寰枢椎复合骨折的治疗

The diagnosis and management for the combination fractures of atlas and axis

目的探讨寰枢椎复合骨折的治疗方法及疗效。方法对2006年7月至2014年3月56例资料完整的寰枢椎复合骨折患者进行回顾性分析，男36例，女20例；年龄21-63岁，平均38．6岁；Dickman寰枢椎复合骨折分型：C1骨折-Ⅱ型齿突骨折21例，C1骨折-稳定性枢椎骨折8例，C1骨折-Ⅲ型齿突骨折9例，C1骨折一Hangman骨折18例。C．骨折．稳定性枢椎骨折8例、C1骨折-Ⅲ型齿突骨折2例、C。1折-Hangman骨折7例采用非手术治疗，C1骨折合并Ⅱ或Ⅲ型齿突骨折，如果寰齿前间隙〉5mm，采用手术治疗39例。术前13例出现四肢感觉、运动和反射障碍，其中Frankel分级B级2例，C级4例，D级7例；日本矫形外科协会（Japanese Orthopaedic Association，JOA）评分5．5-12．8分，平均8．6分。结果56例均获得随访，随访时间6-58个月，平均32个月；寰枢椎椎间稳定性均恢复，植骨融合者在6个月内均获骨性融合（平均4．5个月）。术前13例有神经症状者，术后6个月Frankel分级平均提高1-2级，其中B级1例，C级1例，D级2例，E级9例。术后6个月，JOA评分11．5～15．8分，平均14．1分；JOA改善率为71．5％～95．3％，平均82．7％。末次随访时，39例手术治疗患者无一例发生内固定断裂、脊髓损伤、椎动脉损伤、脑脊液漏；伤口感染1例，经清创换药后1个月愈合。结论对Ⅲ型齿突骨折、稳定枢椎骨折、稳定Hangman骨折采用保守治疗，对寰齿前间距〉5mm的不稳定Ⅱ型齿突骨折及不稳定Hangman骨折采用颈椎后路椎弓根螺钉内固定术治疗。对于寰椎解剖异常、骨折严重粉碎、寰椎椎弓根螺钉固定失败者可采用枕颈固定。

Objective To investigate the treatment strategies and clinical effect of the combination fractures of atlas and axis. Methods Data of 56 cases with combination fractures of the atlas and axis treated from July 2006 to March 2014 were retro- spectively analyzed. There were 36 males and 20 females with mean age of 38.6 years old （range, 21 to 63 years old）. Dickman At- lantoaxial compound fracture classification： C1-Ⅱ type dens fracture 21 cases, C1 fracture-atlantoaxial stability fracture 8 cases; Cl fracture-III type dens fracture 9 cases; C1 fracture-Hangman fracture 18 cases. 8 cases of Cratlantoaxial stability fracture, 2 cases of C1-Ⅲ type dens fracture and 7 cases of C1-Hangman fracture had conservative treatment and the other 39 cases were taken sur- gery. There were 13 patients who suffered from nerve injury such as limbs numbness, movement and the reflecting barrier before surgery： 2 Frankel B, 4 Frankel C, and 7 Frankel D. The mean preoperative JOA score was 8.6 ranging from 5.5 to 12.8. Results All patients were followed-up for a mean period of 32 months （range, 6-58 months）. All the operated segments of atlas and axis showed stability and X ray showed fusion achieved within six months （average 4.5 months）. Postoperative pain, upper limb numb- ness and neck pain were improved. 13 cases who had neurological symptoms before surgery achieved an average of 1-2 degrees of Frankel grade recovery after 6 months. The average JOA scores 6 months after operation were 14.1 ranging from 11.5 to 15.8 and the rate of improvement was 82.7% ranging from 71.5% to 95.3%. At the latest follow-up, 39 cases with surgical treatment had no complications such as fracture fixation, spinal cord injury, vertebral artery injury and cerebrospinal fluid leakage; 1 case occurred wound infection which healed after a month by debridement and dressing. Conclusion C1 fracture-Ⅲ type dens fracture and sta- ble axis fracture and stable Hangman stability fracture should be undertaken with conservative treatment. C1 fracture-Ⅱ type dens fracture with atlantoodontoid interval 〉5 mm and unstable Hangman fracture should be treated with posterior cervical pedicle screw fixation. Oecipitocervical fixation could be taken with the atlas anatomical abnormalities, severe comminuted fractures and atlas pedicle screw fixation loosening.