齿状突骨折合并寰枢椎不稳术式的选择及疗效观察

Surgical options for instability of atlantoaxial complex combined with odontoid fracture

目的探讨撕状突骨折合并寰枢椎不稳的手术方式选择及疗效.方法 对2002年1月至2011年12月收治的54例齿状突骨折合并寰枢椎不稳患者的临床资料进行回顾性分析，男39例，女15例；年龄1l8～55岁，平均36岁；陈旧性齿状突骨折5例，新鲜齿状突骨折49例；齿状突骨折按Anderson—D’Alonzo．分型：Ⅱ型30例，Ⅲ型24例；合并寰椎前脱位12例，寰椎后脱位12例，无明显脱化30例；术前神经功能按美同脊髓损伤协会（ASIA）分级：B级2例，c级5例，D级16例，E级31例、其tf，30例患者仃前路漪状突空心螺钉内固定术（A组），8例患者行前路经寰枢关节螺钉内固定术（B组），16例忠暂行后路寰枢椎椎弓根螺钉内固定术（C组）。结果术中无椎动脉、脊髓损伤发生，术后寰椎脱位患者均获得良好复位。所有患者术后获6～24个月（平均16个月）随访．．A组2例患者术后6个Jj复查爪骨折不愈合，A组其他患者和B、C组所有患者均在术后3～4个月骨折愈合。无螺钉松动、断钉、退钉发生。所有患者术后6个月神经功能按ASIA分级：c级2例，D级6例，E级46洲结论上述二种于术方式均足治疗斯状突骨折合并寰枢椎小稳的有效方法．临床根据患者具体病情首选前路附状突空心螺钉内崮定治疗，此方法不合适时可考虑行前路经寰枢关节螺钉内固定术或后路寰枢椎椎弓根螺钉内固定术等寰枢椎融合术。

Objective To investigate 3 operative treatments and their clinical outcomes for insta- bility of atlantoaxial complex combined with odontoid fracture. Methods From January 2002 to De- cember 2011, 54 cases of instability of atlantoaxial complex combined with ndontoid fracture were treated surgically in our department. They were 39 males and 15 females, with a mean age of 36 years （range, 18 to 55 years） . Of them, 5 fractures were ohsolete and 19 fresh. According to the classification of Anderson-l）＇ Alonzon, 30 eases were type 1] aml 24 type m, 12 cases had atlas anterior dislocation, 12 atlas posterior dislocation and 30 no obvious dislocation. The preoperative neural function by the American Spinal Injury Association （ASIA） system： grade B in 2. grade C in 5, grade I） in 16 and grade E in 31 eases. According to the fracture type and individual status, 30 patients underwent internal fixation with anterior oduntoid ean- nulated serews （group A）, 8 patients had internal fixation with anterior C I-C2 transarticular screws （group B） and 16 patienls receiw^d internal fixation with posterior C1-C2 screw-rods （group C） . Results No in- traoperative injuD＂ to the vertebral artet7 or the spinal cord occurred. The patients with atlas dislocation ob- tained fine reduction post-nperation. The mean time of follow-up was 16 months （range, 6 to 24 months）. All the patients got bony union 3 to 4 nmnths after operation except for the 2 eases in group A who showed mmunion 6 months after operation without clinical symptoms. No instrument failure was fimnd at the final follow-up. According to the ASIA grading 6 months after operation, 2 cases were rated as grade C, 6 as grade D and 46 as grade E. Conclusions The above 3 surgical treatments are all effective for instability of atlantoaxial complex emnbined with odontoid fracture. The internal fixation with anterior odontoid eannulated screws shouht be the first option. Only when it is inappropriate, fixation with anterior C1-C2 transarticular screws and fixation with posterior C1-C2 screw-rods can be taken into consideration.