寰枢椎弓根螺钉置入单节段固定治疗Jefferson骨折合并不稳定齿状突骨折

Single segment fixation with atlantoaxial pedicle screws in the treatment of Jefferson fracture combined with unstable odontoid fracture

背景:Jefferson骨折合并不稳定齿状突骨折比较少见,临床报道较少。目前多采用枕颈融合手术治疗,造成患者颈椎活动度严重丧失,对患者日常生活影响很大,疗效较差。目的:为了避免枕颈融合,保留枕寰关节活动度,应用寰枢椎弓根螺钉固定技术治疗Jefferson骨折伴不稳定性齿状突骨折,评价其可行性及修复效果。方法:对2010年3月至2015年8月收治的15例Jefferson骨折合并枢椎齿状突骨折患者行寰枢椎弓根螺钉固定术,合并齿状突AndersonⅡ型骨折13例,Anderson浅Ⅲ型骨折2例,伴有寰椎横韧带断裂5例。入院后给予患者颅骨牵引,术前行三维CT检查,于CT片中测量寰椎椎弓根钉道并选择合适尺寸螺钉。全麻下行寰枢椎弓根螺钉置入、寰枢椎复位,对横韧带断裂患者行寰枢椎植骨融合,其余患者采用单纯固定。采用ASIA分级及目测类比评分比较术前、术后神经功能和疼痛改善情况,术后随访时观察寰枕关节活动度。结果与结论:(1)平均手术时间(150±41)min(120-270 min);平均失血量(246±95)mL(160-500 mL);(2)所有患者寰枢椎弓根螺钉成功置入,术中无脊髓、神经根和椎动脉损伤发生。寰枢骨折脱位复位良好;(3)术后随访12-36个月。脊髓不完全损伤者共9例,7例患者术后神经功能明显恢复;术后1年目测类比评分(1.20±1.40)分较术前(8.15±0.62)分明显改善(P<0.05);(4)所有骨折及植骨全部愈合,无内固定断裂和松动;术后寰枕关节活动度平均(14.6±2.8)°;(5)综上,寰枢椎弓根螺钉内固定是修复Jefferson骨折合并枢椎不稳定性齿状突骨折的有效方法,固定牢靠,骨折愈合率高,可避免枕颈融合,保留寰枕活动度。

BACKGROUND： Jefferson fracture associated with unstable odontoid fracture is rare, and little reported.Occipito-cervical fusion is the commonly used treatment method, but it causes a severe loss of the motion of cervicalvertebrae, which affects the patients’ quality of life, so the curative effect is poor.OBJECTIVE： To evaluate the feasibility and therapeutic efficacy of atlantoaxial transpedicular screw fixation forJefferson fracture associated with unstable odontoid fracture, so as to avoid occipito-cervical fusion and preserve themotion of the atlanto-occipital joint.METHODS： Fifteen patients with Jefferson fracture associated with unstable odontoid fracture from March 2010 to August2015, were treated with atlantoaxial transpedicular screw fixation. There were 13 cases of Anderson type II and 2 cases ofAnderson shallow type lll odontoid fracture, as well as 5 cases combined with transverse atlantal ligament rupture. All patientsunderwent skull traction after admission, as well as three-dimensional CT was applied preoperatively to determine the atlaspedicle screw trajectory and chose suitable screws. Atlantoaxial transpedicular screw was placed and atlantoaxial joint wasreduced under general anesthesia. Bone graft fusion of atlantoaxial joint was applied only for the transverse atlantal ligament.The pain and neurologic function were evaluated by the Visual Analog Scale and the American Spinal Injury AssociationImpairment Scale before and after operation. The range of motion of the atlanto-occipital joint was observed during follow-up.RESULTS AND CONCLUSION： （1） The mean operation time was （150±41） minutes （120-270 minutes）. The meanblood loss was （246±95） mL （160-500 mL）. （2） Atlantoaxial transpedicular screws were successfully placed in allpatients. No spinal and nerve root injury, or vertebral artery injury occurred intraoperatively. The atlantoaxial achievedgood reduction. （3） The follow-up time was 12-36 months. There were nine cases of incomplete spinal cord injury, and 7cases of obviously improved neurologic function. The visual analog scale scores were significantly improved at 1 yearpostoperatively, from preoperative （8.15±0.62） to postoperative （1.2±1.4） （P 〈 0.05）. （4） All fractures and bone graftswere healed without loosening or rupture of the screws. The range of motion of the atlanto-occipital joint was （14.6±2.8）°postoperatively. （5） To conclude, atlantoaxial transpedicular screw fixation is effective for Jefferson fracture combinedwith unstable odontoid fracture, which not only exhibits a high rate of bone healing and stable fixation, but also avoids the occipital-cervical fusion and preserves occipito-atlantal motion.