采用后路钉棒内固定联合选择性侧块关节松解治疗儿童寰枢关节脱位的临床效果

Clinical effects of posterior screw-rod fixation and selective lateral atlanto-axial joint release for pediatric atlanto-axial dislocation

目的 探讨采用后路钉棒内固定联合选择性寰枢侧块关节松解治疗儿童寰枢关节脱位(AAD)的临床疗效。方法 对2010年1月至2018年3月河南省人民医院脊柱外科收治的AAD患儿32例的临床资料进行回顾性分析。其中男4例,女28例,年龄(8.2±2.7)(3~12)岁。依据治疗方法将全部患儿分为松解组与未松解组。松解组包括患儿7例,术前颈椎过伸过屈位X线示寰枢关节不可复位,采用后路寰枢侧块关节松解复位、植骨融合和钉棒内固定治疗;未松解组包括患儿25例,术前颈椎过伸过屈位X线示寰枢关节可复位,采用后路寰枢关节复位、植骨融合和钉棒内固定治疗。对两组患儿的手术时间、术中出血量、术前及末次随访脊髓可用空间(SAC)、斜坡椎管角(CCA)和延髓颈髓角(CMA)进行比较;计算两组患儿的植骨融合时间及融合率并进行比较;观察两组患儿的并发症发生情况。结果 全部患儿获得随访(33.8±13.0)(24~100)个月。两组患儿的手术时间和术中出血量差异均无统计学意义(均P>0.05)。两组患儿末次随访SAC,CCA和CMA与术前差异均有统计学意义(均P<0.05),组间差异均无统计学意义(均P>0.05)。两组术后各出现髂后上棘取骨区切口愈合不良1例,其中未松解组患儿诊断为深部死腔形成,经再次手术清创缝合后切口愈合,松解组患儿诊断为浅表金黄色葡萄球菌感染,经静脉注射头孢唑啉和伤口换药治疗后切口愈合。未见脊髓损伤、椎动脉损伤和脑脊液漏病例。骨融合时间为(4.0±0.7)(3~6)个月,融合率100%。未见内固定失败或复位丢失病例。结论 采用后路钉棒内固定联合选择性侧块关节松解治疗儿童AAD可获得令人满意的疗效。

Objective To investigate the clinical effect of posterior screw-rod fixation and selective lateral atlanto-axial joint release for pediatric atlanto-axial dislocation(AAD). Methods A retrospective case-control study was conducted to analyze the clinical data of 32 children with AAD who were admitted to the Department of Spinal Surgery of Henan Provincial People’s Hospital from January 2010 to March 2018. There were 4 males and 28 females with an age of(8.2±2.7)(3~12)years. All patients were divided into 2 groups according to the treatment. The release group included 7 patients treated with posterior lateral atlanto-axial joint release, bone graft for fusion and screw-rod internal fixation after preoperative cervical hyperextension and hyperflexion X-ray showed that the atlanto-axial joint could not be reduced. The un-release group included 25 patients treated with posterior atlanto-axial joint reduction, bone graft fusion and screw-rod fixation after preoperative cervical hyperextension and hyperflexion X-ray showed that the atlanto-axial joint could be reduced. The operative time, intraoperative blood loss and postoperative space of available spinal cord(SAC), clivus canal angle(CCA) and cervico-medullary angle(CMA) were compared between the 2 groups. The fusion time and fusion rate were calculated and compared between the 2 groups. The complications were observed in all patients. Results All patients were followed up for(33.8±13.0)(24-100)months. There was no significant difference in operative time and blood loss between the 2 groups(all P<0.05). There were significant differences in SAC, CCA, CMA between pre-operation and post-operation in the 2 groups(all P<0.05). However, there was no significant difference in SAC, CCA, CMA at pre-operation and post-operation between the 2 groups(all P>0.05). Poor healing of incision in posterior superior iliac crest were occurred in 2 cases, of which one case in the release group diagnosed as deep cavity formation and healed after debridement and suture, and one case in un-release group diagnosed as superficial Staphylococcus aureus infection and healed after intravenous injection of cefazolin and wound dressing. No cases of spinal cord injury, vertebral artery injury and cerebrospinal fluid leakage were found. The fusion time was(4.0±0.7)(3-6)months and the fusion rate was 100%. No cases of failure of internal fixation or loss of reduction were found. Conclusion Application of posterior screw-rod fixation combined with selective lateral atlanto-axial joint release can obtain satisfactory effects in the treatment of atlanto-axial joint dislocation in children.