后路钉棒固定不植骨与植骨融合治疗不稳定Hangman骨折的疗效比较

Comparison of efficacies of posterior screw-rod fixation and fusion with or without bone graft in the treatment of unstable Hangman′s fracture

目的:比较后路钉棒固定不植骨与后路钉棒固定植骨融合治疗不稳定Hangman骨折的疗效。方法:回顾性分析2014年1月~2020年12月在我院接受颈后路钉棒内固定手术且随访2年以上的39例不稳定Hangman骨折患者的临床及影像学资料,平均随访3.2±1.9年(2~9年)。男性31例,女性8例,年龄43.1±16.1岁(13~70岁)。其中22例接受单纯后路钉棒固定术(不植骨组:A组),17例接受后路钉棒固定自体髂骨植骨融合术(植骨组:B组)。记录并比较两组患者手术时间、术中出血量、术后并发症,术前、术后1周、术后3个月及末次随访时疼痛视觉模拟评分(VAS),术前、术后3个月及末次随访时颈椎功能障碍指数(NDI),术前及末次随访时美国脊髓损伤协会(ASIA)脊髓损伤分级,末次随访时Odom′s分级。在术前、术后1周及末次随访时颈椎侧位X线片上测量并比较两组间C2/3移位、成角和颈椎前凸角,颈椎正侧位X线片及三维CT上观察骨折愈合情况、C2/3后方关节突关节(小关节)、椎体间融合情况。结果:39例患者均顺利完成手术。手术时间A组99.3±14.2min,B组137.9±19.5min;术中出血量A组94.6±12.6mL,B组140.6±17.8mL,A组比B组手术时间更短,术中出血量更少(P<0.05)。A组2例术后发生浅表切口感染,B组1例术后发生浅表切口感染、4例供骨区疼痛,予以对症处理后均好转。两组患者术后1周、术后3个月及末次随访的VAS评分和术后3个月及末次随访的NDI较术前明显改善(P<0.05),两组间各随访时间点比较无统计学差异(P>0.05)。末次随访时两组患者ASIA分级及Odom′s分级无统计学差异(P>0.05)。两组患者术后1周及末次随访时C2/3成角、移位及颈椎前凸角较术前显著性改善(P<0.05),两组间各随访时间点上述指标比较无统计学差异(P>0.05)。末次随访时,39例患者骨折全部愈合良好。A组C2/3双侧小关节均自发融合,椎体前缘自发融合1例,椎体后缘自发融合9例,椎体前缘和后缘均自发融合4例;B组C2/3双侧小关节均骨性融合,椎体前缘自发融合0例,椎体后缘自发融合10例,椎体前缘和后缘均自发融合3例;末次随访时,两组C2/3小关节(全部融合)和椎间融合率(A组63%、B组76%)无统计学差异(P>0.05)。结论:后路钉棒固定不植骨和后路钉棒固定植骨融合治疗不稳定Hangman骨折均能够获得满意的临床疗效,术后C2/3小关节及椎体间融合率相似。不植骨能明显缩短手术时间、减少术中出血、避免取髂骨相关并发症。

Objectives:To compare the efficacies of posterior screw-rod fixation and fusion without bone graft and with bone graft in the treatment of unstable Hangman′s fracture.Methods:The clinical and imaging data of 39 patients with unstable Hangman′s fracture who underwent posterior cervical screw-rod internal fixation in our hospital between January 2014 and December 2020 and were followed up for more than 2 years were analyzed retrospectively,and the follow-up period was 3.2±1.9 years(range from 2 to 9 years).There were 31 males and 8 females with an average age of 43.1±16.1 years(13-70 years).Among the patients,22 cases received simple posterior screw-rod fixation(non-bone graft group:group A),and 17 cases received posterior screw-rod fixation and autogenous iliac bone graft fusion(bone graft group:group B).The operative time and intraoperative blood loss,postoperative complications,the visual analogue scale(VAS)preoperatively,at 1 week,3 months and final follow-up after surgery,and neck disability index(NDI)preoperatively,at 3 months and final follow-up after surgery,and American Spinal Cord Injury Association(ASIA)grade preoperatively and at final follow-up,and Odom′s grade at final follow-up were recorded and compared between the two groups.The displacement,angulation of C2/3 and cervical lordosis angle were measured on lateral X-ray films before operation,at 1 week after operation and final follow-up.The fracture healing,and C2/3 posterior facet joint and interbody fusion were observed on anteroposterior and lateral X-ray films and three-dimensional CT images.Results:All the 39 patients completed the operation successfully.The operative time was 99.3±14.2min in group A and 137.9±19.5min in group B,the intraoperative blood loss was 94.6±12.6mL in group A and 140.6±17.8mL in group B,and group A was shorter in operative time and less in blood loss(P<0.05).Superficial incision infection occurred in 2 cases in group A and 1 case in group B,and 4 cases of pain in bone donor area occurred in group B,all of which were improved after symptomatic treatment.The VAS score at postoperative 1 week and 3 months,and final follow-up,and NDI at postoperative 3 months and final follow-up of both groups all significantly improved than those before operation(P<0.05),while there was no significant difference in the indexes mentioned above between the two groups at each follow-up time point(P>0.05).At final follow-up,there was no significant difference in ASIA classification and Odom′s grade between the two groups(P>0.05).The angulation,displacement of C2/3 and cervical lordosis angle in the two groups were significantly improved at 1 week after operation and final follow-up(P<0.05).There was no significant difference in the indexes mentioned above between the two groups at each follow-up time point(P>0.05).At final follow-up,all the patients achieved solid bony fusions of fracture lines.In group A,spontaneous fusion at bilateral C2/3 facet joints was found in all the patients,spontaneous fusion of the anterior edge of vertebral body occurred in 1 case,spontaneous fusion of the posterior edge of vertebral body occurred in 9 cases,and spontaneous fusion of both anterior and posterior edges of vertebral body occurred in 4 cases.In group B,bony fusion of bilateral C2/3 facet joints was achieved in all the patients,no spontaneous fusion of the anterior edge of vertebral body,spontaneous fusion of the posterior edge of vertebral body occurred in 10 cases,and spontaneous fusion of both anterior and posterior edges of vertebral body occurred in 3 cases.At final follow-up,there was no statistical difference in the results of C2/3 facet joints and interbody fusion between the two groups(all facet joints were fused in both groups,and the interbody fusion rates in groups A and B were 63%and 76%,respectively)(P>0.05).Conclusions:Posterior screw-rod fixation and fusion without or with bone graft can both achieve satisfactory clinical results in the treatment of unstable Hangman′s fracture,with similar postoperative C2/3 facet joint and interbody fusion rates.Non-bone graft fusion can shorten the operative time,reduce intraoperative blood loss and avoid iliac bone removal-related complications.