后路寰枢椎椎弓根钉固定治疗寰枢椎脱位

Posterior Atlantoaxial Pedicle Screw Fixation for Atlantoaxial Dislocation

目的：探讨后路寰枢椎椎弓根钉技术在治疗寰枢椎脱位中的优势及疗效。方法：自2009年4月-2012年4月，通过后路寰枢椎经椎弓根螺钉内固定技术治疗寰枢椎脱位的患者25例，其中男性14例、女性11例；年龄5～58岁，平均39．6岁。齿状突骨折不愈合13例、齿状突发育畸形6例、先天性颅底凹陷4例、横韧带断裂2例。患者表现为不同程度的枕颈部疼痛及活动受限，并伴有不同程度的神经损害，术前JOA评分5～14分，平均8．7分。对随访患者进行临床疗效及影像学评估。结果：所有手术均顺利完成，共植入100枚椎弓根螺钉，未出现脊髓、神经根及椎动脉损伤，手术时间1．5～4h，平均2．8h；术中出血150～450mL，平均250mL。3例患者在剥离寰椎后弓过程中致侧方静脉丛损伤，后经明胶海绵及棉片压迫后止血。术后行X线片及CT检查，3枚椎弓根钉角度偏外进入椎动脉孔，但术中未出现椎动脉破裂出血，术后患者亦无明显症状。1枚椎弓根钉角度偏内，致椎弓根内侧皮质破裂，椎弓根钉部分进入椎管，但未出现神经损伤。所有患者均获得随访，随访时间6～30个月，平均20个月，临床症状均获得明显改善，术后JOA评分9～16分，平均14．2分；1例患者术后1年影像学显示植骨部分吸收，但寰枢椎侧方小关节已出现骨性愈合，故未予以处理，其余患者植骨均获得良好的融合，随访中所有患者均未出现螺钉松动断裂。结论：后路寰枢椎椎弓根钉固定治疗寰枢椎脱位具有良好的临床疗效。

Objective：To discuss the advantage and effect of posterior atlantoaxial pedicle screw technique in treating atlanto- axial dislocation. Methods：From April 2009 to April 2012, 25 patients （14 males, 11 females, averagely 39.6 years old） with atlantoaxial dislocation were treated with posterior atlantoaxial pedicle screw fixation. Among whom there were 13 ca- ses with nonunion of odontoid fracture, 6 cases of odontoid deformity, 4 cases of congenital basilar invagination, and 2 ca- ses of transverse ligament rupture. All patients suffered from pain and limitation of motion in cervical position accompanied with nervous injury. Preoperative JOA scores ranged from 5 to14, 8.7 on average. The postoperative imaging and clinical efficacy were observed in the follow-up period. Results： All surgeries were performed successfully. A total of 100 screws were inserted without injury of spinal cord, nerve root and vertebral artery. The average operative time was 2.8h ranging from 1.5h to 4h. The intraoperative blood loss ranged from 150ml to 450ml （250ml on average）. Lateral venous plexus were injured in 3 patients during dissection, which were handled via compression of the gelatin sponge. Postoperative X- rays and CT scans showed that 3 screws were inserted into vertebroarterial foramen and 1 into spinal canal. However, there were no intraoperative bleeding, the symptom of vertebral artery injury or nerve injury. Postoperative JOA scores ranged from 9 to 16, 14.2 on average. All patients had bone fusion except 1 patient with bone absorption in the area of bone grafting in the follow-up of 20 months. Furthermore, there was no screw rupture. Conclusion： Posterior atlantoaxial pedicle fixation is feasible and effective for atlantoaxial dislocation.