机器人辅助经椎弓根固定治疗类风湿性寰枢椎脱位合并椎动脉高跨一例报告

Robot-assisted transpedicular screw fixation for rheumatoid atlantoaxial dislocation with high-riding vertebral artery:a case report

寰枢椎脱位(atlantoaxial dislocation,AAD)是指寰椎(C1)与枢椎(C2)之间的关节失去正常对合关系发生错位,导致寰枢椎失去稳定性,运动范围异常,并发生关节功能障碍和(或)神经压迫症状的临床解剖学生物力学改变[1]。AAD是颈椎高位脱位中最常见的一种类型。类风湿关节炎(rheumatoid arthritis,RA)是AAD的重要原因之一,当其产生神经损伤相关症状时,应尽早手术治疗,而寰枢椎后路经椎弓根固定是其首选手术方式[2]。RA常常并发枢椎段椎动脉高跨(high-riding vertebral artery,HRVA)等畸形改变[3-6],增加了手术的难度和风险,术前应对椎动脉走行进行检查和评估。机器人导航下进行寰枢椎手术能有效规划手术路径,精准置钉,减少椎动脉损伤,提高手术成功率[7-8]。广东省中医院珠海医院收治1例56岁女性患者,在机器人导航下行寰枢椎后路经椎弓根内固定治疗RA继发AAD合并HRVA,术后患者症状明显缓解,取得满意疗效,经随访病情稳定。笔者结合此病例及相关文献回顾,探讨RA继发AAD合并HRVA病因、发生率及手术策略的选择,现将病例的诊治过程及文献复习报道如下。

Objective To explore the etiology,incidence,and selection of surgical strategy for rheumatoid atlantoaxial subluxation combined with high-riding vertebral artery(HRVA).Methods A case of robot-assisted transpedicular screw fixation for rheumatoid atlantoaxial dislocation(AAD)combined with high-riding vertebral artery was reported.Relevant literature was reviewed.Results The patient was a 56-year-old female with rheumatoid atlantoaxial dislocation,and the examination revealed high-riding left vertebral artery(V3 segment).The risk of unarmed transpedicular screw fixation was high.Guiding by robot could avoid the high-riding vertebral artery,which greatly enhanced the accuracy and stability,and reduced the risk of surgery.After the operation,symptoms were relieved and the atlantoaxial spine was repositioned.Good atlantoaxial internal fixation,clear atlantodental interval and gradually fused posterior atlantoaxial vertebrae were observed 5 months after operation.The patient returned to normal life.Conclusions Rheumatoid AAD has a higher chance of complicating with HRVA,while atlantoaxial transpedicular screw fixation assisted by robot navigation can enhance the safety and accuracy of nail placement.It significantly shortens the time of nail placement and fluoroscopy,and reduces complications of surgery such as IVAI.But the complications and long-term prognosis of robot-assisted surgery need to be reported in the literature and in more studies.In addition,problems related to the adaptation of instruments such as upper cervical hollow screws should be noted in the robot-assisted surgery.