枢椎棘突肌肉血管复合体移植在寰枢椎后路融合术中的应用

The effects of axial spinous process-muscle-vascellum complex transplantation for posterior atlantoariai fusion

目的 探讨枢椎棘突肌肉血管复合体移植在寰枢椎后路融合术中的临床价值.方法 回顾性分析2015年6月至2016年6月,采用枢椎棘突肌肉血管复合体移植行寰枢椎后路融合术治疗并获得随访的27例寰枢椎疾患患者资料,男19例,女8例;年龄9～68岁,平均（41.0±15.4）岁;寰枢椎脱位2例,单纯寰椎骨折14例,寰、枢椎骨折11例.术前患者均表现为不同程度的颈部疼痛和活动受限.术后均摄X线片和三维CT检查观察寰枢椎复位、融合及固定情况.采用寰齿前间距（atlanto-dens interval,ADI）、视觉模拟评分（visual analogue scale,VAS）、日本骨科协会（Japanese Orthopaedic Association,JOA）评分、JOA改善率及轴性症状评价术后疗效,同时记录术后并发症.结果 27例患者手术时间2.0～2.5 h,出血量150～300 ml;均获得随访,随访时间9～18个月,平均（11.5±2.1）个月.术后X线片和CT均显示复位满意,骨性融合时间为3～8个月,平均（4.2±1.9）个月.VAS评分术前为（3.6±2.7）分（范围,2.0～5.0分）,术后12个月为（1.4±0.2）分（范围,0～2.0分）,两者比较差异有统计学意义（P=0.000）;JOA评分术前为（11.7±1.9）分（范围,10.0～15.0分）,术后12个月为（15.3±0.6）分（范围,14.0～17.0分）,两者比较差异有统计学意义（P=0.000）;术后12个月JOA评分改善率为54.1％± 12.4％,其中23例（85.19％,23/27）优,4例（14.81％,4/27）良;轴性症状评价：无症状22例（81.48％,22/27）,轻微症状5例（18.52％,5/27）.术前ADI测量值平均（4.3±1.1）mm（范围,3.9～4.5 mm）,术后12个月ADI平均为（2.5±0.4） mm（范围,2.1～2.6 mm）,两者比较差异有统计学意义（P=0.000）.随访期间无一例发生复位丢失及内固定失败.结论 将枢椎棘突肌肉血管复合体移植应用于寰枢椎后路融合术,可以重建颈后肌群结构、降低轴性症状发生,减少自体取骨造成的医源性损伤.

Objective To assess the effects of axial spinous process-muscle-vascellum complex transplantation for posterior atlantoarial fusion.Methods Data of 27 cases with altantoarial disease who were treated by posterior atlantoarial fusion using axial spinous process-muscle-vascellum complex transplantation from June 2015 to June 2016 were retrospectively analyzed.There were 19 males and 8 females aged from 9 to 68 years old （mean,41.0±15.4 years old）.Two cases were diagnosed with atlanto-axial instability.Fourteen cases were diagnosed with atlas fracture and eleven cases were diagnosed atlanto-axial fracture.All the 27 patients suffered from neck pain or limitations of cervical motion.All patients were assessed clinically by atlantoaxial reduction and bone graft fusion.The pre-operative and post-operative atlanto-dens interval （ADI）,visual analogue scale （VAS）,Japanese Orthopaedic Association scores （JOA）,improvement rate of JOA score and axial symptoms were measured and statistically analyzed.Complications were recorded.Clinical outcome of latest follow-up was evaluated by X-ray and CT scan.Results The time of operation was 2.0-2.5 h and blood loss was 150-300 ml.All the patients were followed-up for 9 to 18 months （mean,11.5±2.1 months）.The VAS of neck pain improved from 3.6±2.7 （range,2.0-5.0） pre-operatively to 1.4±0.2 （range,0-2.0） 12 months postoperatively （P=0.000）.The JOA score improved from 11.7± 1.9 （range,10.0-15.0） pre-operatively to 15.3±0.6 （range,14.0-17.0）12 months post-operatively （P=0.000）.The improvement rate of JOA score at the latest follow-up was 54.1%± 12.4%,including 23 cases （85.19%） excellent,and 4 cases （14.81%） good.The results of axial symptoms were no-symptom in 22 cases （81.48%） and mild symptoms in 5 cases （18.52%）.Postoperative cervical spine X-ray and CT showed that the sagittal cervical spine alignment was restored.There was statistically significant difference between ADI of 4.3±1.1 mm （range,3.9-4.5 mm） pre-operatively to 2.5± 0.4 mm （range,2.1-2.6 mm） 12 months post-operatively,which was improved significantly （P=0.000）.There were no complications found during the follow-up.Conclusion The application of axial spinous process-muscle-vascellum complex transplantation for posterior atlantoaxial fixation can preserve the dynamic function of muscles and reduce the postoperative pain,as well as avoid donor site morbidity.