两种不同手术方式治疗难复性寰枢椎脱位并颅底凹陷效果对比研究

Comparison of efficacy of two different surgical approaches for treatment of refractory atlantoaxial subluxation with basilar invagination

目的评价经颈前咽前路松解结合枕颈融合内固定术与单纯后路枕颈融合内固定术治疗难复性寰枢椎脱位并颅底凹陷的临床效果。方法回顾性分析2015-01—2019-06郑州大学第一附属医院收治的32例难复性寰枢椎脱位并颅底凹陷患者的临床资料,按手术方式分为经颈前咽前路松解结合枕颈融合内固定术组(前后路联合组)和单纯后路枕颈融合内固定术组(单纯后路组),各16例。比较2组患者的基线资料、术中情况及术后临床指标。记录手术前后钱氏线(CL)、枕大孔线(ML)、寰齿间距(ADI)、斜坡椎管角(CCA)、脊髓活动空间(SAC)影像学参数。统计手术前后视觉模拟评分(VAS)、日本骨科协会评分(JOA)。结果2组患者的基线资料差异无统计学意义(P>0.05)。前后路联合组的手术时间长于单纯后路组,术中出血量多于单纯后路组,并发症发生率高于单纯后路组,差异均有统计学意义(P<0.05)。2组患者术后枕颈关节植骨均获良好融合,植骨融合时间差异无统计学意义(P>0.05)。末次随访,2组患者的ADI、CL、ML、CCA、SAC均较术前显著改善,其中前后路联合组的CL、ML、CCA、SAC改善情况优于单纯后路组,差异有统计学意义(P<0.05);2组患者的ADI差异无统计学意义(P<0.05)。末次随访2组患者的VAS、JOA评分均较术前明显改善,差异均有统计学意义(P<0.05);但组间差异无统计学意义(P>0.05)。结论单纯后路枕颈融合内固定术治疗难复性寰枢椎脱位并颅底凹陷,虽然影像学参数改善效果不如经颈前咽松解结合枕颈融合内固定术,但患者的体征及症状改善效果与之相仿,并能缩短手术时间、减少术中出血量和手术并发症,尤其适用于手术耐受性差的老年患者。

Objective To evaluate the clinical efficacy of transcervical anterior pharyngeal release combined with occipitocervical fusion internal fixation versus simple posterior occipitocervical fusion internal fixation for refractory atlantoaxial dislocation with basilar invagination.Methods The clinical data of 32 patients with refractory atlantoaxial dislocation with basilar invagination admitted to the First Affiliated Hospital of Zhengzhou University from January 2015 to June 2019 were retrospectively analyzed and were divided into combined anterior-posterior and simple posterior internal fixation groups by randomized grouping;the operative time,intraoperative bleeding and perioperative complications were recorded.The postoperative clinical outcomes were evaluated by comparing the pre-and postoperative visual analog scale(VAS),the Japanese Orthopaedic Association score(JOA),and the imaging Chamberlain line(CL)、McRae line,(ML)、atlantodens interval(ADI)、clivus-canal angle(CCA)、space available for the cord(SAC);the postoperative occipitocervical joint fusion rate was evaluated by CT.Results The surgical procedure was smooth in both groups,and no spinal cord or vertebral artery injury occurred intraoperatively,and postoperative atlantoaxial repositioning and improvement of neurological symptoms were satisfactory.The operation time of the combined anterior-posterior group was longer than that of the simple posterior group,and the intraoperative bleeding was more than that of the simple posterior group,and the difference was statistically significant(P<0.05).Postoperatively,the patients in the two groups obtained good fusion of the occipitocervical joint implants on review CT,and there was no statistically significant difference in the fusion time of the implants between the groups(P>0.05).The incidence of perioperative complications in the posterior internal fixation alone group was higher than that of the control group,and the difference was statistically significant(P<0.05),and there was no statistically significant difference in the preoperative ADI,CL,ML,CCA,and SAC between the 2 groups(P>0.05).At the final follow-up,ADI,CL,ML,CCA,and SAC were significantly improved in both groups compared with those before surgery,but the improvement of CL,ML,CCA,and SAC in the combined anterior-posterior group was better than that of the posterior group alone,and the difference was statistically significant(P<0.05).The differences in preoperative VAS and JOA between the two groups were not statistically significant.At the final follow-up,VAS and JOA in both groups improved significantly compared with those before surgery,and the differences were statistically significant(P<0.05),but the differences were not statistically significant when compared between groups(P>0.05).Conclusion Although posterior occipitocervical fusion and internal fixation for refractory atlantoaxial dislocation with basilar invagination depression does not improve the postoperative imaging parameters as much as transcervical anterior pharyngeal release,it can lead to satisfactory repositioning of the refractory atlantoaxial dislocation with basilar invagination depression and similar improvement in clinical symptoms and signs,and it can also reduce the operative time,intraoperative bleeding and surgical complications.It is especially suitable for elderly patients with poor surgical tolerance.