成人寰椎骨折的治疗策略

Treatment strategy of atlas fractures in adults

目的 :探讨成人寰椎骨折的治疗策略。方法 :2013年5月~2015年12月我科共收治成人单纯寰椎骨折患者58例,男31例,女27例;年龄18~72岁(45.3±14.0岁)。7例稳定寰椎骨折患者采用硬颈围固定;22例不伴横韧带断裂的不稳定寰椎骨折患者,采用头颈胸支具固定20例,halo支具固定2例;29例伴横韧带断裂的不稳定寰椎骨折患者,采用后路寰枢椎内固定融合术20例,后路寰椎单椎节内固定术9例。对患者进行常规随访,记录美国脊髓损伤协会(ASIA)分级、疼痛视觉模拟评分(VAS)以及治疗相关并发症。采用CT评估骨折愈合情况和植骨融合情况,采用颈椎动力位X线片评估寰枢椎稳定性。结果:所有患者随访12~24个月(14.3±4.0个月)。随访CT示,采用硬颈围固定的7例稳定寰椎骨折及采用头颈胸支具或halo架固定的22例不伴横韧带断裂的不稳定寰椎骨折均获得骨性愈合。20例行后路寰枢椎内固定融合术的伴有横韧带断裂的不稳定寰椎骨折有18例获得骨性融合,2例未融合但内固定仍牢靠。颈椎动力位X线片示9例行后路寰椎单椎节内固定术的患者均无寰枢椎失稳征象。治疗前ASIA分级D级4例,E级54例;末次随访ASIA分级均为E级(Z=-2.000,P=0.046)。治疗前VAS评分为4~8分(6.6±1.0分),末次随访为0~2分(0.4±0.7分)(Z=-6.682,P<0.001)。保守治疗者有2例枕部发生皮肤压疮;手术者术中均无神经血管损伤,术后2例发生切口感染。结论:对于稳定的寰椎骨折,采用硬颈围固定即可;对于不伴横韧带断裂的不稳定寰椎骨折,采用头颈胸支具或halo架固定可取得良好疗效;对于伴有横韧带断裂的不稳定寰椎骨折,采用后路寰枢椎内固定融合术或后路寰椎单椎节内固定术均可获得较满意的疗效。

Objectives： To discuss the treatment strategy of atlas fractures in adults. Methods： From May 2013 to December 2015, 58 adults with isolated atlas fractures（31 males and 27 females, average age 45.3±14.0, range 18-72 years） were treated in our hospital. Seven stable C1 fractures were treated by collar; while 22 unstable C1 fractures without transverse ligament injury were treated by skull-neck-thorax brace or halo-vest; 29 unstable C1 fractures patients with transverse ligament injury were treated by C1-C2 fusion or C1 fixation. Patients were followed up regularly. American Spinal Injury Association（ASIA） grades, visual analogue scale（VAS） and complications were recorded. Fracture healing and fusion were evaluated by computed tomography（CT） scan, and stability was evaluated by dynamic radiograph. Results： The mean follow-up period was 14.3±4.0（range 12-24） months. Stable fractures treated by collar and unstable fractures without transverse ligament injury treated by skull-neck-thorax brace or halo-vest healed. 18 of 20 who underwent C1-C2 fusion surgery got bony fusion, two failed, but the internal implant was still rigid. Atlantoaxial stability was confirmed by dynamic radiographs in all the 9 patients undergoing C1 fixation. ASIA grade was D in 4 cases and E in 54 cases before treatment. At final follow-up, ASIA grade was E in 58 cases（Z=-2.000, P=0.046）. The average VAS score was 6.6±1.0（range 4-8） before treatment and 0.4±0.7（range 0-2） at final follow-up（Z=-6.682, P＜0.001）. For those treated by external fixation, 2 suffered from skin contact ulcer. For those treated by surgery, no intraoperative blood vessel or nerve injury was observed, but two suffered from skin pressure ulcer. Conclusions： Collar immobilization is effective for stable C1 fractures. Both skull-neck-thorax brace and halo-vest immobilization are effective for unstable C1 fractures without transverse ligament injury. Both C1-C2 fusion and C1 fixation are effective for unstable C1 fractures with transverse ligament injury.