上颈椎合并不连续下颈椎骨折的临床特点及外科治疗

Clinical characteristics and surgical treatment of upper cervical vertebrae combined with noncontiguous lower cervical fractures

目的:探讨上颈椎合并不连续下颈椎骨折的临床特点及外科治疗策略。方法:回顾性分析2011年1月至2017年11月手术治疗的上颈椎合并不连续下颈椎骨折患者44例,其中男34例,女10例;年龄26~64岁,平均(45.6±16.8)岁;单纯寰椎骨折21例,单纯枢椎骨折18例,寰枢椎双骨折5例。按照AO Spine对颈椎骨折的分型:寰椎骨折B型19例、C型7例;枢椎骨折B型12例、C型11例;下颈椎骨折B型14例、C型30例。术前美国脊髓损伤协会(ASIA)分级:B级1例,C级8例,D级16例,E级19例。收集手术时间、术中出血量、并发症发生情况,对比手术前后视觉模拟评分(VAS)、日本骨科协会(JOA)评分和ASIA分级,并通过影像学检查评估颈椎生理曲度及稳定性。结果:上颈椎合并不连续下颈椎骨折节段主要集中在寰枢椎及C6、C7,32例(72.72%)存在合并伤,以脑外伤及胸部损伤为主。3例患者行单纯前路手术,32例行单纯后路手术,9例行前后路联合手术。所有患者随访42~97个月,平均随访时间为(59.8±9.5)个月。术后12个月及末次随访的VAS评分和JOA评分较术前均有明显改善(P<0.05)。末次随访时,患者ASIA分级与术前相比显著改善,差异有统计学意义(χ2=8.87,P=0.03),颈椎生理曲度(24.8°±8.2°)虽较术前(27.7°±11.7°)降低,但差异无统计学意义(t=1.85,P=0.16);16例患者出现手术相关并发症,但均未出现椎动脉损伤、内固定失败等严重并发症。结论:上颈椎合并不连续下颈椎骨折可引起不同程度的颈髓损伤及躯体其他部位的合并伤,手术治疗可取得中长期良好的临床及影像学疗效。

Objective:To explore the clinical characteristics and surgical treatment strategies of upper cervical vertebrae combined with noncontiguous lower cervical fractures.Methods:Totally 44 patients with upper cervical vertebrae combined with noncontiguous lower cervical fractures treated from January 2011 to November 2017 were retrospectively analyzed.There were 34 males and 10 females with an average age of(45.6±16.8)years old(range,26-64 years old).The atlas was invovled in 21 patients,the axis was invovled in 18 patients,and atlantoaxial combined fracture occurred in 5 patients.According to AO Spine cervical classification,19 cases of atlas fracture were type B and 7 cases were type C;12 cases of axial fractures were type B and 11 cases of type C;there were 14 cases of type B and 30 cases of type C lower cervical vertebra fracture.Preoperative American Spinal Injury Association(ASIA)grading was as follows:1 case of class B,8 cases of class C,16 cases of class D,and 19 cases of class E.The operation time,intraoperative blood loss and complications were collected.The pre-and postoperative visual analogue scale(VAS)scores,Japanese Orthopaedic Association(JOA)scores,and American Spinal Injury Association(ASIA)grade were compared.The lordosis and stability of cervical spine were evaluated by X-ray.Results:The upper cervical vertebrae combined with noncontiguous lower cervical fractures were mainly concentrated in the atlantoaxial joint,C6,and C7.32 patients(72.72%)had combined injuries,mainly brain trauma and chest injury.3 patients underwent anterior surgery,32 patients underwent posterior surgery,and 9 patients underwent one-stage combined anterior and posterior surgery.All patients were followed up for 42 to 97 months,with an average(59.8±9.5)months.The VAS score and JOA score of 12 months after operation and the last follow-up were significantly improved compared with preoperative ones(P<0.05).The ASIA grade significantly improved at the last follow-up compared to preoperative one(χ2=8.87,P=0.03).There was no significant difference in the cervical physiological curvature before surgery and at the last follow-up(27.7°±11.7°vs.24.8°±8.2°,t=1.85,P=0.16).Operation related complications occurred in 16 patients,but no vertebral artery injury or internal fixation fracture occurred during follow-up.Conclusions:The upper cervical vertebrae combined with noncontiguous lower cervical fractures can cause cervical spinal cord injury and combined injuries in other parts of the body.Surgical treatment can achieve good curative effect in the medium and long-term follow-up.