经口咽松解复位后路减压融合治疗复杂枕颈畸形

Transoral atlantoaxial reduction combined with posterior occipitocervical fusion for treatment of irreducible craniocervical malformation

[目的]探讨经口咽寰枢椎松解复位后路枕骨大孔扩大减压枕颈固定融合术治疗复杂枕颈畸形的临床疗效。[方法]回顾性分析2012年1月~2015年6月本科共收治并随访57例伴难复性寰枢关节脱位的复杂枕颈畸形患者的临床资料。采用持续颅骨牵引下经口咽寰枢椎松解复位+后路寰椎后弓切除枕骨大孔扩大减压枕颈固定植骨融合术治疗此类畸形,术前、术后1、3、6及12个月随访时行JOA评分和颈椎X线片、CT、MR检查,并测量齿状突超过Chamberlain线距离、延髓脊髓角(CMA)、寰齿前间隙(ADI)、枕大孔正中有效矢状径,所有患者根据手术前后JOA、VAS、NDI评分和测量影像学相关径线评价临床疗效。[结果]平均手术时间5.3 h,术中出血量62~220ml,术中置钉良好,未出现椎动脉损伤和脊髓损伤加重,术后鼻饲3~7 d,2周出院。术后无口咽部感染病例,枕颈部感染2例,经清创VSD负压吸引后均治愈。术前JOA评分6~12分,VAS评分0~7分,NDI评分8~40分,术后12个月JOA评分10~17,VAS评分0~4分,NDI评分5~19分,与术前比较差异有统计学意义。术后复查影像学检查示内固定稳定,植入骨块达骨性融合,术后齿状突超过腭枕线距离-10.00~6.90 mm;CMA 137.00°~159.50°,ADI值1.70~5.80 mm,枕大孔正中有效矢状径25.70~32.90 mm,分别与术前齿状突超过腭枕线(Chamberlain线)距离5.30~16.70 mm;CMA 109.00°~129.80°,ADI值5.30~9.10 mm;枕大孔正中有效矢状径6.00~18.80 mm,比较差异均有统计学意义。[结论]枕颈畸形采用经口咽寰枢椎松解复位后路枕骨大孔扩大减压枕颈固定融合术治疗,可使齿状突明显下移,纠正寰枢脱位,解除脊髓压迫,疗效满意。

[Objective] To explore the clinical outcome of transoral atlantoaxial release and reduction, combined with posterior decompression and occipitocervical fusion for treatment of irreducible craniocervical malformation. [Method] Fifty- seven patients with irreducible atlantoaxial dislocation or congenital craniocervical malformation were surgically treated from January 2012 to June 2015. All patients received transoral atlantoaxial release and reduction, combined with posterior atlas arch resection, foramen magnum decompression, and occipitocervical fusion under skull traction. The JOA score, distance of odontoid over Chamberlain line, cervicomedullary angle （CMA）, atlantodental interval （ADI）, and effective middle sagit- tal diameter of foramen magnum were compared before and after surgery. [Result] All patients had successful operation with an average operative time of 5.3 hour and introperative blood loss of 62-220 ml. All screws were placed in an appropriate posi- tion with proper angle and length. No severe complications, such as injury to vertebral artery and spinal cord, as well as oro- pharyngeal infection were found in any patient. Posterior wound infection occurred in 2 patients and cured after debridement and VSD vacuum drainage. In term of functional evaluation the JOA score increased significantly from 6-12 preoperatively to 10-17 at 12 month postoperatively （t=-30.207, P〈0.05）, whereas VAS decreased from 0-7 to 0-4 （t=24.823, P〈0.05）, and NDI decreased from 8-40 to 5-19 （t=23.353, P〈0.05） . Imaging studies revealed solid bony fusion associated with stable internal fixation. The distance of odontoid over Chamber- lain line decreased significantly from 5.30-16.70 mm preop- eratively to- 10.00-6.90 at the latest follow up （t=35.167, P〈0.05）, while the CMA increased from 109.00-129.80- to137.00--159.50-. （t=-163.512, P〈0.05）, the ADI decreased from 5.30-9.10 mm to 1.70-5.80 mm （t=189.485,P〈0.05）, and the effective middle sagittal diameter of foramen magnum increased from 6.00-18.80 mm to 25,70-32.90 mm （t=-76,191, P〈0.05） . [Conclusion] Transoral atlantoaxial reduction combined with posterior decompression and oeeipito- cervical fusion do achieve satisfactory results for treatment of irreducible eranioeervical malformation in terms of declining the dens, reducing atlantoaxial dislocation and relieving spinal cord compression.