后路固定融合手术治疗类风湿关节炎继发寰枢关节半脱位

Instrumented posterior fusion for atlantoaxial subluxation due to rheumatoid arthritis

背景:类风湿关节炎(RA)是常见的累及颈椎的炎症性疾病,主要表现是寰枢椎半脱位(AAS)、寰枢椎垂直半脱位(VS)和下颈椎半脱位(SAS)。目前累及上颈椎的RA对脊柱外科医师仍是一个挑战,且国内对RA继发AAS的报道较少。目的目的:总结后路固定融合术治疗RA继发AAS的临床经验。方法方法:2009年3月至2014年5月采用后路固定融合术治疗RA继发AAS患者21例,其中寰枢椎固定融合14例,C1-3悬梁臂支撑固定2例,寰椎后弓切除枕颈融合术3例,RA继发SAS行多节段固定融合2例。其中女19例,男2例;年龄41~75岁,平均(56.8±4.3)岁;病程12~30年,平均(22.7±3.8)年。其中难复性AAS 1例,可复性AAS 20例;单纯AAS 15例,AAS+VS 3例,AAS+SAS 2例,AAS+VS+SAS 1例。按影像学表现分为AAS、VS、SAS。术前、术后采用VAS评分进行疼痛评估,采用Ranawat分级及JOA评分对神经症状进行评估,测量术前、术后寰齿间隙(ADI)和脊髓有效间隙(SAC)。结果结果:全部获得随访,随访时间为3~65个月,平均(26.2±10.6)个月。患者术后颈部疼痛症状及神经症状均有明显改善,术后3个月植骨融合率为71%(12/21),术后6个月植骨融合率为100%。术后无一例出现螺钉松动及断裂、肾上腺皮质危象等严重并发症。结论结论:对于RA继发AAS的患者需要采取个体化且合理规范的治疗方案,从而提高手术的安全性。

Background: Rheumatoid arthritis(RA) is a common inflammatory disease involving cervical spine. Main spinal manifestations are atlantoaxial subluxation(AAS), vertical subluxation(VS) and subaxial subluxation(SAS). Surgical management of RA involving upper cervical spines remains a challenge, and there are few Chinese articles on the treatment of ASS related to RA.Objective: To evaluate clinical outcome of instrumented posterior fusion for AAS in RA patients.Methods: Twenty- one RA patients who underwent C1- C3 or occipitocervical posterior fusion due to AAS between March2009 and May 2014 were enrolled in this retrospective study. There were 2 men and 19 women with an average age of(56.8±4.3) years(range, 41-75 years). The average course of disease was(22.7±3.8) years(range, 12-30 years). Atlanto-axial fusion was performed in 14 cases, C1-C3 was fused in 2, posterior atlantal arch excision was done in 3, and multiple segment fusion was performed in 2. Irreducible AAS occurred in one patient and reducible AAS in 20. The lesions included simple AAS(n=15), AAS+VS(n=3) and AAS+ SAS(n=2), AAS+VS+SAS(n=1). Pain was evaluated by Visual Analogue Scale(VAS) scores before and after surgery. Ranawat grading scale and Japanese Orthopaedic Association(JOA) scores were used to determine myelopathy. Clinical and radiological data were collected before surgery, at 3 and(or) 6 months after surgery, and at final follow-up.Results: The average duration of follow-up was(26.2±10.6) months(range, 3-65 months) in all the patients. All of them had a significant neurological improvement at the last follow-up. The fusion rate was 71%(12/21) at 3 months after surgery and100% at 6 months after surgery. No loosening, breakage or addisonian crisis were observed.Conclusions: Careful preoperative evaluation and individualized surgical planning should be adopted in patients with AAS secondary to RA.