寰枢椎脱位伴复杂椎动脉变异的枢椎置钉策略

Axial instrument strategy for atlantoaxial dislocation with complex artery variation

目的探讨寰枢椎脱位伴复杂椎动脉变异的枢椎置钉策略。方法回顾性分析2019年1月至2021年12月于我院接受手术治疗的寰枢椎脱位患者55例,男14例、女41例,年龄(54.0±12.8)岁(范围22~78岁)。单侧椎动脉高跨对侧无椎动脉10例、双侧椎动脉高跨伴一侧优势30例、双侧椎动脉高跨双侧发育对称15例。所有患者均接受后路复位减压内固定手术。采用视觉模拟评分(visual analogue scale,VAS)及日本骨科协会(Japanese Orthopaedic Association,JOA)评分评估术后疗效。结果所有患者均顺利完成手术,随访时间(14.6±5.5)个月(范围6~24个月)。单侧椎动脉高跨的无椎动脉侧及双侧椎动脉高跨伴一侧优势椎动脉的非优势侧行C2椎弓根螺钉内固定(40椎);单侧椎动脉高跨侧和双侧椎动脉高跨伴一侧优势椎动脉的优势侧行C2内侧"in-out-in"螺钉固定(10椎)、C2峡部螺钉固定(21椎)、C2不置钉仅延长固定节段(9椎)。双侧椎动脉高跨双侧发育对称者,一侧行C2外侧"in-out-in"椎弓根螺钉固定(左10椎,右5椎),另一侧行C2内侧"in-out-in"螺钉固定(8椎)、C2峡部螺钉固定(5椎)、C2不置钉仅延长固定节段(2椎)。术前、术后6个月及末次随访时JOA评分分别为(8.5±1.8)分、(13.9±1.3)分、(14.4±1.1)分,差异有统计学意义(F=279.40,P<0.001);术后6个月及末次随访的JOA均大于术前,差异有统计学意义(P<0.05),而术后6个月及末次随访时JOA评分的差异无统计学意义(P>0.05)。术前、术后6个月及末次随访颈椎VAS分别为(3.7±1.9)分、(2.1±0.9)分、(1.6±1.0)分,差异有统计学意义(F=39.53,P<0.001);术后6个月及末次随访时颈椎VAS小于术前,差异有统计学意义(P<0.05);术后6个月时颈椎VAS大于末次随访,差异有统计学(P<0.05)。结论寰枢椎脱位伴复杂椎动脉变异患者的内固定方式可选择C2外侧"in-out-in"螺钉、C2内侧"in-out-in"螺钉、峡部螺钉固定或C2不置钉仅延长固定节段,均能获得良好的临床疗效。

Objective To evaluate the axial instrument strategy for atlantoaxial dislocation with complex vertebral artery variation.Methods A total of 55 patients with atlantoaxial dislocation who underwent surgical treatment from January 2019 to December 2021 were retrospectively analyzed,including 14 males and 41 females,aged 54.0±12.8 years(range,22-78 years).Among these patients,10 patients with unilateral vertebral artery high ride with contralateral vertebral artery occlusion,30 patients with bilateral vertebral artery high ride with single dominant vertebral artery,15 patients with bilateral vertebral artery high ride.All patients underwent posterior reduction and internal fixation.Visual analogue scale(VAS)and Japanese Orthopaedic Association(JOA)score were used to evaluate the postoperative efficacy.Results All patients completed the surgery successfully with a follow-up time of 14.6±5.5 months(range,6-24 months).C2 pedicle screw fixation was performed on the non-dominant side of unilateral vertebral artery high ride and the non-dominant side of bilateral vertebral artery high ride with one dominant vertebral artery(40 vertebraes).The dominant side of unilateral high vertebral artery and bilateral high vertebral artery with one dominant vertebral artery was fixed with C2 medial"in-out-in"screw(10 vertebraes),C2 isthmus screw(21 vertebraes),C2 without screw(9 vertebraes)only extended the fixed segment.For bilateral vertebral artery high ride patients,one side was used C2"in-out-in"pedicle screws(right 10 vertebraes,left 5 vertebraes),and the other side was fixed with C2 medial"in-out-in"screw(8 vertebraes),C2 isthmus screw(5 vertebraes),C2 without screw only extended the fixed segment(2 vertebraes).The JOA scores were 8.5±1.8,13.9±1.3,and 14.4±1.1 preoperatively,6 months postoperatively,and at the final follow-up,respectively,with statistically significant differences(F=279.40,P<0.001).JOA at 6 months postoperatively and at the final follow-up was greater than preoperatively,and the differences were statistically significant(P<0.05),whereas the differences in JOA scores at 6 months postoperatively and at the final follow-up was not statistically significant(P>0.05).Preoperative,6 months postoperatively and final follow-up cervical VAS scores were 3.7±1.9,2.1±0.9 and 1.6±1.0,respectively,with statistically significant differences(F=39.53,P<0.001).The cervical VAS at 6 months postoperatively and at the last follow-up was less than that before surgery,and the differences were statistically significant(P<0.05).Cervical VAS scores at 6 months postoperatively were greater than at the last follow-up,with a statistically significant difference(P<0.05).Conclusion For patients with atlantoaxial dislocation with complex vertebral artery variation,C2 lateral"in-out-in"screw,C2 medial"in-out-in"screw,isthmus screw fixation or C2 without screw only extended the fixed segment can obtain good clinical efficacy.