寰枢椎后路优势侧单边椎弓根螺钉固定植骨融合术治疗不稳定Jefferson骨折

Advantage side unilateral posterior C1 and C2 pedicle screw fixation for treatment of unstable Jefferson fractures

目的探讨单侧寰枢椎后路椎弓根螺钉固定植骨融合术治疗不稳定Jefferson骨折的临床疗效和骨性融合率。方法采用回顾性病例对照研究分析2012年4月-2015年5月收治的22例不稳定Jefferson骨折患者临床资料，其中男18例，女4例；年龄35～67岁，平均52．9岁。视觉模拟评分（VAS）4～8分，平均6．09分。美国脊柱损伤协会（ASIA）分级为D级2例，C级1例；日本骨科学会（JOA）评分平均12．3分。根据置钉难易程度，15例行双侧寰枢椎后路椎弓根螺钉内固定（双侧组）；7例因骨折块极度不稳或椎弓根螺钉骨性通道过细导致寰枢椎后路双侧椎弓根螺钉置入困难，仅行寰枢椎完整性优势侧椎弓根螺钉固定植骨融合术（单侧组）。记录手术时间、术中失血量及并发症。应用VAS评估术前、术后即刻、术后3，6，12个月颈枕区疼痛改善情况。采用ASIA分级及JOA评分评估伴有神经损伤患者的神经功能恢复情况。在X线片上测定术前、术后即刻、术后3，6，12个月寰齿前间隙（ADI）评估寰枢椎复位情况。在寰枢椎CT上评价螺钉位置及融合情况。结果22例患者均顺利完成手术，手术时间（119．5±21．2）min；术中出血量（280．1±83．1）m1。术中共置入74枚寰枢椎螺钉，术后CT显示螺钉位置满意。术中术后均未出现并发症。患者均获随访13～33个月，平均20．7个月。两组术后VAS均较术前改善（P〈0．01），但组间差异无统计学意义（P〉0．05）。术后脊髓功能均得到不同程度改善，双侧组2例ASIA分级由D级恢复至E级，单侧组1例由C级恢复至D级；末次随访时JOA评分提高至平均15．7分。两组术后ADI均较术前减小（P〈0．05），但组间差异无统计学意义（P〉0．05）。两组术后6个月均获得骨性融合，但差异无统计学意义（P〉0．05）。结论对于无法进行寰枢椎双侧椎弓根螺钉固定植骨融合的不稳定Jefferson骨折患者，可以行优势侧单边螺钉固定；该技术能够改善颈部疼痛症状，获得较好的寰枢椎复位效果，提供一定的稳定性和融合率，达到临床需要的生物力学强度。

Objective To compare the clinical efficacy and fusion rate of unilateral and bilateral C1 and C2 pedicle screw fixation of unstable Jefferson fractures. Methods This retrospective case- control study enrolled 22 patients with unstable Jefferson fractures admitted between April 2012 and May 2015. There were 18 males and four females, with the mean age of 52.9 years （range, 35-67 years）. Mean preoperative visual analogue scale （VAS） was 6.09 points （ range, 4-8 points）. According to the American spinal injury association （ASIA） classification, two patients were rated grade D and one patient grade C. Mean Japanese orthopedic association （JOA） score was 12.3 points. Bilateral C1 and C2 pedicle screw fixation was performed for 15 patients （ bilateral group ）. Advantage side unilateral C1 and C2 pedicle screw fixation was performed for seven patients with extremely unstable fracture or narrow pedicle （unilateral group）. Operation time, blood loss and surgical complications were recorded. VAS was used to evaluate the improvement of neck pain after operation. ASIA classification and JOA score were used to assess nerve function recovery. Atlanto-dental interval （ADI）, srew position and bone fusion were evaluated after operation. Results All patients successfully completed the operation. Operation time was （ 119.5± 21.2） min, and blood loss was （280.1 ± 83.1 ） ml. A total of 74 screws were placed and CT scan showed satisfactory position of the screws. No complications were noted either during the operation or after surgery. All patients were followed up for mean 20.7 months （range, 13-33 months）. VAS was improved in both groups after operation （ P 〈 0.01 ） , and there was no significant difference between the two groups （ P 〉 0.05 ）. Two patients with ASIA grade D in bilateral group were improved to ASIA grade E after operation. One patient with ASIA grade C in unilateral group was improved to ASIA grade D after operation. JOA score increased to mean 15.7 points at last follow-up. ADI were decreased in both groups after operation（P 〈0.05 ） , but there was no significant difference between the two groups （ P 〉 0. 05 ）. All patients had bony fusion 6 months after operation, with similar fusion rate between the two groups （P 〉 0.05 ）. Conclusion Advantage side unilateral screw fixation can be used for the patients with bilateral C~ and C2 pedicle screw fixation failure, for the technique can improve cervical pain and provide relatively high stability and fusion rate.