寰枢侧方关节撑开结合关节重塑技术治疗颅底凹陷合并寰枢椎脱位的临床疗效

Clinical efficacy of lateral atlantoaxial joint distraction combined with joint remodeling technique in the treatment of basilar invagination complicated with atlantoaxial dislocation

目的观察寰枢侧方关节间撑开结合关节重塑技术治疗颅底凹陷合并寰枢椎脱位的临床效果。方法回顾性分析2019年10月至2021年9月首都医科大学三博脑科医院脊髓脊柱中心诊治的12例颅底凹陷合并寰枢椎脱位患者的临床资料。所有患者均合并寰枕融合,斜坡枢椎角度均减小。术中均行关节间撑开松解侧方关节,再进行关节重塑,调整关节面的倾斜角度;然后置入融合器,使寰椎向上及向后方旋转移动,并进行固定。所有患者采用日本骨科协会(JOA)评分评估临床症状的改善情况;测量手术前后寰齿间距、齿状突超过钱氏线的距离、斜坡枢椎角度及延髓脊髓角度的变化,评估寰枢椎复位及齿状突成角移位的矫正情况。结果所有患者均成功重塑关节面并置入螺钉,均行枕骨-枢椎内固定。手术时长为(191.7±46.9)min,术中出血量为(182.5±69.3)ml,无一例患者发生椎动脉及硬脊膜损伤。术后1周内,颈椎CT显示12例患者的寰枢椎脱位均获得复位,其中齿状突超过钱氏线的距离由术前的(10.0±3.5)mm减少至术后的(4.2±2.3)mm,寰齿间距由术前的(6.7±2.1)mm减少至术后的(1.4±0.8)mm;颈椎MRI显示,所有患者的齿状突成角移位均得到矫正,其中斜坡枢椎角度由术前的(136.9±5.1)°增加至术后的(150.2±3.5)°,延髓脊髓角度由术前的(129.8±5.5)°增加至术后的(146.5±4.3)°。上述数据差异均有统计学意义(均P<0.01)。术后影像学显示1例患者出现C1下关节面塌陷,但无神经功能缺损症状出现。随访时间为(17.8±4.5)个月(12~25个月)。末次影像学随访,所有患者齿状突下移均保持矫正,可见寰枢侧方关节间骨性融合;未发生螺钉拔出、融合器移位等情况。末次临床随访,JOA评分由术前的(11.8±2.3)分提高至术后的(15.1±1.2)分,差异有统计学意义(P<0.01)。结论寰枢侧方关节撑开结合关节重塑技术可有效增加斜坡枢椎角度及延髓脊髓角度,减轻脑干腹侧压迫,有助于寰枢椎脱位的复位。

Objective To explore the clinical efficacy of lateral atlantoaxial joint distraction combined with joint remodeling technique in the treatment of basilar invagination complicated with atlantoaxial dislocation.Methods A retrospective analysis was conducted on the clinical data of 12 patients with basilar invagination and atlantoaxial dislocation who were diagnosed and treated at the Spine Center,Sanbo Brain Hospital,Capital Medical University from October 2019 to September 2021.All cases had comorbid occipitalization of the atlas and the clivus canal angle decreased.In all patients,the lateral joint was distracted by interarticular distraction,and then the joint was remodeled to adjust the tilt angle of the joint surface.The cage was then inserted to rotate the atlas upward and backward,and internal fixation was performed.The clinical outcomes of all patients were assessed using the Japanese Orthopedic Association(JOA)scale.The atlantodental interval,Chamberlain′s line invasion,clivus canal angle,and cervicomedullary angle were measured before and after surgery.Results All patients successfully underwent reconstruction of the articular surface and screw implantation.All patients underwent occipital-C2 internal fixation.The operation time was 191.7±46.9 min,the intraoperative blood loss was 182.5±69.3 ml,and there was no vertebral artery or dura mater injury.Within one week after surgery,CT showed reduction of atlantoaxial dislocation in all 12 patients.Chamberlain′s line invasion decreased from 10.0±3.5 mm before operation to 4.2±2.3 mm after operation,and atlantodental interval decreased from 6.7±2.1 mm before operation to 1.4±0.8 mm after operation.MRI showed that the angular displacement of odontoid process was corrected in all patients.The clivus canal angle increased from 136.9±5.1°before operation to 150.2±3.5°after operation,and the cervicomedullary angle increased from 129.8±5.5°before operation to 146.5±4.3°after operation.The differences were statistically significant(P<0.01).Postoperative imaging showed that 1 patient had lower C1 articular surface collapse,while no nerve injury symptoms appeared.The follow-up time was 17.8±4.5 months(12-25 months).At the last imaging follow-up,the odontoid downward movement remained corrected in all patients,showing atlantoaxial interarticular bone fusion.No complications such as screw extraction or cage displacement occurred.At the last clinical follow-up,the JOA score increased from 11.8±2.3 points before surgery to 15.1±1.2 points after surgery,and the difference was statistically significant(P<0.01).Conclusion The atlantoaxial joint distraction combined with joint remodeling technology can effectively increase the clivus canal angle and cervicomedullary angle,reduce the compression on the ventral side of the brain stem,and contribute to the reduction of atlantoaxial dislocation.