经钩椎关节及前椎板间隙入路松解交锁关节突联合颈椎前路植骨融合内固定治疗交锁性下颈椎骨折脱位

Treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of interlocking facet through the Luschka joint and anterior lamina space

目的探讨经钩椎关节及前椎板间隙入路松解交锁关节突联合颈椎前路植骨融合内固定治疗交锁性下颈椎骨折脱位的临床疗效。方法回顾分析2013年1月—2015年6月收治的12例交锁性下颈椎骨折脱位患者临床资料。男7例,女5例;年龄25~59岁,平均38.4岁。病程9.6 h~100 d,平均7.3 d。单侧交锁8例,双侧交锁4例;陈旧性4例,新鲜8例。损伤节段:C_(3、4)2例,C_(4、5)5例,C_(5、6)3例,C_(6、7)2例。滑脱程度Meyerding分度为Ⅰ度9例,Ⅱ度3例。神经功能按美国脊髓损伤协会(ASIA)分级:C级2例,D级6例,E级4例。采用经钩椎关节及前椎板间隙入路松解交锁关节突联合颈椎前路植骨融合内固定治疗。手术前后采用ASIA分级评价神经功能,疼痛视觉模拟评分(VAS)、改良日本骨科协会评分、颈椎功能障碍指数(NDI)评分评价临床疗效,摄X线片测量融合节段前凸Cobb角;术后6个月评价椎间植骨融合情况。结果手术时间平均78.30 min,术中出血量平均167.30 m L,术后引流量平均58.12 m L。术中、术后未予以输血处理。术中无大血管、食管、气管意外损伤;术后无喉头水肿、吞咽困难、声音嘶哑、脑脊液漏发生;无脊髓损伤、神经根损伤加重发生;切口Ⅰ期愈合,无感染发生。12例均获随访,随访时间15~20个月,平均16.5个月。术后患者神经损伤症状及功能均较术前明显改善,术后6个月复查颈椎X线片示,Cage或植骨块无移位、断裂,螺钉无松动、脱离,椎间植骨融合率达100%。末次随访时ASIA分级、融合节段前凸Cobb角、颈痛VAS评分、改良JOA评分及NDI评分均较术前明显改善(P<0.05)。结论经钩椎关节及前椎板间隙入路松解交锁关节突联合颈椎前路植骨融合内固定治疗交锁性下颈椎骨折脱位临床疗效明确,使损伤节段获得满意复位、即刻稳定和重建、充分减压,可有效防止脊髓二次损伤。

Objective To investigate the effectiveness of treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of the interlocking facet through the Luschka joint and anterior lamina space.Methods Twelve patients with lower cervical interlocking fracture and dislocation were analyzed retrospectively between January 2013 and June 2015.There were 7 males and 5 females,aged 25-59 years with an average age of 38.4 years.The disease duration was 9.6 hours to 100 days with an average of 7.3 days.There were 8 cases of unilateral locking and 4 cases of bilateral locking;4 cases of old injury and 8 cases of fresh injury.The injured segments were 2 cases of C3,4,5 cases of C4,5,3 cases of C5,6,and 2 cases of C6,7.According to Meyerding classification,there were 9 cases of gradeⅠand 3 cases of gradeⅡ.According to the functional classification of American Spinal Injury Association(ASIA),there were 2 cases of grade C,6 cases of grade D,and 4 cases of grade E.The interlocking facet was released through the Luschka joint and anterior lamina space,and the anterior cervical fusion and internal fixation were used to treat the fracture and dislocation of the lower cervical spine.The recovery of spinal cord function was judged by the functional classification of ASIA;visual analogue scale(VAS)score,neck disability index(NDI)score,modified Japanese Orthopaedic Association(m-JOA)score were used to evaluate the clinical efficacy;the Cobb angle of fusion segment were observed by X-ray film.The intervertebral bone graft fusion was evaluated at 6 months after operation.Results The average operation time was 78.30 minutes,the average intraoperative blood loss was 167.30 mL,and the average postoperative drainage volume was 58.12 mL.No blood transfusion was given during or after operation.During the operation,there was no accidental injury of large blood vessels,esophagus,and trachea;no laryngo edema,dysphagia,hoarseness,and cerebrospinal fluid leakage occurred after operation;no spinal cord injury or nerve root injury aggravated;the incision healed by first intention,and no infection occurred.All 12 cases were followed up 15-20 months,with an average of 16.5 months.The symptoms and function of the nerve injury were significantly improved when compared with that before operation.Re-examination of the cervical spine X-ray film at 6 months after operation showed that the Cage or bone graft was not displaced or broken,the screw was not loosened or detached,and the intervertebral graft fusion rate was up to 100%.At last follow-up,the ASIA grade,Cobb angle of fusion segment,neck pain VAS score,m-JOA score,and NDI score were significantly improved when compared with preoperative one(P<0.05).Conclusion The effectiveness of treatment of locked lower cervical fracture and dislocation with anterior cervical fusion and internal fixation combined with the release of the interlocking facet through the Luschka joint and anterior lamina space is clear,which not only can make the injured segment get satisfactory reduction,immediate stability and reconstruction,and full decompression,but also can effectively prevent the secondary injury of spinal cord.