侧块关节内皮质骨块植入结合侧块椎弓根钉棒内固定治疗难复性寰枢椎脱位

Intraarticular cortical bone graft implantation combined with lateral mass-pedicle screw rod fixation for irreducible atlantoaxial dislocation

目的 :评价侧块关节内皮质骨块植入结合侧块-椎弓根钉棒内固定(Goel技术)治疗难复性寰枢椎脱位的临床疗效。方法:回顾性分析2015年6月~2016年6月行侧块关节内皮质骨块植入辅助Goel技术复位固定的16例难复性寰枢椎脱位患者的临床资料(关节支撑组),以采用单纯Goel技术内固定治疗的15例患者作为对照(对照组)。对两组患者手术前后JOA评分及影像学上寰齿间隙(ADI)、颅底陷入值(BI)、斜坡椎管角(CCA)等指标进行评价,比较两组临床效果。结果 :两组患者年龄、性别比、平均随访时间和术前JOA评分、ADI、BI、CCA均无统计学差异。关节支撑组中14例双侧寰枢椎侧块关节内植入皮质骨块,2例单侧植入皮质骨块(均为单侧脱位病例,在脱位侧植入)。关节支撑组有1例发生单侧骨块沉陷入关节突内,其余病例未发生手术相关并发症。关节支撑组术后JOA评分为15.2±1.1分,ADI为2.4±1.5mm,BI为5.8±3.9mm,对照组术后末次随访时JOA评分为14.7±1.6分,ADI为2.9±2.7mm,BI为5.7±2.6mm,两组间比较无统计学差异(P>0.05)。关节支撑组术前CCA为123.1°±16.3°,术后末次随访时为148.1°±11.2°,对照组术前为125.6°±14.2°,术后末次随访时为116.6°±10.5°,两组末次随访时CCA比较差异有统计学意义(P=0.000)。两组随访期间未出现断钉断棒、内固定松动、复位丢失等并发症,所有病例均实现枕颈间骨性融合。结论:寰枢侧块关节内皮质骨块植入辅助Goel技术行寰枢椎复位固定安全可行,有助于难复性寰枢椎脱位的复位,并可以改善术后斜坡椎管角。

Objectives： To introduce the technique of intraarticular cortical bone graft implantation combined with lateral mass-pedicle screw rod fixation（Goel technique） for irreducible atlantoaxial dislocation, and to evaluate the reduction of dislocation and the reversion of clivus-canal angle. Methods： The study retrospectively reviewed 16 cases with irreducible atlantoaxial dislocation from June 2015 to June 2016（intraarticular pedestal group）, who were treated with intraarticular cortical bone graft implantation combined with Goel technique. Fifteen cases up to the same inclusion criteria in the same period who were treated by single Goel technique, were recruited as the control group（control group）. The JOA scores, the atlanto-dental distance（ADI）, the value of basilar invagination（BI）, and the clivus-canal angle（CCA） before and after operation were compared between the two groups to evaluate the clinical results. Results： There was no statistically significant difference in age, sex ratio, mean follow-up time, preoperative JOA score, ADI, BI, or CCA. The two groups were comparable. In the intra-articular pedestal group, the cortical bone grafts were implanted bilaterally in 14 cases. In the other 2 cases（with unilateral dislocation）, the bone grafts were only implanted in dislocation side. One case in the intraarticular pedestal group occurred bone graft subsidence into articular process. There was no operative complication in the remaining cases of two groups. In intraarticular pedestal group, the postoperative JOA, ADI and BI value were 15.2±1.1, 2.4±1.5mm and 5.8±3.9mm respectively. In control group, the postoperative JOA, ADI and BI value were 14.7±1.6, 2.9±2.7mm and 5.7±2.6mm respectively. There was no statistically significant difference of the values between two groups（P〉0.05）. The CCA reversed from 123.1°±16.3° to 148.1°±11.2° after operation in intraarticular pedestal group. In control group, the CCA changed from 125.6°±14.2° to 116.6°±10.5° postoperatively. There was a statistically significant difference of postoperative CCA between two groups（P=0.000）. No broken of screw/rod, loosen of internal fixation, or loss of reduction was reported in follow-up. All patients had exhibited solid bony fusion between occipital and neck. Conclusions： The intraarticular cortical bone graft implantation technique can be used to assist Goel technique to effectively and safely reduce the atlantoaxial dislocation. The preliminary results show that this technique is helpful for the treatment of irreducible atlantoaxial dislocation and can improve（enlarge） the clivus-canal angle after-operation.