强直性脊柱炎后凸畸形合并颈椎骨折的手术方法选择

Choice of operative methods for kyphosis deformity of ankylosing spondylitis complicated with cervical vertebral fracture

目的探讨强直性脊柱炎(AS)后凸畸形合并颈椎骨折的不同术式及治疗效果。方法采用回顾性病例系列研究分析2007年4月—2017年10月河南省人民医院收治的19例AS后凸畸形合并颈椎骨折患者临床资料,其中男18例,女1例;年龄28~73岁,平均38.6岁。17例伴脊髓功能障碍,美国脊髓损伤协会(ASIA)分级A级4例,B级5例,C级5例,D级3例。根据脊髓损伤程度及骨折移位情况选择复位固定或矫形固定手术治疗:14例脊髓损伤严重(ASIAA^C级)的患者采用复位固定手术治疗,其中6例单纯前路手术;2例单纯后路手术;5例前后路联合手术;另外1例先行Halo架固定,2个月后行前后路联合手术。5例ASIA分级D级或E级患者采用矫形固定手术治疗,先行手法矫正后凸并安装Halo架,然后行手术固定融合,其中1例单纯后路固定,4例采用前后路联合固定融合手术。采用视觉模拟评分(VAS)评价患者颈部疼痛缓解情况;观察神经功能改善情况、矫形固定效果、骨折愈合时间及术后并发症情况。结果1例患者因肺部感染及呼吸功能衰竭于术后11d死亡。余患者均获随访1~10年,平均27.3个月。全部患者颈部疼痛症状明显好转,术后3dVAS[(2.9±0.9)分]较术前[(8.2±1.0)分]明显降低(P<0.05)。12例神经功能较术前明显改善(P<0.05)。矫形固定患者术后颌眉角6°~18°,平均11.8°,恢复平视功能。骨折愈合时间为3~8个月,平均3.9个月。4例并发脑脊液漏,3例并发肺部感染,无切口感染及脊髓损伤加重等并发症。结论对于AS后凸畸形合并颈椎骨折患者,若不伴严重脊髓损伤,先行手法矫正后凸并安装Halo架,然后行固定融合手术,可有效矫正脊柱畸形,改善生活质量;若脊髓损伤严重,应避免Ⅰ期矫正畸形,尽可能复位骨折及长节段融合固定,有利于神经功能恢复。

Objective To investigate the different operation methods for kyphosis deformity of ankylosing spondylitis (AS) complicated with cervical vertebral fracture and their effects. Methods A retrospective case series study was conducted to analyze the clinical data of 19 patients with AS kyphosis complicated with cervical vertebral fracture admitted to Henan People's Hospital from April 2007 to October 2017. There were 18 males and one female, aged 28-73 years, with an average age of 38.6 years. Among the patients, 17 were complicated with spinal cord dysfunction. According to the American spinal injury association (ASIA) classification, there were four patients with grade A, five with grade B, five with grade C and three with grade D. According to the degree of nerve injury and the displacement of fracture, reduction and fixation or orthopedic fixation were selected: 14 patients with severe nerve injury (ASIA grades A-C) were treated with reduction and fixation, of which six were treated by simple anterior approach, two by simple posterior approach, five by combined anterior-posterior approach , and one by combined anterior-posterior approach 2 months after Halo fixation. Five patients with ASIA grade D or E were treated with orthopedic fixation. Firstly, kyphosis was corrected with manual technique and the Halo external fixator was installed, and then surgical fixation fusion was performed via simple posterior approach (one patient) or combined anterior-posterior approach (four patients). Visual analogue scale (VAS) was used to evaluate the relief of neck pain. The improvement of nerve function, the effect of orthopedic fixation, the fracture healing time and the postoperative complications were recorded. Results One patient died 11 days after operation due to pulmonary infection and respiratory failure. The remaining patients were followed up for 1-10 years, with an average of 27.3 months. The neck pain in all patients was relieved significantly, and the VAS score [(2.9±0.9)points] decreased significantly 3 days after operation compared with that before operation [(8.2±1.0)points](P<0.05). The nerve function of 12 patients improved significantly (P<0.05). The chin-brow vertical angle of the patients after orthopedic fixation was 6°-18°(mean, 11.8°), suggesting that the level vision function was restored. Fracture healing time ranged from 3 to 8 months, with an average of 3.9 months. There were 4 patients with cerebrospinal fluid leakage and three patients with pulmonary infection. No complications such as wound infection and aggravation of nerve injury occurred. Conclusions For AS kyphosis combined with cervical spine fracture, if without severe nerve injury, manual correction of kyphosis and installation of Halo frame followed by fixation and fusion can effectively correct spinal deformity and improve the quality of life. Patients with severe spinal cord injury should avoid stage I correction and receive reduction of fracture and long segment fusion fixation as far as possible to facilitate the recovery of nerve function.