The Anatomic Study on Replacement of Artificial Atlanto-odontoid Joint through Transoral Approach

In order to provide anatomical basis for transoral approach （TOA） in dealing with the ventro lesions of craniocervical junction, and the design and application of artificial atlanto-odontoid joint, microsurgical dissecting was performed on 8 fresh craniocervical specimens layer by layer through transoropharyngeal approach. The stratification of posterior pharyngeal wall, course of vertebral artery, adjacent relationship of atlas and axis and correlative anatomical parameters of replacement of artificial atlanto-odontoid joint were observed. Besides, 32 sets of atlanto-axial joint in adults＇ fresh bony specimens were measured with a digital caliper and a goniometer, including the width of bony window of anterior arch of atlas, the .width of bony window of axis vertebra, the distance between superior and inferior two atlas screw inserting points, the distance between two axis screw inserting points etc. It was found that the width of atlas and axis which could be exposed were 40.2±3.5 mm and 39.3±3.7 mm respectively. The width and height of posterior pharyngeal wall which could be exposed were 40.1±5.2 mm and 50.2±4.6 mm respectively. The distance between superior and inferior two atlas screw inserting points was 28.0±2.9 mm and 24.0±3.5 mm respectively, and the distance of bilateral axis screw inserting points was 18.0±1.2 mm. The operative exposure position through TOA ranged from inferior part of the clivus to the superior part of the C3 vertebral body. Posterior pharyngeal wall consisted of 5 layers and two interspaces： mucosa, submucosa, superficial muscular layer, anterior fascia of vertebrae, anterior muscular layer of vertebrae and posterior interspace of pharynx, anterior interspace of vertebrae. This study revealed that it had the advantages of short operative distance, good exposure and sufficient decompression in dealing with the ventro lesions from the upper cervical to the lower clivus through the TOA. The replacement of artificial atlanto-odontoid joint is suitable and feasible. The design of artificial atlanto-odontoid joint should be based on the above data.

Treatment of Anderson Type II Odontoid Fracture in Elderly Patients by Posterior Pedicle Screw Fixation Combined with Iliac Bone Grafting

Objectives: To explore the treatment and related prognosis of elderly patients with Anderson II odontoid fracture with posterior pedicle screw fixation combined with iliac bone grafting. Methods: Retrospective analysis of 17 cases of elderly patients with Anderson II odontoid fracture who underwent posterior pedicle screw fixation combined with iliac bone grafting from January 2013 to December 2016. 17 patients had a history of trauma before surgery, and they all have varying degrees of atlantoaxial instability or subluxation and varying degrees of neck occipital pain and limited mobility. Result: No spinal cord or vertebral artery injury occurred during surgery. Follow-up information is complete. The follow-up period was 6 to 48 months (mean 27.4 ± 12.4 months). Postoperative imaging review prompted a good reduction of cervical spine, stable sequence;no pedicle screw loosening, fracture, iliac bone graft at the location of the situation, odontoid fracture and bone healing at the good, the patient after cervical rotation are limited to varying degrees. Conclusion: Posterior pedicle screw fixation combined with iliac bone grafting in elderly patients with Anderson II odontoid fracture can achieve good stability, and the prognosis is good, but long-term cervical rotation function may be affected to varying degrees.

Evaluation of Conservative Treatment of Acute Fracture of the Odontoid Process of Axis with a Halo-Vest

We fitted a halo-vest on patients with a fracture of the odontoid process of the axis and evaluated the effects of conservative treatment on cervical muscular atrophy and the number and type of patient complaints after bone union. Four patients had Anderson Type II fractures and 6 patients had Type III fractures. Bone union was observed in all patients within 3 months after injury. After halo-vest fitting, cervical muscular atrophy increased with time, however, it gradually improved after removal of the halo-vest. Patients fixed with a halo-vest for more than 10 weeks complained of cervical discomfort and limited range of motion. No patients with fixation for less than 10 weeks had problems in bone union or had cervical complaints. Thus, less than a 10-week fixation period was considered to be appropriate.

Review of Management of Type-2 Odontoid Fracture in Elderly

Odontoid fracture accounts for 15% - 20% of all cervical spine injuries. Among the odontoid fracture, type-2 fracture is the most common variety. This injury is associated with a high incidence of morbidity, mortality and nonunion in the elderly irrespective of mode of treatment. Management of odontoid fracture cannot be standardized till to date and ideal treatment for type-2 odontoid fractures still has some controversial issues. Objective of this review is to find a controversial aspect of management along with opinion to find out a standard guideline by searching the literature in Pubmed and Google scholar databases with key words: odontoid, fracture, type-2, management, nonoperative and operative management. Nonoperative treatment with halo vest is associated with very high rate of complication in elderly patient. When conservative treatment of this fractures is indicated that should be carried out with hard cervical collar or cervicothoracic orthosis. Current studies suggest that surgical management of odontoid fractures may offer a protective benefit but it is limited to patients younger than 75 years of age. Though surgical treatment has a better outcome, it is also limited by the co-mobidities and hazards of anesthesia and surgery in elderly patients. Conservative treatment of this fracture in the elderly should preferably be carried out with hard collar or avoiding halo vest. Surgical treatment is associated with little advantage but should be selected with proper attention to age, comorbidities, fracture geometry and it is better to individualize the treatment strategy.

Anterior Screw Fixation in Type II Odontoid Fractures: Keys for Better Outcome in Early Experience in Developing Countries

Introduction: Representing up to 15% of cervical injuries, odontoid type II fractures may cause spinal cord compression through atlanto-axial instability. Anterior screw fixation provides direct fracture site stability, high fusion rate and most importantly keeping cervical spine move free. We will highlight success keys in early experience for better outcome. Methods: We operated ten cases with traumatic type II odontoid fractures in neurotrauma unit, Cairo University hospitals from March 2015 till June 2017. Six males and four females were included. Preoperative MRI and dynamic CT were among the assessment criteria. Uni-planner fluoroscopy was used. Results: No post-operative deficit appeared. One screw was inserted in all cases. Immediate and 6 weeks later CT cervical spine showed stable reduced fracture site. Conclusions: Anterior odontoid screw fixation done with prior good selection of the patient and fracture shape is an effective motion preserving surgical option for type II odontoid fractures. Limited resources shouldn’t prevent starting experience especially in developing countries, but larger studies are needed.

Posterior Stabilization for Management of Neglected Odontoid Fractures

Background: Odontoid fractures are specific types of cervical fractures that show many challenges in their management. There are several types of Odontoid fractures with different modes of stability. There is no definite widely accepted way of management of Type II fractures among spine surgeons. There is a high rate of delayed or non-union of Odontoid fracture cases that are managed conservatively which may lead to dangerous complications. If non-union occurs, the patient should undergo surgical intervention as early as possible to avoid neurological deterioration. Objective: To demonstrate the value of intra-operative reduction and posterior stabilization of atlanto-axial junction in cases of non-union old Odontoid fractures and their outcome. The study was also to check for criteria associated with a favorable outcome and if posterior decompression will be associated with a better outcome. Patients and Methods: 12 patients of old neglected Odontoid fractures following conservative management and complicated by non-union were operated through intra-operative reduction with posterior stabilization and fixation of atlanto-axial junction at Al-Azhar University Hospitals during the period starting from June 2016 till the end of December 2019 using Screws and Rods. Intra-operative reduction under C-Arm X-ray and firm stabilization were aimed in all cases. Posterior cord decompression was an option in selected 4 patients with severe cord compression. Both intra-operative, post-operative radiological and clinical outcomes were assessed. Results: Good intra-operative reduction and alignment of fractured Odontoid process were obtained in all cases with use of 4 screws and 2 rods (2 screws and 1 rod on each side) in 11 cases and with using 2 screws and 1 rod (unilateral fixation) in one case. Good clinical outcome was obtained in all patients with improvement of pre-operative condition except in 3 patients where there were persistent pre-operative neurological deficits and without deterioration of pre-operative condition. Additional posterior cord decompression was associated with a better clinical outcome in 2 of 4 selected cases with severe cord compression. Conclusion: Good intra-operative reduction under C-Arm X-ray with posterior stabilization through atlanto-axial fixation using screws and rods is a reliable way of management of neglected type II Odontoid fractures complicated with non-union. Better results were obtained with less pre-operative neurological deficits and with absence of myelomalacia in MRI images. Additional posterior decompression may improve clinical outcome in cases of severe cord compression.

Atlantoaxial pedicle screw fixation for old odontoid fracture combined with atlantoaxial instability

Objective To explore the clinical effect of the trans-atlantoaxial pedicle screw-rod internal fixation and fusion in treatment of old odontoid fracture combined with atlantoaxial instability. Methods The study involved 48 patients with

Experience in surgical treatment of typeⅡodontoid fractures:A report of two cases and review of the literature

Two cases of typeⅡodontoid fractures were reported to share our experience in surgery treatment of such cases.A 33-year-old woman with comminuted typeⅡodontoid fracture and a 42-year-old man with fracture end hardened typeⅡodontoid fracture received surgical treatment in our hospital.Though imaging examination suggested that these two patients were suitable for anterior screw fixation,we encountered difficulties during the operation.The two patients eventually underwent posterior C1–C2 fusion surgery and recovered well.According to the experience of these two cases,we found that the fracture line angle and the degree of comminution are two important factors affecting surgical decision-making.Although anterior screw fixation is the ideal choice for typeⅡodontoid fractures with anterior superior to posterior inferior fracture line,it may not be the best choice for comminuted or fracture end hardened typeⅡodontoid fractures.

3D打印导板辅助椎弓根螺钉置入治疗陈旧性Ⅱ型齿状突骨折

目的:比较徒手置钉和应用3D打印导板辅助置钉在陈旧性Ⅱ型齿状突骨折患者中的安全性和临床疗效,并评价临床疗效。方法:2018年11月至2022年12月收治38例陈旧性Ⅱ型齿状突骨折患者,均表现为慢性颈痛,根据寰枢椎椎弓根螺钉置入方式不同分为导板组和徒手组。导板组17例,男9例,女8例,年龄(51.30±13.20)岁;病程(22.18±7.59)个月。徒手组21例,男7例,女14例,年龄(49.46±11.92)岁;病程(19.52±9.17)个月。观察比较两组术中出血量、手术时间和术后引流量等指标。通过CT扫描评价术后寰枢椎置钉准确率。术前和术后1年,采用疼痛视觉模拟评分(visual analogue scale,VAS)评价患者颈部疼痛,采用日本骨科学会(Japanese Orthopaedic Association,JOA)评分评价神经功能变化,采用美国脊髓损伤学会(American Spinal Injury Association,ASIA)损伤量表评估脊髓损伤程度。结果:所用患者获得随访,时间(25.31±1.21)个月。导板组的手术时间(112.00±20.48)min短于徒手组(124.29±15.24)min(P<0.05)。两组术中出血量、术后引流量、住院时间差异均无统计学意义(P>0.05)。术后1年导板组和徒手组VAS[(2.88±0.86)分,(2.90±0.83)分]和JOA评分[(14.94±1.82)分,(14.62±2.19)分]较术前[VAS(4.71±0.92)分,(4.86±0.79)分;JOA(12.18±2.30)分,(11.95±2.31)分]均明显改善(P<0.05),但是两组间比较差异无统计学意义(P>0.05)。两组ASIA评级在术后1年均未见明显改善(P>0.05),两组间比较差异无统计学意义(P>0.05)。导板组在寰椎椎弓根进行置钉的准确度明显优于徒手组(P<0.05),但是两组在枢椎的置钉准确度方面差异无统计学意义(P>0.05)。结论:在后路椎弓根螺钉内固定治疗陈旧性Ⅱ型齿状突骨折中,3D打印导板辅助技术能够显著缩短手术时间,实现和徒手置钉相似的临床疗效,并且能够显著提高寰椎椎弓根螺钉置入的准确性。

齿状突急性骨折骨髓水肿的变异性研究

目的:探讨急性齿状突骨折患者局部骨髓水肿程度与骨折断端分离情况的相关性。方法:回顾性分析2010年10月-2023年10月在本院行CT及MRI检查的35例急性齿状突骨折患者的临床和影像资料。按照骨折断端分离情况将患者分为2组:牵张组(11例)及未牵张组(24例)。基于MRI表现,将骨髓水肿程度分为4级(1~4分)。采用秩和检验比较两组患者骨髓水肿程度的差异。结果:35例中,19例患者可见骨髓水肿,在压脂STIR序列MRI图像上可见局部骨髓呈明显高信号改变,在CT图像上可见邻近骨皮质断裂;余16例患者未出现明显骨髓水肿,即STIR序列上骨髓内未见明显高信号。两组患者骨髓水肿程度的差异有统计学意义(Z=2.86,P=0.01<0.05),牵张组骨髓水肿程度低于未牵张组。结论:急性齿状突骨折患者在MRI上可无明显骨髓水肿表现,这与传统的影像学观念不同,尤其是骨折断端分离时,容易导致漏诊,在MRI阅片时应该提高警惕,需结合CT表现、临床病史及MRI上其它软组织损伤情况等进行综合分析。

后路寰枢椎钉棒复位内固定联合枢椎棘突肌肉血管复合体移植治疗ⅡC型齿状突骨折的疗效观察

目的观察后路寰枢椎钉棒复位内固定联合枢椎棘突肌肉血管复合体移植治疗ⅡC型齿状突骨折的疗效。方法回顾性分析2020年1月至2022年10月联勤保障部队第910医院收治的95例ⅡC型齿状突骨折患者的临床资料,根据患者手术方案不同将其分为对照组(接受后路寰枢椎钉棒复位内固定联合髂骨植骨术,47例)和观察组(接受后路寰枢椎钉棒复位内固定联合枢椎棘突肌肉血管复合体移植术,48例)。比较两组手术相关指标以及术后骨折愈合率、骨折端和颈部稳定性及寰枢椎旋转度。比较两组术前以及术后3个月、6个月的视觉模拟量表(VAS)评分、美国脊髓损伤协会(ASIA)评分、颈椎障碍指数(NDI)、日本矫形外科协会(JOA)评分。比较两组并发症发生情况。结果与对照组相比,观察组手术时间更短,术中出血量更少,骨折愈合时间更快,差异有统计学意义(P<0.05)。在术后6个月,观察组骨折愈合率显著高于对照组[93.75%(45/48)vs 78.72%(37/47);χ^(2)=4.540,P=0.033]。术后6个月,颈椎屈伸动态X线片显示观察组所有患者骨折端和颈部稳定性良好,对照组有4例患者骨折端稳定性欠佳。在骨折愈合后3个月,观察组和对照组寰枢椎旋转度差异无统计学意义[(84.13±6.32)°vs(82.96±7.10)°;t=0.849,P=0.398]。两组术后VAS评分均呈下降趋势(P<0.05),组间变化幅度差异无统计学意义(P>0.05)。与术前相比,两组术后3个月、6个月的ASIA评分均无显著变化(P>0.05)。两组术后NDI均呈下降趋势(P<0.05),在术后3个月、6个月,观察组NDI均显著低于对照组(P<0.05)。两组术后JOA评分均呈上升趋势(P<0.05);在术后3个月、6个月,观察组JOA评分均显著高于对照组(P<0.05)。观察组并发症发生率低于对照组,但差异无统计学意义[4.17%(2/48)vs 14.89%(7/47);χ^(2)=2.058,P=0.151]。结论后路寰枢椎钉棒复位内固定联合枢椎棘突肌肉血管复合体移植治疗ⅡC型齿状突骨折可缩短手术时间,减少术中出血量,促进骨折愈合及颈椎生理功能康复。

机器人辅助下颈椎前路螺钉固定治疗齿状突骨折1例

患者,男,67岁,摔伤致颈部疼痛活动受限4 h于2023年8月10日至我院急诊科就诊。查体:神志清楚,颈部按压疼痛,颈椎活动受限,四肢感觉、肌力正常,肢端血运良好,病理征阴性。颈椎X线片(见图1A)显示:齿状突骨折并向后移位。诊断为Anderson-D′AlonzoⅡ型齿状突骨折。患者入院后行颅骨牵引,排除手术禁忌证后,于2023年8月18日在天玑机器人辅助下行颈椎前路螺钉固定治疗。

后路寰枢椎经关节螺钉内固定治疗陈旧性齿状突骨折

[目的]对后路寰枢椎经关节螺钉内固定治疗陈旧性齿状突骨折进行回顾总结.[方法]33例陈旧性齿状突骨折经Anderson-DAlonzo分类Ⅱ型31例,Ⅲ型2例,无Ⅰ型病例.所有患者行后路寰枢椎经关节螺钉内固定植骨融合术,其中9例同时行Gallie法内固定.[结果]术后进行颈椎正侧位片随访6～52个月(平均7.9个月),32例获牢固骨性愈合,融合率97%.[结论]后路寰枢椎经关节螺钉内固定是治疗陈旧性齿状突骨折简单有效的方法.

新鲜Ⅱ型齿状突骨折的术式选择及治疗效果

目的：总结应用不同术式治疗Ⅱ型新鲜齿状突骨折的效果,探讨其术式选择。方法：2002年6月2010年6月,在我院手术治疗并获得随访的Ⅱ型新鲜齿状突骨折患者84例,男56例,女28例,年龄2168岁。术前均伴有颈项部疼痛和活动受限,17例合并不程度寰枢水平的颈脊髓损伤症状。19例为单纯齿状突骨折,65例合并寰枢椎脱位。入院后均行颅骨牵引,骨折均有不同程度的复位。根据骨折线类型、伴随损伤和骨质情况,58例采用前路单枚中空螺钉固定（A组）,26例采用后路寰枢椎椎弓根钉棒系统固定融合（B组）。结果：术中均未发生椎动脉和脊髓损伤。所有患者均获随访,随访时间3～24个月,平均8个月,A组58例患者54例获得骨性愈合,4例纤维性愈合,颈椎屈伸和旋转功能正常;B组均获得骨性愈合,颈椎旋转功能不同程度受限。结论：Ⅱ型新鲜齿状突骨折应根据齿状突的骨折线类型及患者个体情况选择相应的手术方法,单枚中空螺钉固定可保留颈椎的正常活动功能。

后路寰枢椎钉棒固定非融合治疗新鲜Ⅱ型齿状突骨折保留寰枢椎旋转功能的临床初探

目的：介绍寰枢椎后路钉棒固定非融合治疗新鲜Ⅱ型齿状突骨折保留寰枢椎旋转功能的临床初步疗效。方法：2010年1月~2011年7月收治8例不适合前路齿状突螺钉固定的新鲜Ⅱ型齿状突骨折患者，其中骨折线呈前下后上型者5例，牵引后齿状突骨折复位不佳者3例；男6例，女2例；年龄21~56岁，平均38岁。在气管插管全麻下行一期后路寰枢椎钉棒固定，不进行后路植骨；待术后随访CT复查显示齿状突骨折骨性愈合后，二期后路手术取出内固定，观察寰枢椎旋转功能的恢复情况。结果：8例患者均成功进行寰枢椎后路钉棒固定，共置入直径3.5mm的寰椎、枢椎螺钉各16枚，其中寰椎采用椎弓根螺钉固定13枚、部分经椎弓根螺钉固定3枚，枢椎采用椎弓根螺钉固定11枚、椎板螺钉固定5枚；术中齿状突骨折复位满意，未发生椎动脉、脊髓损伤。一期术后随访12～24个月，平均16个月，末次随访CT复查显示8例患者齿状突骨折均获得骨性愈合，颈椎左、右旋转均约35°～55°，平均约45°。二期后路钉棒内固定取出术后颈椎旋转功能即刻得到部分恢复，颈椎左、右旋转均约50°～70°，平均约60°；随访6～12个月后颈椎旋转功能基本恢复正常，颈椎左、右旋转均约80°～90°，平均约85°。结论：对不适合前路齿状突螺钉固定的新鲜Ⅱ型齿状突骨折患者，采用一期后路寰枢椎钉棒固定非融合、二期取出内固定的方法可保留寰枢椎的旋转功能。

枢椎齿突骨折的有限元分析

目的:建立枢椎的三维有限元(FE)模型,探讨在前、后方不同载荷下齿突的不同损伤机制和骨折类型。方法:对一例新鲜枢椎标本进行CT扫描,层厚1 mm,扫描图像转换后输入微机,通过软件PRO／E重建枢椎的三维立体模型,再转入有限元软件MARK并赋予此模型物理材料属性,然后模拟齿突骨折的受力条件,在齿突中性矢状面对齿突施加不同角度的载荷,分析各种条件下枢椎模型的应力、应变分布,探讨相应条件下可能导致的枢椎齿突骨折类型。结果:(1)对于齿突前部斜向后下方载荷,应力集中区从齿突前上部斜贯穿至后下部;对于齿突前部斜向后上方载荷,应力集中区从齿突前下部斜贯穿至后上部;齿突腰部始终保持高应力;(2)在齿突后部载荷下,其应力集中情况与前部载荷相似,不过应力集中区位置有所偏下。结论:(1)在齿突中性矢状面,齿突前部载荷容易导致齿突腰部发生断裂,形成枢椎齿突Ⅱ型骨折,也可能导致基底部发生断裂,形成枢椎齿突Ⅲ型骨折;(2)齿突后部载荷更容易导致基底部发生断裂,形成枢椎齿突Ⅲ型骨折。

齿状突骨折的经皮微创治疗策略

目的：探讨齿状突骨折经皮微创手术方法的选择。方法：同顾性分析2003年7月～2010年5月因齿状突骨折在我院行微创手术治疗随访1年以上患者113例，按患者骨折的不同特点和接受手术方式的不同分成5组，组1为可复位、非ⅡC型骨折及部分骨折面整齐的陈旧性齿状突骨折患者采用经皮前路齿状突螺钉内固定术．共65例；组2为移位重、陈旧性、ⅡC型骨折或伴有寰椎前弓、后弓骨折者患者采用经皮前路颈1／2关节突螺钉内固定术，共29例；组3为联合寰椎前后弓多发骨折患者采用经皮前路齿状突螺钉联合颈1／2侧方关节螺钉内固定术，共6例；组4为移位重、ⅡC型骨折者患者，均无椎动脉高拱畸形采用经皮后路颈1／2侧方关节螺钉内固定术，共4例：组5为陈旧性骨折伴寰枢椎难复性脱位患者采用经皮显微内窥镜下松解复位植骨内固定术，共9例。记录和分析不同组别患者的骨折愈合情况、疗效和并发症。结果：113例患者术后得到12～67个月的随访，未发现弯钉及断钉现象。组1患者中末次随访7例仍见骨折线，其余患者均骨性愈合；组2中1例术后2个月发现螺钉切割，予以取出螺钉＋后路开放手术．6例无植骨患者末次随访影像最示颈椎稳定，其余患者均得到骨性愈合：组3患者均骨性愈合；组4患者1例术后发现轻度前移，予以二期开放后路C1／2植骨钛缆内固定，另1例术后CT示螺钉可疑损伤椎动脉；组5患者均骨性愈合，5例症状基本缓解，3例中度缓解，1例轻度缓解。结论：不同类型齿状突骨折可以选择不同方式的经皮微创上颈椎技术治疗．只要正确选择手术方式，掌握手术适应证，可以取得安全、有效的结果。

新鲜齿状突骨折的分型与治疗方式选择

目的:总结新鲜齿状突骨折的治疗效果,探讨不同类型骨折治疗方法的选择。方法:2000年1月～2007年12月,共收治新鲜齿状突骨折患者54例。按Grauer改良的Anderson-D′Alonzo分型,ⅡA型7例,ⅡB型23例,ⅡC型8例,Ⅲ型16例。4例伴有脊髓损伤(ⅡB型3例,ⅡC型1例)。ⅡA型、2例合并相邻椎体骨折的ⅡB型、6例ⅡC型和Ⅲ型患者采用Halo-vest外固定;16例ⅡB型采用齿状突螺钉固定,5例移位严重的ⅡB型和2例ⅡC型采用后路寰枢固定融合术。随访时间均超过24周,拍摄颈椎侧位、开口位X线片并行CT检查观察骨折愈合情况。结果:31例Halo-vest外固定治疗者中,30例在12周时获得骨折愈合,其中4例(ⅡB型1例,Ⅲ型3例)原始骨折有前移位者,在牵引复位、Halo-vest固定后发生再移位,畸形愈合,但无神经压迫表现;1例2周时复查骨折前移位,改行后路寰枢椎固定融合术后获骨性融合。16例采用齿状突螺钉固定的ⅡB型骨折患者13例骨折愈合,3例在24周时骨折仍未愈合,骨折端有明显骨质吸收;7例寰枢关节固定融合患者在12周时均获得骨性融合。4例有脊髓损伤的患者均有不同程度的功能恢复。结论:Halo-vest外固定适合治疗ⅡA型、无或轻度移位ⅡC型和Ⅲ型齿状突骨折,但原始有前移位的骨折在固定过程中容易出现再移位。可复位的ⅡB型骨折适合齿状突螺钉固定,但骨折移位大的ⅡB型和粉碎性骨折宜及早采用寰枢固定融合术。

经皮和开放前路螺钉内固定术治疗齿状突骨折的比较

目的:比较经皮和开放前路螺钉内固定术治疗齿状突骨折的效果,初步评价经皮前路螺钉固定治疗齿状突骨折的临床价值。方法:自2003年3月至2007年6月,共收治22例Ⅱ型和浅Ⅲ型齿状突骨折患者,年龄25￣65岁,平均41.9岁。10例经皮前路螺钉固定,12例经开放前路螺钉固定,比较两组患者的治疗结果。结果:经皮固定组平均手术时间41.3min(36￣55min),失血3.1ml(0.5￣5ml),平均随访7.2个月(4￣15个月),9例骨折愈合,1例骨折不愈合患者无症状,无其他并发症发生。开放固定组平均手术时间75.2min(56￣110min),失血量35.9ml(20￣65ml),平均随访28.9个月(5￣47个月),11例骨折愈合,1例未骨性愈合患者无症状,1例术后出现一过性声音嘶哑。结论:经皮前路螺钉固定治疗Ⅱ型和浅Ⅲ型齿状突骨折与开放手术具有相同的疗效,但手术时间更短,创伤更小。

寰枢椎椎弓根螺钉术中复位固定融合术治疗陈旧性齿状突骨折并寰枢椎脱位

目的：总结应用后路寰枢椎椎弓根螺钉术中提拉复位固定植骨融合术治疗陈旧性齿状突骨折并寰枢椎脱位的疗效。方法：2007年1月~2010年1月收治21例陈旧性齿状突骨折并寰枢椎脱位患者，男13例，女8例；年龄13~68岁，平均38.5岁。患者均有不同程度的枕颈部疼痛和活动受限，均伴有神经功能障碍，ASIA分级：B级2例，C级13例，D级6例；JOA评分4～14分，平均8.3分。根据Anderson和D′Alonzo分型，Ⅱ型骨折17例（81%），Ⅲ型骨折4例（19%）。MRI检查示18例患者有不同程度的脊髓受压，7例脊髓受压节段髓内出现T2加权像高信号改变。均为寰椎前脱位，术前均进行颅骨牵引术，15例（71.4％）可部分复位，6例（28.6％）不可复位。术前寰齿间距（atlanto-dens interval，ADI）9～15mm，平均12.3mm。均采用后路寰枢椎椎弓根螺钉术中提拉复位固定和植骨融合术，随访观察患者临床症状和神经功能改善情况，影像学检查寰枢椎复位和植骨融合情况。结果：患者均顺利完成手术，术中均未发生椎动脉和脊髓损伤。共置入84枚寰枢椎椎弓根螺钉，术后X线片及三维CT检查3枚寰椎椎弓根螺钉内倾角偏小，螺钉部分穿破椎动脉孔内侧壁，椎动脉造影未见椎动脉损伤；1枚寰椎椎弓根螺钉内倾角过大，螺钉部分穿破椎管内侧壁，未出现新的神经损伤症状；其余螺钉位置满意。术后颈椎CT及MRI显示寰枢椎序列重建满意，齿状突区域脑脊液线清晰，脊髓无压迫，ADI为2～4mm，平均2.8mm。患者均获随访，随访时间6～36个月，平均20个月，术后6个月随访时3例患者的ASIA分级无改变，其余患者的神经功能明显改善，ASIA分级：C级3例，D级10例，E级8例； JOA评分为10～17分，平均14.6分，平均改善率为81.2%。1例患者植骨块有部分吸收，其余患者均在术后6个月获得骨性融合，融合率为95.2％；随访期间未发现螺钉松动、移位、断裂和寰枢椎再移位、失稳现象。结论：应用寰枢椎椎弓根螺钉术中提拉复位技术治疗陈旧性齿突骨折并寰枢椎脱位可获得良好的临床效果。