枕颈后路术中置入"in-out-in"枢椎椎弓根螺钉对椎动脉影响的观察研究

The effect of in-out-in axis pedicle screws on the vertebral artery in the posterior occipitocervical surgery

目的观察在寰枢椎脱位或不稳的枕颈后路手术中置入"in-out-in"枢椎椎弓根螺钉对椎动脉的影响。方法回顾性分析2015年1月至2021年2月河南省人民医院脊柱脊髓科在寰枢椎脱位或不稳的枕颈后路手术中置入"in-out-in"枢椎椎弓根螺钉内固定治疗的52例寰枢椎脱位或不稳的患者资料。男30例,女22例;年龄17~65岁,平均41.2岁;单侧椎动脉高跨26例,双侧高跨3例,C2,3融合致单侧枢椎椎弓根狭窄19例,双侧狭窄4例。术前及术后3 d行X线、CT血管造影(CTA)和MRI检查,记录患者的临床症状,利用CTA在C2,3横突孔处测量椎动脉直径,观察"in-out-in"螺钉对椎动脉形态的影响。术后6个月行X线和CT检查,观察植骨融合情况。结果所有患者手术均顺利完成,9例行前、后路联合手术,手术时间平均271.2 min(213~352 min),出血量平均471.5 mL(230~830 mL)。余43例行单纯后路手术,手术时间平均171.6 min(131~226 min);出血量平均395.9 mL(170~660 mL)。无脊髓血管损伤等并发症。术后3 d复查CTA,椎动脉在C2、C3横突孔层面的直径分别为(2.92±0.55)、(3.04±0.54)mm,与术前[(2.91±0.68)、(3.11±0.50)mm]相比,差异均无统计学意义(P>0.05);椎动脉在21例次中出现外下方移位。所有患者术后获7~24个月(平均11个月)随访,术后6个月影像学检查见植骨融合,未见内固定物断裂、移位。结论枕颈后路术中置入"in-out-in"枢椎椎弓根螺钉对椎动脉影响小,临床效果可靠。

Objective Toobserve the effect of insertion of in-out-inaxis pedicle screws on thevertebral artery in the posterior occipitocervical surgery foratlantoaxial subluxation orinstability.Methods The data of 52 patients with atlantoaxial dislocation or instability were analyzed who had been treated by internal fixation with in-out-in pedicle screws in the posterior occipitocervical surgery from January 2015 to February 2021 at Department of Spine and Spinal Cord Surgery,Henan Provincial People's Hospital.There were 30 males and 22 females,aged from 17 to 65 years(mean,41.2 years).There were 26 cases of unilateral vertebral artery high-riding,3 cases of bilateral high-riding,19 cases of unilateral narrow pedicle due to C2 and C3 fusion,and 4 cases of bilateral narrow pedicles.X-ray,CTA and MRI were performed before and 3 days after surgery.The patients'clinical symptoms were recorded.CTA was used to measure the diameter of the vertebral artery at the transverse foramina of C2 and C3 and to observe the effect of in-out-in screws on the morphology of the vertebral artery.X-ray and CT examinations were performed at 6months after surgery to observe thebone fusion.ResultssThe surgery went on uneventfully in all the patients.In the 9 cases undergoing anterior and posterior surgery,the operation time averaged 271.2 min(from 213 to 352 min)and the bleeding volume 471.5mL(from230to830mL).In the43casesundergoing posterior surgery,the operation time averaged 171.6min(from131to226min)and thebleedingvolume395.9mL(from170 to660mL).Therewas no such complication as spinal or vascular injury.The CTA reexamination 3 days after surgery showed that the diameter of the vertebral artery was(2.92±0.55)mm and(3.04±0.54)mm,respectively at the cervical 2 and 3 transverse foramina,showing no significant change compared with the preoperative values[(2.91±0.68)mm and(3.11±0.50)mm)(P>0.05)and that thevertebral arterywas displaced externallyand inferiorly in 21 cases.Follow-ups for all patients ranged from 7 to 24 months(mean,11 months).At 6 months after surgery,bone fusion was observed by imaging and no breakage or displacement of the internal fixation was ob-served.Conclusion The in-out-in pedicle screws in the posterior occipitocervical surgery may have little impact on the vertebral artery,leading to reliable clinical outcomes.