muscle power gradually recovered to grade 3. Fifty patients were followed up more than 3 months, all of them achieved articular fixation. JOA scale improved from 8.90 ± 1.22 before operation to 14.72 ± 1.57 （t = 4.914, P = 0.015） at the follow up period. In Odom＇s rank： assessment 18 patients were excellent, 30 good, 2 fair and 0 poor. Conclusion Posterior reduction and arthrodesis with rigid internal fixators by Goel＇s technique could achieve satisfactory outcomes in patients with atlantoaxial dislocation.