成人新鲜齿突骨折的手术治疗策略

Operative surgical procedures of treatment for adult new odontoid fracture

目的总结应用前路齿突拉力螺钉或后路寰枢椎植骨融合技术治疗成人新鲜齿突骨折的疗效。方法回顾性分析2009年1月-2012年1月期间收治的46例成人齿突骨折患者,男29例,女17例;年龄19-68岁,平均40.5岁。患者均有不同程度的枕颈部疼痛和活动受限,其中7例患者伴有神经功能障碍,术前日本骨科学会（Japanese Orthopaedic Association,JOA）评分9-14分,平均12.7分。根据Anderson-D’Alonzo分型,Ⅱ型骨折33例（71.7%）,Ⅲ型骨折13例（28.3%）。8例患者有不同程度寰椎前脱位,术前寰齿间距（atlanto-dens interval,ADI）3-7 mm,平均4.3 mm,术前进行颅骨牵引术,均可复位。采用前路齿突拉力螺钉或后路寰枢椎植骨融合术治疗,随访患者临床症状和神经功能改善情况,影像学观察寰枢椎复位和植骨融合情况。结果患者均顺利完成手术,术中均未发生椎动脉和脊髓损伤。共置入25枚齿突螺钉和84枚寰枢椎椎弓根螺钉,术后X线片及三维CT检查显示25枚齿突螺钉位置均较好,3枚寰椎椎弓根螺钉内倾角不够,螺钉部分穿破椎动脉孔内侧壁,椎动脉造影未见椎动脉损伤;1枚寰椎椎弓根螺钉内倾角过大,螺钉部分穿破椎管内侧壁,未出现新的神经损伤症状;其余螺钉位置满意。术后ADI为1-2.5 mm,平均1.6 mm。患者均获随访,随访时间8-36个月,平均23个月,术后6个月随访时神经功能明显改善,JOA评分为14-17分,平均16.2分,平均改善率为89.3%。1例行前路齿突螺钉内固定术的患者齿突骨折端硬化,有明显的骨不连发生,其余患者均在术后6个月获得骨性融合,融合率为97.8%;随访期间未发现螺钉松动、移位、螺钉断裂和寰枢椎再移位、失稳现象。结论选择前路齿突拉力螺钉或后路寰枢椎植骨融合技术治疗成人新鲜齿突骨折,可获得良好的临床效果。

Objective To summarize the clinical results of anterior screw fixation and posterior atlantoaxial pedicle screw-rod internal fixation in treatment of adult new odontoid fracture. Methods The clinical and radiographic records of 46（ 17 female and29 male） patients with an average age of 40. 5（ 19-68） years at the time of injury from January 2009 and January 2012 were retrospectively analyzed. The preoperative atlanto-dens interval（ ADI） was 3-7 mm（ average 4. 3 mm）. The patients had various degrees of occipital neck pain,limited mobility and 7 patients associated with neurological dysfunction. Japanese Orthopaedic Association（ JOA） scores before operation were recorded from 9 to 14（ mean,8.3）. Eight patients had anterior atlantoaxial dislocation,and underwent skull traction before operation,All cases were fully reduced. Patients were treated with anterior screw fixation or posterior atlantoaxial pedicle screw-rod internal fixation. All patients were assessed clinically for neurologic recovery,atlantoaxial reduction and bone graft fusion. Results No intraoperative vertebral artery injury and spinal cord injury were noted. A total of 25 lag screws and 84 pedicle screws were inserted,postoperative CT reconstruction showed that 4 screw malposition was noted,3 of which penetrated lateral pedicle cortex,1 penetrated medial pedicle cortex,80 screws were sited completely in pedicle. All 46 patients were followed up for an average of 23 months（ range,8-36 months）. The postoperative ADI was reduced to 1-2. 5 mm（ average 1. 6 mm）.JOA scores after operation were recorded from 14 to 17（ mean 16. 2）. The overall improvement rate was 89. 3% on average. Solid bony fusion was achieved in 45 patients at 6 months after operation,but nonunion of the odontoid fracture occurred in 1 case. The rate of fusion was 97. 8%,With no loosening,displacement,instability or breakage of the screws. JOA scores before operation were recorded from 4 to 14（ mean,8. 3）. Six months after surgery all patients were substantially improved with C degree in 3 cases,D degree in 10 cases and E degree in 8 cases. JOA scores after operation were recorded from 10 to 17（ mean,14. 6）. The overall improvement rate was 89. 3% on average. The postoperative ADI was reduced from 2 mm to 4 mm（ average 2. 8 mm）. Postoperative cervical spine MRI showed that the sagittal cervical spine alignment was restored,cerebral spinal fluid line was clear in the odontoid process area and no spinal cord compression was found. Conclusion Good clinical results can be achieved by the anterior screw fixation and posterior atlantoaxial pedicle screw-rod internal fixation.