前后联合入路与单纯后路手术治疗难复性寰枢椎脱位型颅底凹陷症的疗效比较

Comparison of efficacy between anterior and posterior combined approach and posterior reduction alone in the treatment of basilar invagination with irreducible atlantoaxial dislocation

目的比较前后联合入路与单纯后路松解复位内固定治疗难复性寰枢椎脱位型颅底凹陷症的临床疗效。方法回顾性分析2000年7月至2017年12月接受手术治疗的47例难复性寰枢椎脱位型颅底凹陷症患者的病历资料。按手术方式分为前后联合入路组23例和单纯后路组24例。主要观察指标包括:Chamberlain线(Chamberlain line,CL)、Wackenheim线(Wackenheim line,WL)、McGae线(McGae line,ML)、寰齿间距(atlantodens interval,ADI)、延髓脊髓角(cervicomedullary angle,CMA)、斜坡枢椎角(clivus-canal angle,CCA)、日本骨科协会(Japanese Orthopedic Association,JOA)评分和Ranawat分级。结果前后联合入路组随访时间为(48.7±31.2)个月,单纯后路组为(44.4±33.4)个月。前后联合入路组JOA评分术前为(8.20±2.75)分,末次随访时为(14.98±1.05)分,改善率为77.35%±11.35%;单纯后路组JOA评分术前为(8.06±2.52)分,末次随访时为(14.71±0.62)分,改善率为74.38%±10.52%;两组末次随访时JOA评分(t=0.877,P=0.262)及改善率(t=1.478,P=0.206)的差异均无统计学意义。前后联合入路组术前CL、WL、ML、ADI、CMA和CCA分别为(13.12±5.76)mm、(6.94±3.55)mm、(7.04±4.57)mm、(9.75±2.06)mm、110.85°±13.6°、95.32°±18.3°,末次随访时分别为(1.68±2.53)mm、(-2.76±2.26)mm、(-1.52±2.43)mm、(1.12±1.55)mm、149.26°±12.6°、141.42°±13.7°,与术前比较差异均有统计学意义。单纯后路组术前CL、WL、ML、ADI、CMA和CCA分别为(12.52±5.17)mm、(6.59±3.04)mm、(6.94±4.32)mm、(9.88±1.93)mm、115.35°±12.4°、97.25°±16.4°,末次随访时分别为(2.00±3.67)mm、(-3.06±1.85)mm、(-1.76±2.88)mm、(1.17±1.18)mm、146.76°±11.4°、137.56°±10.4°,与术前比较差异均有统计学意义。术前及末次随访时两组间比较差异均无统计学意义。前后联合入路组植骨融合时间为(9.2±4.9)个月,单纯后路组为(9.5±4.7)个月,差异无统计学意义(t=0.547,P=0.382)。两组共8例发生术后并发症,前后联合入路组6例(21.7%),单纯后路组2例(8.3%),单纯后路组并发症发生率明显少于前后联合入路组。结论一期后路松解复位植骨内固定术治疗颅底凹陷症合并寰枢椎脱位可获得与前后联合入路基本相同的临床疗效,但后路手术的并发症发生率明显低于前后联合入路。

Objective To compare the clinical efficacy and complications of combined anterior and posterior approach and simple posterior release reduction and internal fixation in the treatment of basilar invagination(BI)with irreducible atlantoaxial dislocation(IAAD).Methods The medical records of 47 patients with basilar invaginationdepression complicated with refractory atlantoaxial dislocation who received surgical treatment from July 2000 to December 2017 were retrospectively analyzed.The patients were divided into anterior and posterior combined approach group(23 cases)and posterior approach group(24 cases).Key observation indicators include:Chamberlain line(CL),Wackenheim line(WL),McGae line(ML),atlantodens interval(ADI),cervicomedullary angle(CMA),clivus-canal angle(CCA),JOA scores(Japanese Orthopedic Association,JOA)and Ranawat grade.Results The average follow-up was 48.7±31.2 months in the A-P group and 44.4±33.4 months in the P group.The average preoperative JOA score of the A-P group was 8.20±2.75 points and 14.98±1.05 points at the last follow-up,and the improvement rate was 77.35%±11.35%.The average preoperative JOA score of the P group was 8.06±2.52 points,and the last follow-up was 14.71±0.62 points,and the improvement rate was 74.38%±10.52%.There was no statistically significant difference between the two groups in JOA score(t=0.877,P=0.262)and improvement rate(t=1.478,P=0.206)at the last follow-up.The preoperative CL,WL,ML,ADI,CMA and CCA angles of the A-P group were 13.12±5.76 mm,6.94±3.55 mm,7.04±4.57 mm,9.75±2.06 mm,110.85°±13.6°,95.32°±18.3°,respectively.The last follow-up was 1.68±2.53 mm,-2.76±2.26 mm,-1.52±2.43 mm,1.12±1.55 mm,149.26°±12.6°,and 141.42°±13.7°,respectively,with statistically significant differences from preoperative.The preoperative CL,WL,ML,ADI,CMA and CCA angles of P group were 12.52±5.17 mm,6.59±3.04 mm,6.94±4.32 mm,9.88±1.93 mm,115.35°±12.4°,97.25°±16.4°,respectively.The results of the last follow-up were 2.00±3.67 mm,-3.06±1.85 mm,-1.76±2.88 mm,1.17±1.18 mm,146.76°±11.4°and 137.56°±10.4°,respectively,which were statistically significant compared with the preoperative results.There was no significant difference between the two groups in preoperative and final follow-up.The average bone graft fusion time of the A-P group was 9.2±4.9 months,and the average bone graft fusion time of the P group was 9.5±4.7 months.There was no statistically significant difference in the bone graft fusion time between the two groups(t=0.547,P=0.382).Postoperative complications occurred in a total of 8 cases in the two groups,including 6 cases(21.7%)in the combined approach group and 2 cases(8.3%)in the posterior approach group.The incidence of complications in the posterior approach group was significantly lower than that in the combined approach group.Conclusion The clinical and imaging results of the treatment of basilar depression with atlantoaxial dislocation by one-stage posterior release reduction and internal fixation are basically the same as those obtained by the anterior and posterior combined approach,but the complication rate of the posterior approach is significantly lower than that of the anterior and posterior combined approach.