颈前路松解后路固定治疗伴咽后颈内动脉的难复性寰枢椎脱位

Anterior cervical release and posterior fixation for the treatment of irreducible atlantoaxial dislocation with retropharyngeal internal carotid artery

目的探讨颈前路松解后路固定治疗伴咽后颈内动脉的难复性寰枢椎脱位的临床疗效。方法回顾性分析2015年1月至2019年7月收治13例伴有咽后颈内动脉的难复性寰枢椎脱位患者的病历资料,均采用一期颈前路寰枢关节松解,后路复位固定融合术。男8例、女5例,年龄(46.1±12.6)岁(范围34~65岁)。术前均行正侧位及动力位X线片、MR和CTA检查,伴有双侧咽后颈内动脉4例、单侧9例。记录手术时间、术中出血量及并发症发生情况。主要观察指标为颈椎日本骨科协会(Japanese Orthopaedic Association,JOA)评分、寰齿间距(atlantodental interval,ADI)、Chamberlain线(Chamberlain line,CL),以及咽后颈内动脉形态变化和植骨融合情况。结果13例患者手术均顺利完成。手术时间(245±21)min(范围210~260 min);术中出血量(490±107)ml(范围350~600 ml)。13例患者均获得随访,随访时间(15.1±6.2)个月(范围9~24个月)。术前JOA评分为(6.9±2.3)分,术后1个月为(13.5±2.5)分,末次随访为(14.3±2.1)分,差异有统计学意义(F=30.91,P<0.001);术后1个月与术前的差异有统计学意义(P<0.001),JOA评分改善率为75.6%±15.2%;末次随访与术后1个月的差异无统计学意义(P>0.05)。术前ADI为(8.9±2.2)mm,术后1个月为(1.1±0.8)mm,末次随访为(1.2±0.9)mm,差异有统计学意义(F=114.69,P<0.001);术后1个月与术前的差异有统计学意义(P<0.001),ADI恢复正常水平;末次随访与术后1个月的差异无统计学意义(P>0.05)。术前CL为(11.7±4.8)mm,术后1个月为(1.6±2.1)mm,末次随访为(1.8±2.3)mm,差异有统计学意义(F=34.19,P<0.001);术后1个月与术前的差异有统计学意义(P<0.001),齿突位置恢复正常水平;末次随访与术后1个月的差异无统计学意义(P>0.05)。术后植骨融合时间平均10.2个月(范围6~12个月)。术中未发生颈内动脉、椎动脉、脊髓或神经根损伤等并发症。结论寰枢椎脱位患者前路松解术前应行CTA检查,了解颈内动脉位置和形态;颈前路松解联合后路植骨融合固定是治疗伴咽后颈内动脉难复性寰枢椎脱位的有效术式,且术中需注意避免损伤颈内动脉。

Objective To investigate the clinical effect of anterior cervical release and posterior fixation in the treatment of irreducible atlantoaxial dislocation with retropharyngeal internal carotid artery.Methods Thirteen patients with irreducible atlantoaxial dislocation of retropharyngeal internal carotid artery from January 2015 to July 2019 were treated with anterior cervical release and posterior fixation.There were 8 males and 5 females,aged from 34 to 65 years with an average of 46.1±12.6 years.Positive,lateral and dynamic X-ray films,MR and CTA were performed before operation.There were 4 cases with bilateral retropharyngeal internal carotid artery and 9 cases with unilateral retropharyngeal internal pharyngeal artery.The time of operation,the amount of bleeding and intraoperative and postoperative complications were recorded.The main observations were Japanese Orthopaedic Association(JOA)score,atlantodental interval(ADI),Chamberlain line(CL),and changes in the morphology of the retropharyngeal internal carotid artery and implant fusion.Results All the operations completed successfully.The operation time was 210-260 min,the average was 245±21 min;the blood loss was 350-600 ml,the average blood loss was 490±107 ml.There was no injury of internal carotid artery,vertebral artery,spinal cord or nerve root during the operation.All patients were followed up for 9 to 24 months,with an average of 15.1±6.2 months.Preoperative JOA score was 6.9±2.3 points,1 month after operation was 13.5±2.5 points,and the last follow-up was 14.3±2.1 points.The difference was statistically significant(F=30.91,P<0.001).The difference between 1 month after operation and before operation was statistically significant(P<0.001),and the improvement rate of JOA score was 75.6%±15.2%.There was no significant difference between the last follow-up and 1 month after operation(P>0.05).The preoperative ADI was 8.9±2.2 mm,1 month after operation was 1.1±0.8 mm,and the last follow-up was 1.2±0.9 mm.The difference was statistically significant(F=114.69,P<0.001).The difference between 1 month after operation and before operation was statistically significant(P<0.001),and ADI had returned to normal level.There was no significant difference between the last follow-up and 1 month after operation(P>0.05).The preoperative CL was 11.7±4.8 mm,1 month after operation was 1.6±2.1 mm,and the last follow-up was 1.8±2.3 mm.The difference was statistically significant(F=34.19,P<0.001).The difference between 1 month after operation and before operation was statistically significant(P<0.001),and the position of odontoid process returned to normal level.There was no significant difference between the last follow-up and 1 month after operation(P>0.05).Bone graft fusion was received at 6 to 12 months after operation,with an average of 10.2 months.Conclusion CTA examination should be performed before anterior release of atlantoaxial dislocation to understand the position and shape of internal carotid artery.Anterior cervical release combined with posterior bone graft fusion is an effective method for the treatment of irreducible atlantoaxial dislocation with retropharyngeal internal carotid artery without increasing the risk of internal carotid artery injury.