后路寰椎单轴与多轴螺钉内固定植骨融合术治疗Gehweiler Ⅲb型寰椎骨折的疗效比较

Efficacy comparison of posterior atlas uniaxial and polyaxial screw instrumentation and fusion with bone graft for Gehweiler type IIIb atlas fracture

目的比较后路寰椎单轴与多轴螺钉内固定植骨融合术治疗GehweilerⅢb型寰椎骨折的疗效。方法采用回顾性队列研究分析2015年1月至2020年10月河南省人民医院收治的36例GehweilerⅢb型寰椎骨折患者的临床资料,其中男29例,女7例;年龄23~82岁[(48.8±15.5)岁]。患者均采用后路寰枢椎钉棒内固定植骨融合术治疗,其中14例行寰椎单轴螺钉内固定(单轴螺钉组),22例行寰椎多轴螺钉内固定(多轴螺钉组)。比较两组手术时间、术中出血量。比较术后3,6个月两组寰椎骨折愈合率及寰枢椎后弓植骨融合率。比较术前、术后1,3,6个月及末次随访时两组寰齿前间距(ADI)、颅底齿突间距(BDI)、侧块移位距离(LMD),评价骨折块复位情况;比较两组视觉模拟评分(VAS)和颈椎功能障碍指数(NDI),评价颈部疼痛和功能恢复情况。观察并发症情况。结果患者均获随访12~44个月[(27.2±9.9)个月]。两组手术时间、术中出血量差异无统计学意义(P均>0.05)。术后3个月单轴螺钉组寰椎骨折愈合率为85.7%(12/14),寰枢椎后弓植骨融合率为78.6%(11/14);多轴螺钉组分别为72.7%(16/22)、77.3%(17/22)(P均>0.05)。术后6个月两组均获寰椎骨折愈合和寰枢椎后弓植骨融合。术前及术后各时间点两组ADI差异无统计学意义(P均>0.05)。术前两组BDI差异无统计学意义(P>0.05)。术后1,3,6个月及末次随访时单轴螺钉组BDI为(5.9±1.3)mm、(5.8±1.3)mm、(5.9±1.2)mm、(5.8±1.2)mm,多轴螺钉组分别为(3.1±0.6)mm、(3.1±0.6)mm、(3.1±0.6)mm、(3.1±0.6)mm。术后1,3,6个月及末次随访时单轴螺钉组BDI高于多轴螺钉组(P均<0.01)。术前两组LMD差异无统计学意义(P>0.05)。术后1,3,6个月及末次随访时单轴螺钉组LMD为(1.6±0.8)mm、(1.5±0.8)mm、(1.5±0.7)mm、(1.5±0.9)mm,多轴螺钉组分别为(4.8±1.6)mm、(4.6±1.6)mm、(4.9±1.6)mm、(4.9±1.6)mm。术后1,3,6个月及末次随访时单轴螺钉组LMD低于多轴螺钉组(P均<0.01)。术前两组VAS差异无统计学意义(P>0.05)。术后1,3,6个月及末次随访时单轴螺钉组VAS为3.0(3.0,4.0)分、2.0(1.0,2.0)分、1.0(0.8,2.0)分、1.0(0.0,1.3)分,多轴螺钉组分别为3.5(3.0,4.0)分、2.0(2.0,3.0)分、2.0(1.0,2.0)分、2.0(1.0,3.0)分。术后6个月及末次随访时单轴螺钉组VAS低于多轴螺钉组(P均<0.01)。术前两组NDI差异无统计学意义(P>0.05)。术后1,3,6个月及末次随访时单轴螺钉组NDI为34.9±6.3、23.4±6.2、13.9±2.7、9.4±2.8,多轴螺钉组分别为33.2±6.1、24.4±6.3、18.1±4.1、12.7±3.2。术后6个月及末次随访时单轴螺钉组NDI低于多轴螺钉组(P均<0.01)。单轴螺钉组并发症发生率为21.4%(3/14),多轴螺钉组为22.7%(5/22)(P>0.05)。结论后路寰枢单轴螺钉与多轴螺钉内固定植骨融合术治疗GehweilerⅢb型寰椎骨折均可获得寰椎骨折愈合及寰枢椎后弓间植骨融合,但前者具有对寰椎骨折移位及侧块关节分离复位更好、术后颈部疼痛缓解和功能改善更佳的优势。

Objective To compare the efficacy of posterior atlas uniaxial and polyaxial screw instrumentation and fusion with bone graft for Gehweiler type IIIb atlas fracture.Methods A retrospective cohort study was performed to analyze the clinical data of 36 patients with Gehweiler type IIIb atlas fracture admitted to Henan Provincial People′s Hospital from January 2015 to October 2020.There were 29 males and 7 females,with age range of 23-82 years[(48.8±15.5)years].All patients were treated with posterior atlas screw-rod internal fixation and fusion with bone graft,of which 14 received atlas uniaxial screw internal fixation(uniaxial screw group)and 22 received atlas polyaxial screw internal fixation(polyaxial screw group).The operation time and intraoperative blood loss were compared between the two groups.The atlas fracture union rate and atlantoaxial posterior arch bone fusion rate were compared between the two groups at 3 months and 6 months after operation.The anterior atlantodental interval(ADI),basion-dens interval(BDI)and lateral mass displacement(LMD)were compared between the two groups to evaluate the reduction of fracture fragments before operation,at 1,3,6 months after operation and at the last follow-up.At the same time,the visual analogue scale(VAS)and neck dysfunction index(NDI)were compared between the two groups to evaluate neck pain and functional recovery.The postoperative complications were observed.Results All patients were followed up for 12-44 months[(27.2±9.9)months].There was no significant difference in operation time or intraoperative blood loss between the two groups(all P>0.05).The atlas fracture union rate and atlantoaxial posterior arch bone fusion rate were 85.7%(12/14)and 78.6%(11/14)in uniaxial screw group at 3 months after operation,insignificantly different from those in polyaxial screw group[72.7%(16/22)and 77.3%(17/22)](all P>0.05).All patients in the two groups achieved bone union and fusion at 6 months after operation.There was no significant difference in ADI between the two groups before and after operation(all P>0.05).The BDI in the two groups did not differ significantly before operation(P>0.05),but a significantly higher value was found in uniaxial screw group at 1,3,and 6 months after operation and at the last follow-up[(5.9±1.3)mm,(5.8±1.3)mm,(5.9±1.2)mm and(5.8±1.2)mm]than in polyaxial screw group[(3.1±0.6)mm,(3.1±0.6)mm,(3.1±0.6)mm and(3.1±0.6)mm](all P<0.01).The two groups did not differ significantly before operation(P>0.05),but LMD at 1,3,and 6 months after operation and at the last follow-up was(1.6±0.8)mm,(1.5±0.8)mm,(1.5±0.7)mm and(1.5±0.9)mm in uniaxial screw group,significantly lower than that in polyaxial screw group[(4.8±1.6)mm,(4.6±1.6)mm,(4.9±1.6)mm and(4.9±1.6)mm](all P<0.01).There was no significant difference in VAS between the two groups before operation(P>0.05).The VAS at 1,3,and 6 months after operation and at the last follow-up was 3.0(3.0,4.0)points,2.0(1.0,2.0)points,1.0(0.8,2.0)points and 1.0(0.0,1.3)points in uniaxial screw group and was 3.5(3.0,4.0)points,2.0(2.0,3.0)points,2.0(1.0,2.0)points and 2.0(1.0,3.0)points in polyaxial screw group.In comparison,the VAS scored much lower in uniaxial screw group than in polyaxial screw group at 6 months after operation and at the last follow-up(all P<0.01).There was no significant difference in NDI between the two groups before operation(P>0.05).The NDI at 1,3,and 6 months after operation and at the last follow-up was 34.9±6.3,23.4±6.2,13.9±2.7 and 9.4±2.8 in uniaxial screw group and was 33.2±6.1,24.4±6.3,18.1±4.1 and 12.7±3.2 in polyaxial screw group,showing a significantly lower NDI in uniaxial screw group than in polyaxial screw group at 6 months after operation and at the last follow-up(all P<0.01).The complication rate was 21.4%(3/14)in uniaxial screw group when compared to 22.7%(5/22)in polyaxial screw group(P>0.05).Conclusion For Gehweiler type IIIb atlas fracture,both techniques can attain atlas fracture union and atlantoaxial posterior arch bone fusion,but the posterior atlas uniaxial screw instrumentation and fusion is superior in reduction of atlas fracture displacement and lateral mass separation,neck pain relief and functional improvement.