后路寰枢关节轴向松解植骨内固定治疗可部分复位的难复型寰枢关节脱位

Posterior atlantoaxial joint axial release,bone grafting and internal fixation for irreducible atlantoaxial dislocation with partial reduction

目的探讨后路寰枢关节轴向松解植骨内固定与前路经口或经颈前咽后入路松解后路植骨内固定治疗可部分复位的难复型寰枢关节脱位(IAAD)的疗效.方法采用回顾性病例对照研究分析2014年1月-2017年10月河南省人民医院收治的42例IAAD患者临床资料,其中男17例,女25例;年龄12~72岁[(47.2±11.3)岁].全身麻醉下大重量颅骨牵引复位达到50%以上,18例行后路寰枢关节轴向松解、复位、植骨融合内固定(A组),24例行前路经口或经颈前咽后入路松解、复位、后路植骨融合内固定(B组).比较两组手术时间、术中出血量、术前及末次随访寰齿前间隙(ADI)、斜坡椎管角(CCA)、延髓颈髓角(CMA)、日本骨科学会(JOA)评分.比较两组末次随访JOA改善率及两组术后3个月和6个月寰枢关节融合率.观察并发症情况.结果患者均获随访12~40个月,平均24.6个月.A组手术时间为(138.1土25.6)min,B组为(242.8±38.1)min(P<0.05);A组术中出血量为(179.3±48.7)ml,B组为(218.2±42.6)ml(P<0.05).A组和B组的ADI、CCA、CMA、JOA评分术前及末次随访组内比较差异均有统计学意义(P<0.05),组间比较差异均无统计学意义(P>0.05).末次随访JOA评分:A组优8例,良8例,可2例,改善率为89%;B组优13例,良8例,可3例,改善率为87%(P>0.05).A组术后3个月寰枢关节融合率为83%,术后6个月融合率为100%;B组术后3个月融合率为79%,术后6个月融合率为100%(P>0.05).两组均无内固定失败或复位丢失.结论可部分复位的IAAD可以采用后路寰枢关节轴向松解植骨内固定治疗,其复位效果与前路经口或经颈前咽后入路松解后路植骨内固定相当,且手术时间短、术中出血量少,疗效满意.

Objective To investigate the efficacy of posterior atlantoaxial joint axial release,bone grafting and internal fixation for the treatment of irreducible atlantoaxial dislocation(IAAD)with partial reduction.Methods A retrospective case-control study was conducted to analyze the clinical data of 42 patients with IAAD admitted to Henan Provincial People's Hospital from January 2014 to October 2017.There were 17 males and 25 females,aged from 12 to 72 years[(47.2±11.3)years].After more than 50%reduction by high weight skull traction,18 patients underwent posterior atlantoaxial joint axial release,reduction,bone grafting and fusion with internal fixation(Group A),and 24 patients underwent anterior transoral or retropharyngeal release,reduction,posterior bone grafting and fusion with internal fixation(Group B).The operation time,intraoperative blood loss,preoperative and postoperative anterior atlantodental interval(ADI),clivus-canal angle(CCA),cervicomedullary angle(CMA),and Japanese Orthopaedic Association(JOA)scores between the two groups were compared.The improvement rate of JOA scores at the last follow-up of the two groups and the atlantoaxial joint fusion rate at 3 months and 6 months after surgery were calculated and compared.The complications were recorded.Results All patients were followed up for 12 to 40 months with an average of 24.6 months.Group A had significant decreases in operation time[(138.1±25.6)minutes∶(242.8±38.1)minutes]and intraoperative blood loss[(179.3±48.7)ml∶(218.2±42.6)ml]compared with Group B(P<0.05).There were significant differences between the ADI,CCA,CMA and JOA scores before operation and during the last follow-up in both Group A and Group B(P<0.05),but there was no significant difference between the two groups in terms of these scores(P>0.05).The JOA scores in Group A were excellent in eight patients,good in eight patients,and fair in two patients,with the improvement rate of 89%.The JOA scores in Group B were excellent in 13 patients,good in eight patients,and fair in three patients,with the improvement rate of 87%(P>0.05).In Group A,the atlanto-axial joint fusion rate was 83%at 3 months and 100%at 6 months postoperatively;in Group B,the fusion rate was 79%at 3 months and 100%at 6 months postoperatively(P>0.05).There was no failure of internal fixation or loss of reduction in both groups.Conclusion Posterior atlantoaxial joint axial release,bone grafting and fusion with internal fixation can be used to treat the partially reducible IAAD through a single approach.The reduction effect was comparable to that of anterior transoral or retropharyngeal release,bone grafting and fusion,with less operation time and intraoperative blood loss.