内镜经口入路齿状突切除治疗颅底凹陷

Endoscopic transoral odontoidectomy for basilar impression

目的探讨不伴颈枕融合的内镜经口入路切除齿状突治疗颅底凹陷的可行性。方法回顾性分析6例具有难以缓解的延颈髓交界区压迫症状病人的临床资料，临床表现为颈痛、肢体感觉异常、脊髓性四肢轻瘫。术前影像学检查显示后半脱位的游离齿状突压迫颈枕交界区。病人均在没有颈枕后固定和骨性融合的情况下实施内镜经口入路齿状突切除术。结果病人经单纯内镜经口齿状突切除术后均成功获得颈枕交界区减压，且术后清醒即拔除麻醉插管，未行气管切开或术后置入胃管。本组病例术后未出现鼻咽反流、脑脊液漏、局部感染或脑膜炎等术后并发症。术后CT和MRI显示齿状突全切除和颈枕交界区充分减压。随访1～5年，未见颈枕交界区不稳定，且病人神经功能均显著恢复。结论内镜经口入路是到达寰椎和齿状突最近、最直接的手术入路。该入路在实现齿状突完全切除、颈枕交界充分减压的同时，不需要行颈枕后固定及融合，不要求气管切开，不会增加发生并发症的风险。

Objective To investigate the feasibility of endoscopic transoral odontoidectomy without occipitocervical fusion for basilar impression. Methods Clinical data of 6 patients with irreducible symptoms of cervicomedullary junction compression were analyzed retrospectively. All the six patients in this series presented with symptoms of neck pain, acroparesthesia and myelopathy-associated quadriparesis. The preoperative imaging demonstrated compression of the cervico-occipital junction from os odontoideum with posterior subluxation. The patients were subjected to endoscopic transoral odontoidectomy without occipitocervical posterior fixation and bone fusion. Results Decompression of the cervico-occipital junction was achieved successfully by endoscopic transoral odontoidectomy alone in 6 patients. All the patients were extubated after the procedure. There was no patient experiencing tracheotomy and postoperative gastrostomy tube placement in this series. There were no postoperative complications such as nasopharyngeal regurgitation, cerebrospinal fluid leakage, local infection or meningitis. Postoperative imaging demonstrated complete resection of the odontoid process and excellent decompression of the cervico-occipital junction. There were no evidence of instability at the cervico-occipital junction during a follow-up period of 1 to 5 years and remarkable improvement in neurological function was observed in each patient. Conclusions The endoscopic transoral approach is the nearest and most direct approach to C1 and the odontoid. This approach allows complete resection of the odontoid to decompress the cervico-occipital junction without increase the risk of complications. Usually, the posterior occipitocervical fusion and tracheotomy are not required in this approach.