前弓切除联合后路固定治疗齿突骨折畸形愈合

Anterior arch resection combined with posterior fixation for odontoid malunion

目的 探讨经口前路寰椎前弓切除、寰枢椎侧块关节松解联合后路复位内固定融合术治疗齿突骨折畸形愈合伴难复性寰枢椎脱位的疗效.方法 2007年2月至2012年2月共收治6例齿突骨折畸形愈合伴难复性寰枢椎脱位患者,均有外伤史,均存在脊髓损伤表现.男5例,女1例;年龄36～57岁,平均45.5岁.术前日本骨科协会（Japanese Orthopaedic Association,JOA）评分为4～10分,平均（7.5±2.2）分;脊髓有效空间（space available for cord,SAC）为5～11 mm,平均（8.1±2.5） mm.采用经口前路寰椎前弓切除、寰枢椎侧块关节松解联合后路枕颈复位固定融合术,术后颈托外固定3个月.术后观察神经功能改善情况,行X线、CT检查观察寰枢椎复位及融合情况.结果 6例患者均获得随访,随访时间12～20个月,平均16个月.寰枢椎术中得到较好复位,术后3个月获得骨性融合,随访期间内固定无松动.6例患者神经功能末次随访时JOA评分为10～15分,平均（14.7±2.1）分,较术前明显提高（差异有统计学意义）,神经功能改善率75.5％.末次随访时SAC为11～17 mm,平均（13.5±2.6）mm,较术前明显增大,差异有统计学意义.1例术后第5天出现后路切口渗液,督促患者采取侧卧位,避免切口受压,3周后切口愈合.1例术后第3天出现神智淡漠,化验室检查显示低钠、低钾血症,经及时补液,1d后神智恢复正常.结论 经口前路寰椎前弓切除、寰枢关节松解联合后路复位固定融合术是治疗齿突骨折畸形愈合伴难复性寰枢椎脱位的安全、有效方法,临床效果满意.

Objective To study the clinic efficacy of anterior arch resection,atlantoaxial joint release combined with posterior fixation and fusion for odontoid malunion associated with irreducible atlantoaxial dislocation.Methods From February 2007 to February 2012,6 patients （5 males,1 female） were diagnosed with odontoid malunion associated with irreducible atlantoaxial dislocation.The ages ranged from 36 to 57 years （average 45.5 years）.There were traumatic histories and spinal injury symptoms in all patients.The preoperative Japanese Orthopaedic Association （JOA） score was 7.5 ±2.2 （range,4-10）,and the space available for the cord （SAC） of preoperation ranged from 5 to 11 mm （8.1 ±2.5 mm）.All cases received anterior arch resection,atlantoaxial joint release combined with posterior fixation and fusion.They all wore cervical collar for 3 months after operation.The function of spinal cord was observed and atlanto-axial reduction and fusion was evaluated by postoperative X-ray and CT scan.Results All the patients underwent surgery successfully and their atlanto-axial reductions were complete.6 cases were followed up for 12-20 months （average 16 months）.No instrument failure or dislocation was observed during follow-up.Bone graft fusion was achieved 3 months after operation.The JOA score at the last follow-up was 10-15 （average 14.7±2.1）,which showed significant difference compared with preoperative score.The average improving rate of JOA was 75.5%.The SAC at the last followup was 11-17mm （average 13.5±2.6 mm）,which had significant difference compared with preoperative score.On the 5th day after operation,one patient experienced exudation and poor healing of posterior incision which was resolved by lateral position avoiding compression of wound.The posterior incision healed within 3 weeks.On the 3th day after operation,apathy occurred in one case and laboratory tests showed hypernatremia and hypokalemia.The consciousness of the patient recovered within 1 day after venous fluid infusion timely.Conclusion Anterior arch resection,atlantoaxial joint release combined with posterior fixation and fusion is a safe and efficient method with satisfactory short-term outcome for odontoid malunion associated with irreducible atlantoaxial dislocation.