儿童寰枢椎脱位的临床特征及手术疗效分析

Clinical features and surgical results of atlantoaxial dislocation in children

目的观察并分析后路复位内固定治疗儿童寰枢椎脱位的临床特征及手术疗效。方法以2010年9月至2017年12月陆军军医大学第一附属医院神经外科收治的18例明确诊断为寰枢椎脱位(2例齿状突骨折)儿童患者作为研究对象,其中男9例、女9例,年龄6~17岁,平均(13.17±3.48)岁;采取经后路复位螺钉-钛棒(板)系统内固定技术,于手术前后应用颅颈交界区CT薄层扫描及上颈椎CT三维重建测量寰齿间距(Atlantodens interval,ADI)、硬腭枕骨大孔线(Chamberlain's line,CL)和斜坡枕骨大孔线(McRae's line,ML)上距离,通过延髓脊髓角(Cervicomedullary angle,CMA)评价高位脊髓受压程度,采用日本骨科协会(Japanese Orthopedic Association Scores,JOA)评分标准评估颈脊髓神经功能改善程度;采用神经电生理学方法监测神经传导功能,系统分析经后路复位内固定术治疗儿童寰枢椎脱位术前、术后神经功能的改善情况及脱位复位、植骨融合的可行性。结果15例患儿随访18~100个月,平均(45.8±14.49)个月,失访3例。患儿寰椎侧块及枢椎椎弓根均能容纳3.5mm钛钉,术中无椎动脉损伤、骨质裂开等情况,术后恢复较为理想,除个别出现颈椎活动受限外,无其他并发症。术前ADI(3.86±2.71)mm,CL(10.05±6.55)mm,ML(2.17±4.48)mm,CMA(122.84±18.02)°,JOA(11.5±3.26);术后ADI(1.96±2.041)mm,CL(6.42±4.85)mm,ML(0.56±3.78)mm,CMA(128.29±17.8)°,JOA(15.44±1.46);上述指标差异均有统计学意义(P<0.05)。寰枢关节脱位13例完全复位,5例有不同程度复位;神经电生理检查结果均有明显改善,末次随访影像学检查示植骨区获得骨性融合,无内固定松动、断裂等情况出现。结论后路复位内固定治疗儿童寰枢椎脱位的疗效明确,远期预后较好。

Objective To explore the clinical features and surgical efficacies of posterior reduction and internal fixation for atlantoaxial dislocation in children. Methods Between September 2010 and December 2017,18 children with a definite diagnosis of atlantoaxial dislocation (2 cases of odontoid fracture) were admitted successively.There were 9 boys and 9 girls with a mean age of 13.17 (6-17) years.Posterior reduction was applied with screw-titanium rod (plate) internal fixation.Computed tomography (CT) thin layer scanning and three-dimensional reconstruction measurements were performed pre-and postoperatively.Atlantodens interval (ADI),Chamberlain's line (CL),McRae's line (ML),cervicomedullary angle (CMA) were measured for evaluating the degree of spine cord compression.And Japanese Orthopedic Association Scores (JOA) scores were used for evaluating function curing and nerve electrophysiology for monitoring nerve conduction. Results Fifteen children were followed up for an average period of 45.83 (18-100) months.Three cases were lost to follow-ups.Lateral mass of atlas and axial pedicle of children may accommodate 3.5mm titanium screws.No vertebral arterial injury or bone fracture occurred intraoperatively.Postoperative recovery was decent and there was only limited activity of cervical spine.And with preoperative ADI (3.86±2.71) mm,CL (10.05±6.55) mm),ML (2.17±4.48) mm,CMA (122.84±18.02)°,JOA (11.5±3.26),postoperative ADI (1.96± 2.041) mm,CL (6.42±4.85) mm,ML (0.56±3.78) mm,CMA (128.29±17.8)°,JOA (15.44±1.46).The postoperative improvement was significantly better than that before surgery ( P <0.05). Conclusion Posterior reduction and internal fixation are efficacious for atlantoaxial dislocation in children and the long-term outcome is excellent.