齿状突骨折合并无骨折脱位型下颈髓损伤的诊治

Treatment of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation

目的探讨齿状突骨折合并无骨折脱位型下颈髓损伤的特点、机制和诊治策略。方法回顾分析2007年6月—2015年10月收治的符合选择标准的7例齿状突骨折合并无骨折脱位型下颈髓损伤患者临床资料。患者均为男性,年龄37~71岁,平均51.4岁。致伤原因:交通事故伤2例,摔伤2例,击打伤3例。受伤至入院时间2 h^3 d,平均9 h。齿状突骨折采用Anderson-Grauer分型,ⅡA型1例,ⅡB型3例,ⅡC型2例,浅Ⅲ型1例。颈髓损伤受累节段:C_(4、5) 1例,C_(4~6) 2例,C_5~7 4例。颈椎退变程度:轻度2例,中度3例,重度2例。无骨折脱位型下颈髓损伤采用下颈椎损伤分型系统评分(SLIC)为4~6分,平均5.1分。枕颈部疼痛采用疼痛视觉模拟评分(VAS)为(7.8±1.0)分。神经功能采用ASIA分级,B级1例,C级4例,D级2例;日本骨科协会(JOA)评分为(9.2±3.9)分。齿状突骨折采用前路螺钉固定术4例,后路寰枢椎固定融合术3例;下颈髓损伤采用前路椎体次全切除钛网植骨融合术4例,椎间盘切除Cage植骨融合术3例。结果手术时间178~252 min,平均210.2 min;术中出血量60~140 m L,平均96.5 m L,均未输血。术后切口均Ⅰ期愈合。7例患者均获随访,随访时间12~66个月,平均18个月。均未出现与颈椎手术直接相关的并发症。术后植骨均完全融合,融合时间6~9个月,平均7.7个月。随访期间未见内固定物松动、脱落。末次随访时枕颈部疼痛VAS评分为(1.7±0.7)分,JOA评分为(15.1±1.7)分,均较术前显著改善(t=18.064,P=0.000;t=–7.066,P=0.000)。末次随访时神经功能ASIA分级为D级5例,E级2例,与术前比较差异有统计学意义(Z=–2.530,P=0.011)。结论复合暴力和下颈椎退变是齿状突骨折合并无骨折脱位型下颈髓损伤的主要原因,依据齿状突骨折的类型与下颈髓的损伤状态制定并实施一期手术可获满意疗效。

Objective To discuss the clinical characteristics, mechanism, and treatment of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation. Methods According to the inclusion and exclusion criteria, 7 male patients aged 37-71 years （mean, 51.4 years）, suffered from odontoid fractures combined with lower cervical spinal cord injuries without fracture or dislocation were analyzed retrospectively between June 2007 and October 2015. The trauma causes were traffic accidents in 2 cases, fall in 2 cases, and hit injury in 3 cases. The time from injury to admission was 2 hours to 3 days with an average of 9 hours. According to Anderson-Grauer classification of odontoid fracture, 1 case of type IIA, 3 cases of type IIB, 2 cases of type IIC, and 1 case of shaUow type III were found. The cervical spinal cord injuries affected segments included C4.5 in 1 case, C4-6 in 2 cases, and C5-7 in 4 cases. All the cervical spine had different degenerative changes： 2 of mild, 3 of moderate, and 2 of severe. The lower cervical spinal cord injury was assessed by Sub-axial Injury Classification （SLIC） with scoring of 4-6 （mean, 5.1）. The visual analogue scale （VAS） score was used to evaluate the occipital neck pain with scoring of 7.8±1.0; the neurological function was assessed by American Spinal Injury Association （ASIA） as grade B in 1 case, grade C in 4 cases, and grade D in 2 cases; and/apanese Orthopedic Association score （]OA） was 9.2±3.9. For the odontoid fractures, 4 cases were fixed with anterior screw while the others were fixed with posterior atlantoaxial fixation and fusion. For the lower cervical spine, 4 cases were carried out with anterior cervical corpectomy and titanium fusion while the others with anterior cervical disecotomy and Cage fusion. Results The operation time was 178-252 minutes （mean, 210.2 minutes）; the intraoperative blood loss was 60-140 mL （mean, 96.5 mL） and with no blood transfusion. All incisions healed primarily. All the patients were followed up 12-66 months （mean, 18 months）. There was no direct surgical related complications during operation, and all bone grafting got a fusion at 6-9 months （mean, 7.7 months） after operation. There was no inter-fixation failure or loosening. At last follow- up, the VAS score declined to 1.7±0.7 and JOA score improved to 15.1±1.7, showing significant differences when compared with preoperative ones （t=18.064, P=0.000; t=-7.066, P=0.000）. The neurological function of ASIA grade were also improved to grade D in 5 cases and grade E in 2 cases, showing significant difference （Z=-2.530, P=0.011）. Conclusion Complex forces and degeneration of lower cervical spine were main reasons of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation. The type of odontoid fracture and neurological deficit status of lower cervical spinal cord were important to guide making strategy of one-stage operation with a satisfactory clinic outcome.