轻中型颅脑损伤合并上颈椎骨折的外科治疗

Surgical treatment of upper cervical fracture accompanied with craniocerebral trauma

[目的]总结轻中型颅脑损伤合并上颈椎骨折的手术治疗经验,以提高对颅颈联合伤的认识。[方法]2008年6月~2012年6月本院手术治疗颅脑损伤合并上颈椎骨折患者46例,对其中无颈髓损伤的22例进行回顾性分析,男13例,女9例,年龄23~68岁,平均41岁。致伤原因:交通伤12例,高处坠落伤7例,暴力及其他伤3例,进行格拉斯哥预后评分(GOS),术后随访X线或CT片评价骨折愈合、植骨融合及颈椎稳定性情况。[结果]入院格拉斯哥评分(GCS)12~14分10例,9~11分12例。均有不同程度脑挫裂伤、硬膜外血肿、硬膜下血肿、脑内血肿;其中合并齿突骨折7例,Jefferson骨折5例,枢椎椎弓骨折4例;寰枢椎复合骨折6例。早期颈椎骨折漏诊3例。12例颅内血肿行开颅手术,3例一期联合颈椎手术,19例二期行颈椎手术。22例均行手术治疗,术中无明显并发症。随访12~36个月,平均18个月。出院GOSⅣ级3例,Ⅴ级19例,枕部放射痛、颈部活动受限等临床症状均减轻,术后复查X线片示骨折愈合良好,颈椎稳定,无内固定松动、脱出及断裂。[结论]颅颈联合伤在临床上并不少见,应重视颅脑损伤患者的颈部检查及保护。早期脑外科与骨科同台手术可取得较好的疗效。

[Objective] To summarize the clinical experiences of surgical treatment of upper cervical fracture accompanied with mild and moderate craniocerebral trauma. [Methods] From June 2008 to June 2012, 46 patients who suffered from upper cervical fracture accompanied with craniocerebral trauma were surgically treated in our department. Of the 46 patients, 22 patients who has upper cervical fracture without spinal cord injury were included into this retrospective study, including 13 males and 9 females with a mean age of 41 years （range, 23 - 68 years）. Glasgow outcome scale （GOS）, fracture healing, bone fusion and cervical stability measured by X-ray or CT scan were evaluated. [Results] GCS scores ranged from 12 to 14 in 10 patients, while 9-11 in the remaining 12 patients as hospitalized. The craniocerebral injury included cerebral contusions and lacerations, epidural or subdural hematomas, as well as intracerebral hematomas. In term of upper cervical fracture, there were dens fracture in 7 patients, Jefferson fracture in 5. vertebral arch fracture of axis in 4, and combined atlas and axis fracture in 6. Missed diagnosis occurred in 3 patients. Regarding to surgical treatment, 12 patients received emergency craniocerebral operation, including 3 patients who had cervical surgery in the same stage, while 19 patients underwent elective or second stage cervical surgery. All patients were followed up for an average of 18 months （range, 12-36 months）. GOS score was graded as IV in 3 patients and V in 19 patients when discharged. Occipital pain, limited neck mobility and other clinical symptoms were alleviated. The X ray showed good healing of the bone without malposition of the screws [Conclusion] The combined craniocervical trauma is not rare. It is important to perform a careful cervical examination and protection for patient with craniocerebral injury. Early simultaneous craniotomy and cervical surgery are helpful to reduce complications.