枢椎骨折合并相邻节段不稳的分型和手术治疗选择

The classification and surgical management for axis fracture complicated with adjacent segment instability

目的：提出枢椎骨折合并相邻节段不稳的分型,探讨分型对于手术方式选择的指导意义。方法：2003年8月-2011年6月我院手术治疗枢椎骨折合并相邻节段不稳患者47例,其中男31例,女16例;年龄19-59岁,平均32岁。术前合并脊髓损伤11例,脊髓功能Frankel分级A级1例,B级2例,C级3例,D级5例。JOA评分为1-15（10.60±3.29）分。根据枢椎骨折的类型及其寰枢关节、C2/3关节的稳定情况分为3型：A型,枢椎骨折合并C1/2不稳,21例;B型,枢椎骨折合并C2/3不稳,17例;C型,枢椎骨折同时合并C1/2及C2/3不稳,9例。A型采用后路寰枢椎固定术,可联合齿状突螺钉固定;B型采用前路椎间盘切除、植骨融合、钢板固定术;C型采用后路C1-C3固定术。3例寰枢椎螺钉置入困难,采用枕颈融合术。均在固定骨折枢椎的同时,稳定C1/2和C2/3节段。术后3个月行JOA评分,术后随访X线片或CT片评价骨折愈合、植骨融合及颈椎稳定性情况。结果：47例均顺利完成手术,术中无椎动脉损伤、神经损伤、气管食管损伤等手术并发症。随访9-48个月,平均15个月。术后3个月JOA评分为2-17（13.83±3.93）分,与术前比较有统计学差异（P〈0.05）,JOA评分改善率为72.3%-90.8%,优良率为98%。术后6个月脊髓功能Frankel分级,1例B级无变化,10例Frankel分级改善1-2级。术后6-9个月复查X线片示骨折愈合良好,39例行植骨融合者在术后3-6个月（平均4.5个月）均获骨性融合。随访期间,颈椎序列良好,颈椎伸屈侧位X线片显示颈椎稳定,无内固定松动、脱出及断裂。结论：根据枢椎骨折合并相邻节段不稳的分型合理选择手术方案,在固定枢椎同时兼顾相邻节段的稳定性,能取得良好疗效。

Objectives： To provide the classification of axis fracture complicated with adjacent segment instability and investigate its significance to surgical management.Methods： 47 patients（31 males and 16 females） with axis fractures from August 2003 to June 2011 with a mean age of 32 years（range,19 to 59） were treated surgically and analyzed retrospectively.The Frankel scale was used to assesse neurofunction as following： 1 grade A,2 grade B,3 grade C and 5 grade D before surgery.The classification was determined according to the fracture type and stability of adjacent segment.Type A（21 cases）： axis fracture with C1/2 instability;Type B（17 cases）： axis fracture with C2/3 instability;Type C（9 cases）： axis fracture with both C1/2 and C2/3 instability.Operations were performed as following： Type A,posterior atlantoaxial fixation plus anterior screw fixation for odontoid fracture;Type B,anterior discectomy,fusion,and cervical plate fixation;Type C,posterior C1-C3 fixation or occipitocervical fusion when C1-C2 fusion was unavailable.JOA score was applied to e valuate the therapeutic effect.The fracture healing,bone graft fusion and stability were observed on X-ray or CT scan.Results： All patients underwent surgery safely without spinal cord injury,cerebrospinal fluid leakage and vertebral artery injury.The average follow-up was 15 months（9-48 months）.There was significant difference（P0.05） in JOA score between pre-operation（10.60±3.29） and post-operation（13.83±3.93）,and the rate of improvement was 72.3%-90.8%,with the excellent to good rate of 98%.1-2 degree improvement of neurofunction was achieved in all except 1 Frankel B.After operation,all patients were immobilized in a hard collar for 3 months.Fusion was achieved in 39 cases from 3 to 6 months（mean 4.5 months）.X-ray verified no malposition of the screws.No instrument failure was noted during follow-up.Conclusions： Axis fracture complicated with adjacent segment instability should be treated individually based on fracture type and adjacent segment instability,and the classification can be used to guide the surgical management.