颅底凹陷症伴寰枢椎脱位后路术后TARP翻修

Revision surgery of transoral atlantoaxial reduction plate (TARP) for the treatment of basilar invagination with atlantoaxial dislocation after posterior decompression failure

目的评价经口寰枢椎复位钢板（TARP）内固定在颅底凹陷症伴寰枢椎脱位后路减压术后翻修手术中的应用价值。方法 2008年9月至2012年6月广州军区广州总医院采用TARP内固定翻修手术治疗30例颅底凹陷症伴寰枢椎脱位后路减压术后症状无改善或加重的患者。通过手术前后颈椎过伸过屈位X线片、上颈椎CT扫描及三维重建、MRI检查观察寰枢椎脱位和颈脊髓压迫改善情况,根据日本骨科学会（JOA）评分标准评估患者术后神经功能恢复情况。结果所有翻修手术成功完成,手术时间120~250 min,平均手术时间150 min;术中出血量50~200 mL,平均出血量120 mL。随访6~39个月,平均随访时间16个月。30例患者寰枢椎脱位均获得满意减压复位,脊髓压迫完全解除,术后3~6个月均达到骨性愈合。寰齿间隙从术前的（9.1±1.4）mm降至术后的（1.6±1.4）mm,颈髓角从术前（116.5±12.0）°提高到术后（149.3±10.4）°,手术前后比较,差异有统计学意义（t=18.842,P=0.000;t=—16.520,P=0.000）。29例神经功能获得改善、1例无变化;JOA评分由术前的（10.8±2.3）分提高至术后6个月的（14.5±1.9）分,手术前后比较,差异有统计学意义（t=—17.440,P=0.000）。随访期内无寰枢椎再次脱位或症状加重表现;1例术后2周出现肺部感染,术后1个月枢椎螺钉松动,予抗感染治疗及螺钉调整术后痊愈出院。结论 TARP内固定是颅底凹陷症伴寰枢椎脱位安全有效的治疗方式之一,对于后路减压术后内固定及植骨融合困难的翻修病例具有较好的应用价值。

Objective To evaluate clinical efficacy of revision surgery of transoral atlantoaxial reduction plate （TARP） fixation for the treatment of basilar invagination （BI） with atlantoaxial dislocation （AAD） after failed posterior decompression. Methods From September 2008 to June 2012, 30 patients who suffered from BI with AAD followed by unsuccessful posterior decompression underwent one-stage revision surgery by TARP fixation in Guangzhou General Hospital of Guangzhou Military Command. Pre- and postoperative dynamic cervical X-rays, CT and MRI were performed to assess the status of dislocation and ventral compression of cervical spinal cord. The neurological status was evaluated by Japanese Orthopaedic Association （JOA） scoring system. Results All cases underwent revision surgeries successfully. The average operative time was 150 min （120-250 min）, and the intraoperative estimate blood loss was 120 mL （50-200 mL）. All patients were followed up with the average time of 16 months （range, 6-39 months）, and for all of the cases, satisfied decompression and reduction had been achieved, and they obtained bone fusion within 3-6 months. Atlanto-dens interval and cervicomedullary angle improved from preoperative （9.1 ± 1.4） mm, （116.5 ± 12.0）°, to postoperative （1.6 ± 1.4） mm, （149.3 ± 10.4）° respectively, there were statistical differences between preoperation and postoperation （t = 18.842, P = 0.000; t = -16.520, P = 0.000）. Clinical symptoms were resolved in 29 patients and stabilised in 1 patient. JOA score increased from preoperative 10.8 ± 2.3 to 14.5 ± 1.9 at 6 months after the surgery, the difference between preoperative and postoperative results had statistical significance （t = -17.440, P = 0.000）. During the follow-up, no atlantoaxial redislocation or symptom aggravation were found. Lung infection occurred in 1 case 2 weeks after the surgery, and axial screw loosening was found 1 months postoperatively, finally the patient was cured by antibiotics therapy and screw adjustment. Conclusion Considering an effective and safe method for patients suffered from BI and AAD, revision procedure of TARP internal fixation is valuable for those who confronted the difficulties of posterior fusion and internal fixation after unsuccessful posterior decompression.