枢椎峡部螺钉在椎动脉高跨患者枢椎螺钉内固定术中的应用

Application of pars interarticularis screw in internal fixation of axial screw in patients with high riding vertebral artery

目的探讨在椎动脉高跨患者枢椎螺钉内固定术中置入枢椎峡部螺钉的准确性和安全性。方法回顾性病例对照研究。纳入2013年1月—2020年6月宁波市第六医院脊柱外科合并椎动脉高跨的上颈椎病变患者74例,其中男51例、女23例,年龄29~71(53.2±7.6)岁。患者均接受枢椎螺钉内固定术治疗,根据枢椎螺钉置入方式的不同分为峡部螺钉组(38例)和椎板螺钉组(36例)。对比2组患者基线资料,以及置钉时间、螺钉长度、手术时间、术中X线透视次数、术中出血量、住院时间等围术期指标,术中、术后并发症发生情况;基于术后颈椎CT扫描及三维重建的Upendra螺钉分级标准评估枢椎峡部和椎板螺钉置入准确率;分别于术前、术后3个月和末次随访时,采用视觉模拟评分法(VAS)评价患者颈部疼痛程度,采用改良日本骨科协会(mJOA)评分评价患者神经功能;末次随访时,采用Odom评分标准评估临床疗效。结果2组患者年龄、性别、体质量指数(BMI)、疾病类型等基线资料比较,以及置钉时间、术中出血量、术中X线透视次数、住院时间等围术期观察指标比较,差异均无统计学意义(P值均>0.05)。峡部螺钉组手术时间为(125.75±13.64)min,短于椎板螺钉组的(145.53±20.25)min,差异有统计学意义(t=-4.90,P<0.001)。峡部螺钉组螺钉长度为(16.24±2.35)mm,短于椎板螺钉组的(20.67±2.62)mm,差异有统计学意义(t=7.67,P<0.001)。峡部螺钉组术中发生螺钉穿透椎动脉孔后壁2例,术后无螺钉松动、脱出等并发症发生;椎板螺钉组术中发生螺钉穿破椎板皮质4例,术后并发椎板螺钉松动脱出2例、切口浅表感染2例:峡部螺钉组并发症发生率为5.26%(2/38),低于椎板螺钉组的22.22%(8/36),差异有统计学意义(χ^(2)=4.55,P=0.033)。2组74例手术患者均获得随访,随访时间10~96个月,平均30.8个月。2组患者术后3个月及末次随访时VAS评分和mJOA评分均较术前明显改善,差异均有统计学意义(P值均<0.05);但各时间点VAS评分及mJOA评分组间比较,差异均无统计学意义(P值均>0.05)。峡部螺钉组和椎板组置入螺钉数分别为55枚和50枚,置钉准确率分别为96.4%(53/55)、94.0%(47/50),组间比较差异无统计学意义(χ^(2)=0.56,P=0.906)。末次随访时,按照Odom评分标准评价,峡部螺钉组临床疗效优65.8%(25/38)、良21.1%(8/38)、可13.2%(5/38),椎板螺钉组优63.9%(23/36)、良19.4%(7/36)、可16.7%(6/36),组间比较差异无统计学意义(Z=0.25,P=0.803)。结论在椎动脉高跨患者中,峡部螺钉和椎板螺钉可达到相似的临床效果,但在置钉准确性方面,峡部螺钉更占优势,同时它能显著缩短手术时间,降低手术并发症。

Objective This study investigates the accuracy and safety of pars interarticularis screw placement of axial screw internal fixation in patients with high riding vertebral artery.Methods A retrospective case control study was performed on 74 patients with high riding vertebral artery who received axial screw internal fixation in the Spinal Surgery Department of The Ningbo No.6 Hospital from January 2013 to June 2020.The patients were composed of 51 males and 23 females aged 29-71(53.2±7.6)years.The patients were divided into the isthmus screw group(n=38)and laminar screw group(n=36),and the baseline data of the two groups were compared and observed.Screw placement time,operation time,intraoperative X-ray frequency,intraoperative blood loss,incidence of complications,and hospital stay were observed and compared between the two groups.The visual analog scale(VAS)was used in evaluating the degree of neck pain before operation,3 months post-operation,and at the last follow-up,and the modified Japanese Orthopaedic Association(mJOA)score was used in evaluating neurological function.At the last follow-up,the Odom criteria were used in evaluating clinical efficacy.The accuracy of axial pars and lamina screw placement was evaluated according to the screw grading criteria proposed by Upendra et al.These criteria were based on postoperative cervical CT scan and 3D reconstruction.Results No significant differences in age,gender,body mass index,disease type,and other general information was found between the two groups(all P values>0.05).Likewise,no significant differences in screw placement time,intraoperative X-ray frequency,intraoperative blood loss,and hospital stay were found(all P values>0.05).The operation time of the isthmus screw group(125.75 min±13.64 min)was shorter than that in the lamina screw group(145.53 min±20.25 min),and the differences were statistically significant(t=−4.90,P<0.001).The screw length in the isthmus screw group was(16.24±2.35)mm,which was shorter than that in the lamina screw group(20.67±2.62)mm,and the difference was statistically significant(t=−7.67,P<0.001).Two patients in the isthmus screw group penetrated the posterior wall of the vertebral artery foramen during operation,and four cases in the lamina screw group penetrated the lamina cortex,but none of them had angioneurotic symptoms.In the laminar screw group,two patients with atlantoaxial dislocation had laminar screw loosening and prolapse during follow-up,and two patients had superficial incision infection after occipitocervical fusion.The incidence of complications in the isthmus screw group was 5.26%(2/38),lower than that in the lamina screw group(22.22%,8/36),and the difference was statistically significant(χ^(2)=4.55,P=0.033).All patients in both groups were followed up for 10-96 months,with an average of 30.8 months.The VAS and mJOA scores in both groups significantly improved 3 months after operation and at the last follow-up(all P values<0.05),and no statistical difference was found between the groups(all P values>0.05).A total of 55 screws were inserted in the isthmus screw group,and 50 screws were inserted in the lamina group.The accuracy of screw placement(Ⅰ+Ⅱa+Ⅱb)was 96.4%(53/55)and 94.0%(47/50),respectively,and no significant difference was found between the groups(χ^(2)=0.56,P=0.906).In patients in the isthmus screw group,no complications,such as screw loosening and prolapse,occurred during follow-up.The clinical efficacy was evaluated according to the Odom score at the last follow-up,and 65.8%(25/38),21.1%(8/38),and 13.2%(5/38)were superior,good,and acceptable in the isthmus screw group,respectively,and 63.9%(23/36),19.4%(7/36),and 16.7%(6/36)were superior,good,and acceptable in the lamina screw group,respectively.No significant difference was found between the groups(Z=0.25,P=0.803).Conclusion In patients with HRVA,isthmus and lamina screws provide similar clinical results,but in terms of the accuracy of screw placement,the isthmus screw is superior,and it can significantly shorten the time of operation and reduce the complications of operation.