前路撑开撬拨复位固定治疗下颈椎骨折脱位伴关节突绞锁的效果

Effect of anterior distraction and leverage reduction for lower cervical spine fracture and dislocationcombined with locked facet

目的评价前路撑开撬拨复位固定治疗下颈椎骨折脱位伴关节突绞锁的有效性和安全性。方法回顾性分析2009年1月-2014年7月收治的61例下颈椎骨折脱位伴关节突绞锁的患者，其中男48例，女13例；年龄18～81岁，平均48．6岁。损伤节段：C3/48例，C4/5515例，C5/623例，C6/711例，C7／T，4例。其中单侧小关节脱位18例，双侧小关节脱位43例。脊髓损伤按美国脊髓损伤协会（ASIA）分级标准：A级9例，B级13例，C级17例，D级16例，E级6例，选择全身麻醉下经颈前路减压、复位固定融合术。评价术中复位及术后维持复位情况；术后观察椎间隙高度、椎体水平位移和颈椎后凸畸形角度变化。采用Bridwell标准评价椎间植骨融合情况，采用ASIA分级标准评价术前术后神经功能变化情况，采用日本骨科协会（JOA）评分评价脊髓功能，计算神经功能改善率。结果本组所有患者顺利完成完全复位，56例获随访3—36个月，平均18个月。1例术后2个月出现再脱位，行二次手术，2例出现迟延愈合。无切口感染、神经损伤、食管损伤等围术期并发症，所有切口I／甲级愈合。颈椎生理曲度及椎间高度维持良好，椎间隙高度由术前正常椎间隙高度的39％～86％[（67．6±14．1）％]，提高到术后的89％～109％[（101．2±15．1）％]；椎体水平位移由术前5．36～11．74mm[（8．12±1．89）mm]，降为术后0～2．56mm[（1．29±0．29）mm]；颈椎后凸畸形Cobb角由术前的-3°～26°[（14．3±6．2）°]，改善为术后的-13°-7°[（-3．6±0．7）°]，差异均有统计学意义（P〈0．05）。术后ASIA分级均有提高，神经功能不同程度恢复，未出现神经损伤加重患者。术前JOA评分为0—17分[（7．3±0．9）分]，末次随访时为0～17分[（13．9±0．7）分]（P〈0．01），术后脊髓功能改善率为68％。结论前路撑开撬拨复位内固定可有效改善脊髓功能，是治疗下颈椎骨折脱位伴关节突绞锁安全有效的治疗方法。

Objective To evaluate the efficacy and safety of anterior distraction and leverage reduction for lower cervical spine fracture and dislocation combined with locked facet. Methods Sixty- one patients with lower cervical spine fracture and dislocation combined with locked facet presenting to hospital between January 2009 and July 2014 were analyzed retrospectively. There were 48 males and 13 females, aged 18-81 years （mean, 48.6 years）. Responsible injured segments were C3/4 in eight patients, C4/5 in 15, C5/6 in 23, C6/7 in 11 and C7/T1 in four. A total of 18 patients had unilateral locking of facets and 43 patients bilateral locking of facets. American Spinal Injury Association （ASIA） impairment score was grade A in nine patients, grade B in 13, grade C in 17, grade D in 16 and grade E in six. Under general anesthesia, the patients were performed decompression, reduction and fixation throughcervical anterior approach. Postoperative intervertebral height, vertebral horizontal displacement and cervical kyphosis angle and reduction condition were evaluated. Interbody fusion was evaluated using the Bridwell criterion, neurological function using the ASIA score, and spinal cord function using the Japanese Orthopedic Association （JOA） score. Results Complete reduction was achieved in all patients. Fifty-six patients received 3-36 month follow- up （mean, 18 months）. A second surgery was required for the postoperative recurrent dislocation in one patient and postoperative delayed union was seen in two patients. No patients had perioperative complications such as incision infection, nerve damage and esophageal injury. All incisions were stage I/first category healed. Cervical physiological curvature and intervertebral height were well maintained. Intervertebral height improved from preoperative 39% -86% [ （67.6 ± 14.1 ） % ] to postoperative 89% -109% [ （ 101.2± 15. 1 ） % ], horizontal displacement of vertebrae improved from preoperative 5.36-11.74 mm [ （ 8.12 ±1.89） mm ] to postoperative 0- 2.56 mm[ （ 1.29 ± 0.29 ）mm ], and Cobb angle itrrproved from preoperative - 3°- 26 °[ （ 14.3 ± 6.2 ） ° ] to postoperative - 13±7 o [ （ - 3.6 ± 0.7 ） ° ] （ all P 〈 0.05 ）. Nerve function was improved with no aggravation after operation. JOA score was 0 to 17 points [ （ 13.9 ± 0.7 ） points ] at follow-up versus 0-17 points [ （7.3 ± 0.9 ） points ] before operation （ P 〈 0. 01 ）, and the improvement of spinal cord function was 68% after operation. Conclusion Anterior distraction and leverage reduction effectively improves spinal function, indicating an effective and save method in the treatment of cervical spine fracture dislocation combined with locked facet.