强直性脊柱炎颈椎骨折的手术方法选择

Operation choices for cervical spinal fracture in patients with ankylosing spondylitis

目的探讨手术治疗强直性脊柱炎颈椎骨折的不同术式及治疗结果，总结术式选择的经验和依据。方法回顾性分析2005—2011年收治的获得完整随访资料的强直性脊柱炎颈椎骨折患者19例，其中前后联合人路手术（联合组）9例，单纯后路手术（后路组）7例，单纯前路手术（前路组）3例。总结患者临床资料、随访资料及影像学结果。结果患者均获随访12～20个月（平均14个月）。联合组术后4—6个月骨折愈合，1例发生喉返神经麻痹，术后3个月恢复，7例脊髓不全损伤患者脊髓功能按照美国脊髓损伤协会（ASIA）分级标准改善多于1级，内固定位置维持良好无松动移位。后路组术后4～6个月骨折愈合，未发生手术相关并发症，内固定无松动及移位，5例脊髓不全损伤者均获得神经功能改善多于1级。前路组1例术后4周发生内固定松动进行二次手术，2例术后4个月及5个月骨折愈合，内固定无松动。结论强萱性脊柱炎颈椎骨折手术选择前后联合人路为主，对骨折局部存在缺损或骨折端分离的患者，可选择前后联合入路固定手术，术后不需要外固定。对骨折经过椎体、无骨缺损、骨折端间隙小、无移位或轻度移位的患者，可选择单纯后路复位固定术，术后需要外固定。单纯前路存在内固定失败的风险，术后需要外固定。

Objective To investigate outcomes of different operations in treatment of cervical spinal fracture in patients with ankylosing spondylitis and summarize experiences and bases in selection of operation. Methods A retrospective study was done on 19 patients with cervical spinal fracture following ankylosing spondylitis treated between 2005 and 2011 and received complete follow-up. Among them, nine patients were treated with combined anterior and posterior surgical approach （combined treatment group）, seven with single posterior surgical approach （posterior approach group ） and three with single anterior surgical approach （anterior approach group）. Clinical data, follow-up data and image outcome of the patients were collected and compared. Results All patients received average 14 months of follow-up （range, 12-20 months）. In combined treatment group, the fracture was healed at postoperative 4-6 months. One patient had palsy of recun＇ent laryngal nerve but was recovered at postoperative three months. Seven patients with incomplete spinal cord injury had at least one level improvement in neurological function according to American Spinal Injury Association （ASIA） classification. No implant loosening or shifting were found in internal fixation. In posterior approach group, fracture was healed at postoperative 4-6 months, with no surgical complications, loosening or shifting of implants. Five patients with incomplete spinal cord injury had at least one level improvement in neurological function according to ASIA classification. In anterior approach group, an additional operation for implant loosening was performed in one patient at postoperative fortr weeks. The other two patients obtained fracture healing at postoperative four and five months respectively, without implant loosening. Conclusions Combined anterior and posterior approaches can not only be the first choice for treatment of cervical spinal fracture following ankylosing spondylitis, but also be used for patients with bone defect at fracture site or separation at fracture end, with no necessity of postoperative external fixation. Single posterior reduction and fixation can be considered in patients with transvertebral fracture in the absence of bone defect, separation at fracture end, displacement or slight displacement, with necessary postoperative external fixation. However, single anterior fixation takes risk of implant failure and needs postoperative external fixation.