上颈椎骨折合并轻中型颅脑损伤的手术策略

Surgical strategies for upper cervical fracture combined with mild to moderate craniocerebral injury

目的分析上颈椎骨折合并轻中型颅脑损伤的手术治疗经验，以提高颈颅联合损伤的治疗效果。方法选择2008年6月-2012年6月手术治疗的上颈椎骨折合并轻、中型颅脑损伤且无颈髓损伤的22例进行回顾性分析，其中男13例，女9例；年龄23～68岁，平均41岁。致伤原因：交通伤12例，高处坠落伤7例，暴力及其他伤3例。齿突骨折7例，Jefferson骨折5例，枢椎椎弓骨折4例，寰枢椎复合骨折6例。入院时格拉斯哥昏迷评分（GCS）12～14分10例，9～11分12例。均有不同程度脑挫裂伤、硬膜外血肿、硬膜下血肿、脑内血肿。早期颈椎骨折漏诊3例。12例因颅脑损伤较重急诊行开颅手术，待病情稳定后择期行上颈椎手术，为颅脑损伤为主组。10例颅脑损伤行非手术治疗，上颈椎骨折脱位严重，1周内行颈椎手术治疗，为颈椎损伤为主组。比较两组手术时间、出血量、住院时间、住院总费用、围术期并发症等指标。出院时行格拉斯哥预后评分（GOS），术后摄x线或CT片评价骨折愈合、植骨融合及颈椎稳定情况。结果所有患者均获随访12～36个月，平均18个月。颅脑损伤为主组手术时间（115±22）min，出血量为（280±72）ml，住院时间为（23±7）d，住院总费用平均8．8万元，术后伤口感染1例，经清创换药后2周愈合；肺部感染2例，经抗生素治疗后痊愈。出院时GOS分级Ⅳ级2例，V级10例。颈椎损伤为主组手术时间为（125±38）min，出血量为（330±90）ml，住院时间为（17±6）d，住院总费用为6．1万元。无围术期并发症。出院时GOS分级Ⅳ级1例，V级9例。两组出院时枕部放射痛、颈部活动受限等临床症状均减轻，术后复查X线片示骨折愈合良好，颈椎稳定，无内固定松动、脱出或断裂。结论对于颈椎骨折合并颅脑损伤的患者，应重视颈部检查及保护，在病情稳定后，对上颈椎骨折尽早行手术治疗。

Objective To summarize clinical experiences for the management of upper cervical fracture associated with mild to moderate craniocerebral injury in order to improve the outcome of patients with eranioeervical injury. Methods Twenty-two cases （ 13 males and 9 females） of non-nerve damage treated surgically from June 2008 to June 2012 were enrolled. Mean age was 41 years （ range, 23-68 years）. Mechanisms of injury were traffic accidents in 12 cases, high falls in 7 cases and violence or others in 3 cases. Dens fractures were noted in 7 cases, Jefferson fractures in 5 cases and axial vertebral arch fractures in 4 cases, and combined atlas and axis fractures in 6 cases. Admission Glasgow Coma Score （GCS） was 12-14 points in 10 cases and 9-11 points in 12 cases. All cases suffered some degree of brain damage including brain contusion and laceration, and epidural, subdural or intracerebral hematoma. Three cases of cervical fractures were misdiagnosed in the early stage. Twelve cases required emergent craniotomy due to the primary craniocerebral injury and had elective upper cervical spine surgery until the medical condition was stabilized. Another 10 cases underwent conservation treatment of craniocerebral injury and had cervical spine surgery within 1 week due to the severe dislocation of the upper cervical spine. Operation time, blood loss, hospital stay, hospitalization cost and perioperative complications were analyzed. Outcome was evaluated with Glasgow Outcome Scale （GOS） at discharge. Fracture union, bone fusion and cervical stability were assayed with X-rays and CT films. Results All were followed up for a mean period of 18 months （range, 12-36 months）. Among the 12 cases of primary craniocerebral injury, operation time was （ 115 ± 22） min, blood loss was （280 ± 72） ml, hospitalization period was （23 ± 7）d and overall cost was 88,000 yuan; one case sustained wound infection cured two weeks after debridement and dressing and two cases sustained pulmonary infection cured after antibiotic treatment; discharge GOS was grade IV in 2 cases and grade V in 10 cases. Among the 10 cases of primary cervical injury, operation time was （ 125 ± 38 ） min, blood loss was （ 330 ± 90 ） ml, hospitalization period was （17 ± 6）d and overall cost was 61,000 yuan; no perioperative complications occurred; discharge GOS was grade IV in 1 case and grade V in 9 cases. Pain radiating to occipital region, limited neck mobility and other clinical symptoms were alleviated at discharge. X-rays verified good healing of the bone and no malposition of the screws. Conclusion For cervical fracture associated with eranioeerebral injury, cervical examination and protection are important. Once medical condition becomes stable, early surgery can be performed for upper cervical fracture.