后路寰枢椎椎弓根非融合固定治疗Ⅱ型齿突骨折

C1-2 segmental fixation without anterior screw for the motion-preservative treatment of type Ⅱ dens injuries

目的 探讨后路寰枢椎椎弓根钉棒内固定非融合治疗不适合前路齿突螺钉固定的Ⅱ型齿突骨折以保留寰枢椎旋转功能的临床疗效.方法 2012至2013年期间,选取13例不适合行前路齿突螺钉固定的Ⅱ型齿突骨折患者,男10例,女3例;年龄18～62岁,平均40岁.采用一期寰枢椎后路椎弓根钉棒复位内固定,术中不进行植骨融合,术后复查CT显示骨折骨性愈合后取出内固定,在内固定拆除至少1个月后采用动力位CT评估寰枢椎及颈椎总体旋转活动度的保留情况,采用文献报道的颈椎总体旋转活动度正常值作为历史对照.结果 13例患者成功置入直径3.5 mm的寰枢椎椎弓根螺钉共计52枚,螺钉长度为24～28 mm.术中骨折复位满意,未发生脊髓及椎动脉损伤等严重并发症.所有患者均得到随访,随访时间7～20个月,平均（14.2 ± 4.5）个月.术后骨折骨性愈合时间6～15个月,平均（9.0±2.8）个月.骨折骨性愈合即行二期手术拆除内固定,期间无内固定失败.手术前后患者颈痛症状明显改善,视觉模拟疼痛评分（visual analogue pain score,VAS）自术前平均（7.5±1.0）分（6～9分）下降至内固定拆除术后末次随访的（2.3±0.6）分（1～3分）,差异有统计学意义.动力位CT显示术后寰枢椎旋转活动度平均向左17.0°、向右17.2°,寰枢椎总体旋转活动度平均为34.2°;术后颈椎旋转活动度平均向左59.7°、向右56.8°,颈椎总体旋转活动度平均为116.5°.术后寰枢椎总体旋转活动度下降至颈椎总体旋转活动度的27.3％,颈椎总体旋转活动度下降至同年龄组、同性别正常人群的78.2％.结论 后路寰枢椎椎弓根内固定非融合治疗不适合前路齿突螺钉固定的Ⅱ型齿突骨折可以在一定程度上保留寰枢椎的旋转活动度.

Objective To observe the preliminary clinical results of temporary atlantoaxial segmental fixation for motion preservation of type Ⅱ dens fractures not amenable to anterior cancellous screw fixation.Methods Between 2012 and 2013,thirteen patients with type Ⅱ dens fractures not amenable to anterior screw fixation were enrolled and treated using temporary C1-2 pedicle screw fixation without fusion,including 10 males and 3 females,aging 18-62 years old （mean,40 years）.The internal fixations were removed after the consolidation of the fractures was radiologically confirmed.Functional CT scan was carried out to evaluate residual atlantoaxial rotation and axial neck rotation at least one month after the implant removal.Results All of 52 pedicle screws were successfully placed and satisfactory fracture reduction was achieved and maintained by internal fixation in all of the 13 patients.No major complication was noted.The average follow-up time was 14.2 months （7 to 20 months）.The fusion time after the surgery was 6 to 15 months,with an average of 9.0±2.8 months.At 9 months after initial surgery,the consolidation of the fractures was confirmed with no failure of fixation,and then the internal fixations were removed.The neck pain was released significantly,from preoperative VAS of 6 to 9 points （average,7.5± 1.0） to postoperative 1 to 3 points with an average of 2.3±0.6.The mean axial neck rotation was 59.7° to the left and 56.8° to the right.The mean atlantoaxial rotation was 17.0° to the left and 17.2° to the right.Total axial neck rotation was a mean of 116.5° and total atlantoaxial rotation was 34.2° on average.Atlantoaxial rotation took up about 27.3% of total axial neck rotation.In comparison to age and gender matched normal individuals,total axial neck rotation was reduced to about 78.2%.Conclusion As an alternative to fusion,posterior reduction and temporary segmental fixation could be a feasible technique for the motion-preservative treatment of type Ⅱ dens fractures not amenable to anterior screw.