寰枢椎脱位不同后路融合术对相邻节段退变的影响

目的:观察寰枢椎脱位不同后路融合术对其相邻节段退变的影响。方法:2000年6月~2010年6月共纳入43例寰枢椎脱位患者,按照后路融合方式分为寰枢融合组(23例)和枕颈融合组(20例)。记录两组患者末次随访时相邻节段C2-3半脱位(SAS)的出现率及活动度,术前及末次随访时的C2/3椎间隙高度与C3椎体高度的比值(S值)及C2-7矢状位角度,并进行统计学比较。结果:两组术前的JOA评分、S值及C2-7矢状位角度差异均无统计学意义(P0.05)。寰枢融合组随访时间为7.40±1.51年,枕颈融合组随访时间为6.97±1.32年,组间比较无统计学差异(P0.05)。23例行寰枢融合术者出现2例SAS(8.7%),20例行枕颈融合术者出现7例SAS(35%),差异有统计学意义(P0.05)。寰枢融合组和枕颈融合组末次随访时S值均较术前减小,枕颈融合组S值减小更明显,两组之间差异有统计学意义(P0.05)。末次随访时,寰枢融合组及枕颈融合组C2-3活动度分别为3.78°±3.01°和1.45°±1.72°,两组比较有统计学差异(P0.05)。寰枢融合组C2-7矢状位角度由术前的15.16°±5.66°降至末次随访的12.40°±9.34°,枕颈融合组由术前的15.54°±6.54°降至末次随访的-0.22°±12.45°,两组末次随访的C2-7矢状位角度有统计学差异(P0.05)。结论:寰枢融合术比枕颈融合术的颈椎相邻节段退变发生率低、程度轻,临床上应严格掌握手术指征,不要轻易行枕颈融合。     

类风湿性关节炎继发寰枢椎脱位的手术治疗

目的:总结手术治疗类风湿性关节炎(rheumatoid arthritis,RA)继发寰枢椎脱位的临床疗效。方法:2010年1月~2018年12月收治57例RA继发寰枢椎脱位的患者,男14例,女43例;年龄46~79岁(61.8±12.4岁)。类风湿性关节炎病史2.5~36.8年(17.5±3.7年),诊断RA后出现上颈椎相关症状时间为1.5~19.4年(8.9±2.4年)。患者均有不同程度的枕颈部疼痛、颈部姿势异常和活动受限。术前神经功能ASIA分级:B级3例,C级12例,D级20例,E级22例;JOA评分4~14分(8.7±1.8分),VAS 4~10分(7.4±1.5分)。寰椎前向脱位44例,其中寰齿前间距(anterior atlantodental interval,AADI)>10mm者8例;寰椎后向脱位9例;寰椎前后向脱位4例。6例合并下颈椎不稳,10例合并枕颈部其他畸形。13例枕寰关节先天性融合及骨性融合无枕寰关节活动度者采用枕颈固定融合术治疗(A组);44例有枕寰关节活动度的患者采用寰枢椎融合固定融合术治疗,其中16例寰枢椎脱位牵引不能复位的患者先行前路经下颌下寰枢椎关节松解术再一期后路行寰枢椎融合术治疗(B组),28例寰枢椎脱位牵引能复位的患者直接采用后路寰枢椎融合内固定术治疗(C组)。定期随访患者的临床症状和神经功能改善情况,影像学观察寰枢椎复位和植骨融合情况。结果:患者均顺利完成手术,A组手术时间100~130min(118.2±13.5min),术中出血量100~300ml(190.5±42.8ml);B组手术时间180~240min(221.4±20.3min),术中出血量100~260ml(157.3±36.1ml);C组手术时间100~130min(109.4±12.1min),术中出血量100~200ml(124.1±32.7ml)。术中均未发生椎动脉和脊髓损伤。所有患者随访期间复查颈椎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,术后AADI为2~3mm(2.4±0.4mm)。患者均获随访,随访时间12~84个月(34.4±10.3个月),术后12个月随访时,2例ASIA分级B级患者恢复至C级,C级患者6例恢复至D级、3例恢复至E级,9例D级患者恢复至E级,其余患者无变化;JOA评分改善至10~17分(14.6±3.5分),VAS评分降至1~5分(3.6±1.4分),与术前比较均有显著性差异(P<0.05)。1例患者植骨块发生自发性部分吸收,随访1年半时植骨块吸收停止并部分融合,未再次行植骨术;其余患者植骨均融合。随访期间均未发现螺钉松动、移位、断裂和寰枢椎再脱位、失稳现象。结论:RA累及上颈椎时会造成寰枢椎脱位导致脊髓受压,依据枕寰关节活动度情况采用寰枢椎融合术或枕颈融合术治疗可获得良好的临床效果。     

上颈椎非融合固定技术的研究进展

上颈椎包括寰椎和枢椎,主要涉及寰枕关节和寰枢关节,上承头颅,下接下位颈椎,生物力学复杂。颈椎具有旋转、屈伸和侧屈的运动功能,旋转运动的一半主要来自上颈椎的寰枢关节,屈伸主要来自寰枕关节。上颈椎损伤多由身体或头部加速撞击到静止物体上所致,主要包括寰枕关节脱位、寰枢关节脱位、寰椎骨折、枢椎齿状突骨折、枢椎创伤性滑脱和以上病变的叠加损伤。传统治疗上颈椎损伤的术式主要是寰枢椎融合术和枕颈融合术,但植骨融合技术在稳定结构的同时,导致上颈椎大部分活动度的丧失,旋转、屈曲等功能明显受限。上颈椎活动度的丧失对颈椎的生理和生物力学产生长期的负面影响,并对患者的生活质量产生不利影响。近年来,随着非融合理念和技术的推广,人工寰齿关节、经椎弓根动态固定系统等上颈椎非融合固定方式开始出现,以达到不植骨融合就可以同时实现稳定上颈椎结构和保留一定活动度的治疗目的。为进一步了解上颈椎非融合固定技术的研究进展,笔者对其做一综述。     

Goel技术联合一侧寰枢外侧关节内植骨治疗寰枢椎不稳

目的评估Goel技术联合一侧寰枢外侧关节内植骨治疗寰枢椎不稳的临床疗效。方法回顾性分析2013年1月—2017年4月中国人民解放军北部战区总医院收治的64例寰枢椎不稳患者临床资料。其中32例采用Goel技术联合一侧寰枢外侧关节内植骨治疗(A组),另32例采用单纯Goel技术治疗(B组)。术后通过影像学资料评估植骨融合情况,记录并比较2组手术并发症、内固定失败率、骨融合率、寰齿前间距(ADI)及日本骨科学会(JOA)评分。结果所有手术顺利完成,所有患者随访 12个月,骨融合率为100%。术后所有患者症状均显著改善,未见明显并发症,无内固定失败病例。2组患者术后6、12个月ADI和JOA评分均较术前明显改善,差异有统计学意义(P 0.05);组间比较差异均无统计学意义(P 0.05)。结论 Goel技术联合一侧寰枢外侧关节内植骨治疗寰枢椎不稳的疗效与单纯Goel技术相当,不增加手术时间及术中出血量,还可减少自体骨植骨量,增加植骨面积,可以作为治疗寰枢椎不稳的补充技术。     

经后路寰枢椎椎弓根螺钉固定融合术治疗寰枢椎失稳

目的:探讨应用寰枢椎椎弓螺钉固定技术治疗寰枢椎失稳的临床疗效。方法:对2003年6月至2010年3月对收治的32例寰枢椎失稳患者采用寰枢椎椎弓根螺钉技术进行治疗,其中男21例,女11例;年龄28～66岁,平均42.5岁;齿状突骨折18例,先天性游离齿状突7例,Jefferson骨折合并齿状突骨折4例,类风湿性关节炎致寰枢椎不稳3例。所有患者均伴有寰枢椎半脱位或失稳。术前JOA评分4～14分,平均(9.1±0.3)分。术前完善颈椎X线(包括动力位片)、螺旋CT三维重建及MRI等影像学检查,在CT轴位片上对寰枢椎椎弓根螺钉的置入点、置入角度及钉道长度等数据进行测量,并行颅骨牵引术。手术在全麻下进行,直视下完成寰枢椎椎弓根螺钉的置入、复位和植骨融合,植骨块被向后预弯的横联紧紧卡压于寰椎后弓与枢椎椎板棘突之间。比较术前和术后6个月的JOA评分,并计算改善率。结果:32例患者共置入寰枢椎螺钉128枚,无脊髓、神经根和椎动脉损伤发生。所有患者获随访,时间6～48个月,平均16个月。术后JOA评分11～17分,平均(15.9±0.2)分,平均改善率为86.1%。骨折的齿状突均完全愈合,植骨块全部融合,无内固定断裂和松动。结论:寰枢椎椎弓根螺钉固定技术是治疗寰枢椎失稳的有效方法,具有固定牢靠,操作相对安全方便、融合率高等优点,值得临床应用。     

经口咽前路减压侧块关节融合器植骨融合联合颈椎压力固定器治疗难复性寰枢椎脱位

目的 :探讨经口咽前路减压侧块关节融合器(cage)植骨融合联合颈椎压力固定器(mini compressive cervical frame/C-JAWS)内固定术治疗难复性寰枢椎脱位的临床初步应用效果。方法 :应用经口咽前路减压侧块关节cage植骨融合联合C-JAWS内固定术治疗难复性寰枢椎脱位患者14例,包括单纯难复性寰枢椎脱位8例,陈旧性寰枢椎脱位后路术后复发1例,颅底凹陷症伴寰枢椎脱位4例,颅底凹陷症伴寰枢椎脱位枕颈融合术后复发1例。根据美国脊髓损伤学会(ASIA)分级对神经功能进行评估,采用ASIA运动评分进行运动功能评估,术前D级9例,E级5例。术后定期随访X线、CT评价复位、内固定及植骨融合情况。结果:14例患者均成功完成手术,术中未发生神经血管损伤。术后1例患者诉颈部不适,1例患者诉咽喉部异物感,经对症处理后缓解。术后患者枕颈部疼痛和肢体麻木无力症状均不同程度改善。9例术前ASIA分级为D级的患者中3例术后改善为E级,其余6例分级无变化;5例术前分级为E级的患者术后分级无变化。ASIA运动评分由术前68.1±9.7分改善至术后的91.7±6.6分,手术前后比较,差异有统计学意义(t=-17.220,P=0.000)。随访3~24个月,平均12.2±6.8个月,X线片、CT复查示无复发脱位,cage位置满意,C-JAWS固定良好,无松动,均获骨性融合。结论:经口咽前路减压寰枢椎侧块关节cage植骨融合联合C-JAWS内固定术是治疗难复性寰枢椎脱位一种有效的、可选择的手术方法。     

颈前咽后入路病灶清除联合后路枕颈融合固定术治疗上颈椎结核

目的:探讨颈前咽后入路病灶清除联合后路枕颈融合固定术治疗上颈椎结核的临床效果。方法:2002年1月~2012年6月在我院接受手术治疗的上颈椎结核患者共21例,均伴有寰枢关节、寰枕关节严重破坏且寰椎侧块破坏无法置钉的11例,男7例,女4例,年龄40.4±9.5岁(26~54岁),寰椎结核4例,寰椎并枢椎结核7例,均行颈前咽后路病灶清除并一期后路枕颈融合内固定术。根据枢椎椎弓根破坏情况,2例采用双侧枢椎椎弓根螺钉固定,3例采用双侧椎板螺钉固定,6例采用一侧椎板螺钉和一侧椎弓根螺钉混合固定。术后应用抗结核药物治疗18个月,并随访其神经功能(JOA评分)、枕颈部VAS评分、植骨融合情况、复位程度及并发症。结果:11例患者平均随访39.5±13.1个月。术后9例获解剖复位,2例达部分复位;术后4个月10例达到骨性融合,1例出现部分植骨吸收,经对症治疗,于术后6个月获骨性融合。术后18个月结核病变均达到临床治愈。JOA评分由术前的8.4±1.3分上升到末次随访时的15.0±1.3分(P0.05),枕颈部疼痛症状也由术前的6.7±0.6分下降到末次随访时的0.64±0.6分(P0.05),围手术期及术后随访未发现严重的并发症。结论:采用经咽后入路病灶清除联合后路固定融合术治疗上颈椎结核临床疗效可靠,病灶清除彻底,内固定牢靠,是一种安全有效的治疗方法。     

BMP-2混合自体髂骨植骨在寰枢椎脱位后路复位固定融合术中的应用

目的评价BMP-2混合自体髂骨植骨在可复性寰枢椎脱位后路复位固定植骨融合术中的融合效果的。方法回顾性分析自2004-01—2012-01采用BMP-2与自体髂骨混合植骨进行寰枢椎后路复位固定融合术治疗的41例可复性寰枢椎脱位(BMP-2组),并与同期仅采用自体髂骨植骨治疗的65例(自体髂骨组)进行比较。比较2组手术时间、术中出血量、术后引流量、自体髂骨取骨量、并发症发生率,以及术后12个月时VAS评分、JOA评分、颈椎曲度、颈椎活动度。结果 106例获得平均(25.8±1.6)个月随访,术后12个月影像学检查显示均获得满意复位及骨性融合,融合率达100%。2组手术时间、术中出血量、术后引流量,以及术后12个月的VAS评分、JOA评分、颈椎曲度、颈椎活动度比较差异无统计学意义(P0.05);但BMP-2组自体髂骨取骨量明显少于自体髂骨组,差异有统计学意义(P0.05)。2组并发症发生率差异无统计学意义(χ~2=1.459,P=0.083)。结论采用BMP-2混合自体髂骨进行可复性寰枢椎脱位后路钉棒内固定植骨融合术可以减少自体髂骨的切取量,缩短术后疼痛缓解时间,而且并未增加术后并发症的发生率。     

寰枢椎侧块关节内碎骨植骨融合术治疗寰枢椎不稳的临床疗效

【摘要】 目的：探讨寰枢椎侧块关节内碎骨植骨融合术治疗寰枢椎不稳的临床疗效。方法：对2016年1月~2019年12月在海军军医大学附属长征医院骨科行寰枢椎后路螺钉内固定植骨融合术的49例寰枢椎不稳患者进行回顾性分析。其中男性17例,女性32例;年龄8~72岁（45.2±17.1岁）。所有病例均采用寰枢椎后路椎弓根钉棒内固定技术,根据所行植骨方式不同将患者分为两组：2016年1月~2018年12月期间行寰椎后弓与枢椎椎板间结构性植骨融合术的28例患者纳入A组,男9例,女19例,年龄42.1±20.2岁;2018年1月~2019年12月期间行寰枢椎侧块关节内碎骨植骨融合术的21例患者纳入B组,男8例,女13例,年龄49.3±19.8岁。记录两手术时间、术中出血量和随访时间,比较两组患者术前和末次随访时的日本骨科协会评分（Japanese Orthopaedic Association,JOA）、颈部残疾指数（neck disability index,NDI）和颈部疼痛视觉模拟评分（visual analogue scale,VAS）,术前、术后和末次随访时在冠状位CT上测量寰枢椎侧块关节间隙的高度,观察植骨融合情况。结果：两组患者年龄、性别、疾病种类无统计学差异（P>0.05）,具可比性。两组患者均顺利完成手术,术中无椎动脉和神经损伤。A组术中出血量显著性低于B组（210.2±26.6mL vs 230.5±6.2mL,P＜0.05）,两组手术时间和随访时间无统计学差异（P>0.05）。两组患者末次随访时的JOA评分、NDI和VAS评分与术前比较均明显改善（P＜0.05）,两组间同时间点比较均无统计学差异（P>0.05）。术前两组患者的寰枢侧块关节间隙高度无显著性差异（P>0.05）;术后即刻B组侧块关节间隙高度显著性高于A组（P＜0.05）;末次随访时,两组侧块关节间隙高度均有不同程度的下降,但B组侧块关节间隙高度仍显著性高于A组（P＜0.05）。所有患者植骨均融合,两组植骨融合时间无统计学差异（P>0.05）。随访期间未出现螺钉松动、移位、断裂等并发症。结论：寰枢椎后路钉棒固定融合术中采用寰枢椎侧块关节内碎骨植骨能够实现良好的骨融合,可应用于后弓缺失等不能行寰椎后弓与枢椎椎板植骨术的患者,避免取自体髂骨植骨供骨区疼痛、感染等并发症,且能够在一定程度上维持寰枢椎的关节间隙高度,增强其稳定性。     

后路寰枢椎椎弓根螺钉内固定植骨融合治疗成人不稳定性寰椎骨折的效果

目的:探讨后路寰枢椎椎弓根螺钉内固定并植骨融合治疗成人不稳定性寰椎骨折的效果。方法:对2014年1月～2018年8月我院收治的27例不稳定性寰椎骨折的患者进行回顾性研究,其中女性7例,男性20例,年龄29～78岁(54.1±10.8岁)。以横韧带断裂作为不稳定的标准,其中单纯不稳定性寰椎骨折16例,寰椎骨折合并枢椎齿状突骨折10例,合并枢椎Hangman骨折1例。致伤因素为交通伤6例,高处坠落伤20例,重物砸伤1例。均行寰枢椎椎弓根螺钉内固定并植骨融合手术,记录患者术前和术后的临床资料与影像学资料,比较术前与术后的颈部疼痛视觉模拟评分(VAS评分)、日本骨科协会(JOA)评分,随访观察骨折愈合和植骨融合情况、有无内固定物松动和/或断裂以及伤口感染等情况。结果:所有患者手术顺利,手术时间89～125min(103.7±9.3min),术中出血90～180ml(135.6±24.2ml),未出现椎动脉损伤、脊髓损伤或脑脊液漏等手术并发症。所有患者均获随访,随访时间12～30个月(21.6 3±4.64个月),随访期内未出现内固定物松动、断裂和伤口感染等情况,所有患者骨折均愈合,植骨均获得骨性融合。术前颈部疼痛VAS评分6.70±0.70分,术后3个月随访时为1.59±0.61分,差异有统计学意义(P0.05);术前JOA评分为10.85±1.11分,术后3个月随访时JOA评分为15.96±0.84分,差异有统计学意义(P0.05)。结论:后路寰枢椎椎弓根螺钉内固定并植骨融合手术对成人不稳定性寰椎骨折能重建良好的上颈椎稳定性,可获得满意的临床疗效。     

选择性融合联合单开门椎管扩大椎板成形术治疗局部不稳的颈椎后纵韧带骨化症的疗效

目的:比较三种颈椎后路术式治疗存在局部不稳的颈椎后纵韧带骨化症(ossification of the posterior longitudinal ligament,OPLL)患者的临床疗效,探讨选择性融合联合单开门椎管扩大椎板成形术的临床应用价值。方法:回顾分析我院2014年6月~2017年6月收治的存在局部不稳的颈椎OPLL患者107例,其中男性61例,女性46例;年龄68.1±10.2岁(33~84岁),随访时间2.1±1.3年(0.5~3.5年)。所有患者证实存在OPLL及颈椎局部不稳,且存在颈脊髓压迫相关症状体征,其中38例行单纯颈后路单开门椎管扩大椎板成形术(A组),35例行选择性融合联合单开门椎管扩大椎板成形术(B组),34例行传统颈后路椎板切除固定术式(C组)。分别于术前、术后2d及末次随访时采用日本矫形外科学会(Japanese Orthopaedic Association,JOA)评分并计算Hirabayashi改善率,对患者的神经功能情况进行评估;拍摄颈椎正侧位及过屈过伸位X线片测量颈椎的曲度(C2-7 Cobb角)、颈椎整体活动度(C2-7 range of motion,C2-7 ROM)和颈椎不稳节段的活动度,统计内固定相关并发症。通过颈椎MRI评估患者颈髓高信号的情况并计算高信号强度比值(high signal intensity ratio,HSIR)。比较三组患者颈椎整体活动度和不稳节段的活动度,比较存在颈髓高信号患者的术前、术后HSIR及三组之间的差异。结果:三组患者均取得了满意的神经功能改善,末次随访时JOA评分分别为14.93±3.18分、15.22±2.79分和14.72±3.02分,Hirabayashi改善率分别为(66.35±13.48)%、(70.06±14.14)%和(64.14±18.05)%。三组患者术前颈椎曲度分别为7.43°±3.69°、7.66°±2.99°、6.96°±4.38°,组间比较无统计学差异(F=13.19,P=0.071),末次随访时颈椎曲度与术前相比基本一致(5.58°±4.26°、5.73°±3.81°、5.49°±4.33°),随访期间未发现颈椎曲度明显改变、后凸等情况。随访期间未出现内固定相关并发症。末次随访时A、B两组患者颈椎整体活动度(C2-7 ROM)无统计学差异(17.63°±8.31°和18.72°±9.52°,P=0.089),C组患者末次随访颈椎整体活动度明显差于A、B两组患者(3.90°±7.74°vs 17.6°±8.3°,P=0.012;3.90°±7.74°和18.72°±9.52°,P=0.003);B组、C组患者术后颈椎不稳节段活动度明显降低,末次随访时已完全融合。共有71例(71.03%)患者出现颈椎MRI T2加权高信号表现,存在高信号的节段与存在不稳的节段一致。三组患者HSIR值末次随访时均较术前明显降低(1.33±0.18 vs 1.68±0.11,1.12±0.12 vs 1.71±0.14和1.20±0.33 vs 1.65±0.18,P=0.001),但与A组患者相比,B组和C组患者的降低程度均较显著,差异存在统计学意义(P<0.05)。结论:选择性融合联合单开门椎管扩大椎板成形术是治疗存在局部不稳的颈椎OPLL患者的有效方法,可以在广泛减压颈脊髓压迫的同时增加颈椎的节段稳定性,同时保留颈椎一定的活动度、减少术后轴性症状发生。     

Two asymmetric contoured plate-rods for occipito-cervical fusion

The author presents a retrospective clinical study addressing the outcome after posterior stabilisation of the occipital-cervical spine using a new cranio-spinal implant. The range of surgical methods for operative treatment of occipito-cervical instability remains wide, and it is still a demanding technique that frequently requires improvisation by the surgeon. No previous studies have been published of occipito-cervical reconstructions using two contoured asymmetrical occipital plates interdigitating in the midline at the occiput and allowing various methods of cervical fixation, by means of different hooks, a claw device or screws. Nine patients with severe occipito-cervical instability and/or subaxial malalignment underwent reconstructive surgery with the new implants between 1998 and 2001. Seven patients suffered from rheumatoid arthritis (RA) including cranial settling. Two patients had widespread cervical metastases. All patients suffering RA were treated by preoperative cervical traction for up to 28 days, and intraoperative traction, to try to restore the malalignment. Traction was also used, to diminish pain and to improve neurological symptoms. The lowest vertebra fused was T3. All patients were immobilised with an external orthosis or brace for 6 weeks or 3 months. A solid fusion was achieved in all patients. None of the patients deteriorated postoperatively. No serious complications occurred. One occipital screw broke and one hook loosened, needing a re-fixation. The simplicity of applying these cranio-cervical implants makes them practical for every orthopaedic or neurosurgeon with a special interest in cervical spine surgery.     

Clinical and radiographic reports following cervical arthroplasty: a 24-month follow-up

We reviewed patients with cervical disc prosthesis replacement for single-level cervical disc disease to evaluate its clinical effect and maintenance of cervical spine motion. Fifteen patients underwent Bryan artificial cervical disc replacement and were followed-up for at least 24 months. No neurological or vascular complications were observed during or after operation. JOA, VAS, and NDI scores showed statistical significant improvement in our follow-up. The procedure achieved an 87% (13/15) satisfactory rate at 24-month evaluations according to Odom's criteria. The range of motion (ROM) of the cervical spine, treated segment, adjacent segment, and functional spinal unit (FSU) decreased at early follow-up, but they recovered to the preoperative level at 12- and 24-month follow-up. Also, preoperative lordosis of the cervical spine and FSU were not only maintained but also even improved during the 24-month follow-up. No obvious degeneration of adjacent discs were found at MRI. There were no cases of prosthesis subsidence or extrusion. The cervical disc prosthesis showed a good clinical outcome; it also restored ROM of the cervical spine and reestablished cervical curvature in our 24-month follow-up. But to be sure of its long term effect, a longer follow-up is needed.     

Cervical spine fusion in rheumatoid arthritis.

Spinal fusion for deformity of the cervical spine was done in thirty-three patients with rheumatoid arthritis. The average follow-up was three years. The deformities present were atlano-axial subluxation, superior migration of the odontoid process into the foramen magnum, and subaxial subluxation of the vertebral bodies. We devised a classification of the pain and the neural involvement in these patients and a new method of measuring superior migration. The surgical procedures for treating instability, intractable pain, or neural involvement, or a combination of the three, were: (1) a Gallie fusion of the first and second cervical vertebrae for atlanto-axial subluxation, (2) a fusion of the occiput and the second cervical vertebra for superior migration of the odontoid process, and (3) a posterior fusion for subaxial subluxation. The occiput was included in the fusion if superior migration of the odontoid process was demonstrated. The results show that four of five patients who had an anterior fusion had no improvement. Twenty-five patients had posterior fusion; in seventeen the condition was improved, in five there was improvement, and in three the condition was worse. Of nineteen patients with neural involvement, the condition was improved in eight, it was unchanged in seven, and it was made worse in two. There were three postoperative deaths and six additional unrelated deaths within two years of surgery. There were five pseudarthroses.     

人工椎间盘置换术治疗跳跃型多节段颈椎病的中期疗效

 目的 评价 Bryan 人工间盘置换术治疗跳跃型多节段颈椎病的疗效。方法 回顾性分析 2002 年 2 月至 2012 年 5 月接受 Bryan 间盘置换术（Bryan 组）或颈前路减压植骨融合术（ACDF 组）治疗的跳跃型多节段颈椎病患者相关资料。临床功能评估采用日本矫形外科协会（Japanese orthopaedic association,JOA）评分、颈椎功能障碍指数（neck disability index,NDI）、疼痛视觉模拟评分（visual analoguc scale,VAS）,影像学评估采用颈椎矢状位曲度、颈椎整体活动度及中间节段活动度,并于末次随访时评估邻近节段退变情况。结果 49 例患者随访超过 24 个月,Bryan 组 18 例,ACDF 组 31 例。两组患者性别、年龄、疾病类型等人口学资料的差异无统计学意义。两组患者术后 JOA、NDI、VAS 评分均较术前有明显改善。两组间各时间节点比较仅末次随访时 VAS 评分的差异有统计学意义。Bryan 组术后轴性症状发生率、颈椎活动度和未手术节段活动度分别为 11.1%、35.5°±5.9°和 7.3°±1.4°,ACDF 组分别为 45.2%、24.5°±6.2°、10.1°±1.6°,差异均有统计学意义。Bryan 组患者邻近节段无明显退变,ACDF 组 2 例出现退变,但无需再次手术。结论 应用 Bryan 间盘置换术治疗跳跃型多节段颈椎病,可有效改善神经功能,保留颈椎整体活动度,减少未手术节段活动度的代偿性增加,从而降低邻近节段退变及轴性症状发生率。     

Solis融合器在前路颈椎椎间融合术治疗邻椎病中的应用

目的探讨Solis融合器在前路颈椎椎间融合术治疗邻椎病(ASD)中的应用,总结其在颈椎前路术后ASD翻修术中的临床疗效、优势及缺点。方法回顾性分析2007年4月—2016年6月收治的使用Solis融合器行颈椎前路手术后需行翻修术的12例ASD患者的临床资料,记录手术时间、术中出血量,通过患者术前、术后日本骨科学会(JOA)评分、颈椎功能障碍指数(NDI)、吞咽困难情况等评估神经功能,结合手术前后X线片、CT及MRI影像学表现评估临床疗效。结果所有患者术后随访4～114(61.8±29.3)个月。术后JOA评分、NDI均较术前明显改善,差异具有统计学意义(P 0.05)。所有患者翻修术后均未出现吞咽困难等并发症,复查颈椎正侧位X线片均证实获得骨性融合。结论 Solis融合器应用在颈椎前路手术后ASD翻修术中安全有效,具有暴露范围小、手术时间短、对原手术节段无干扰、术后吞咽困难发生率低等优点。     

Bryan人工间盘置换与前路减压融合治疗颈椎退行性疾病的中期随访研究

 目的 评价人工椎间盘置换术治疗颈椎退行性疾病的中期疗效,并探讨其是否可以减少邻近节段退变的发生。方法 前瞻性对比分析接受颈椎人工间盘置换术(置换组,45例)与颈椎前路减压融合术(融合组,48例)治疗的颈椎退行性疾病患者的随访6年临床疗效和影像学资料。临床疗效评价指标为日本骨科协会评分(Japanese Orthopaedic Association Scores,JOA)、颈椎功能残障指数量表(neck disability index,NDI)和Odom评分。影像学评价指标为矢状位曲度、活动度、邻近节段退变。结果28例置换组患者和35例融合组患者完成随访。两组患者末次随访的JOA评分和NDI均较术前有明显改善,组间比较差异无统计学意义。92.9%的置换组患者和97.1%的融合组患者Odom评分获得很好或较好的结果。两组患者颈椎矢状位曲度末次随访较术前均得到保持。颈椎整体活动度置换组末次随访与术前无明显差异,而融合组则是明显降低。置换组置换节段活动度术前为9.5°±3.7°,术后3个月为7.0°±3.0°,末次随访为6.6°±4.1°,末次随访较术后3个月无明显改变。邻近节段退变评估采用侧位X线片和MRI T2加权像,置换组上、下邻近节段退变均明显少于融合组。结论 Bryan人工椎间盘置换术6年的随访结果基本满意,能更好地保留颈椎生理活动及生物力学环境,从而降低邻近节段退变的发生率。     

人工颈椎间盘置换术在后纵韧带骨化症中的应用

[目的]观察应用Bryan颈椎间盘假体置换术治疗后纵韧带骨化症的近期效果。[方法]2005年10月～2007年6月应用Bryan人工颈椎间盘假体置换术治疗局限型后纵韧带骨化症患者15例,术前和术后6个月时进行JOA评分,并摄颈椎前屈后伸位X线片,观察假体稳定性及颈椎置换节段的活动度。[结果]患者术后症状均明显缓解,随访6～24个月,JOA评分由术前平均8.5分上升至术后平均15.8分。置换节段保留了运动功能,假体稳定无移位。[结论]人工颈椎间盘置换术近期可保持前路减压的良好效果,同时可获得术后即刻稳定性。维持颈椎近正常的活动度。人工颈椎间盘置换术是治疗局限型后纵韧带骨化症的一种有效方法。     

Occipito-cervical fusion using posterior titanium plates

Occipito-cervical fusion may be indicated for instability of the occipito-cervical junction or atlanto-axial spine secondary to a wide spectrum of pathology. Many techniques exist to stabilize the spine until fusion is achieved. Recent reports of plate fixation have been favorable. In this study we set out to determine the effectiveness and advantages of titanium plate fixation when used to stabilize the occipito-cervical junction. Thirteen patients with occipito-cervical instability or atlanto-axial instability underwent occipito-cervical fusion using posterior titanium plates. The plates were contoured to the occipito-cervical junction and fastened to the skull with screws, and to the spine with lateral mass screws. The patients were followed prospectively clinically and radiographically to a minimum of 24 months. Outcome parameters included peri-operative morbidity and complications, hardware integrity, spinal alignment, fusion, and neurological status. Twelve of thirteen patients went on to solid fusion radiologically and clinically, and recovered or improved from their myelopathy. One patient did not. Three patients had radiographic evidence that two screws were loose and one screw was broken. There were no instances of plate breakage. We conclude that titanium plate fixation of the occipito-cervical junction is versatile and stable. The plates maintain axial correction and allow for future MR imaging. Received: 19 February 1997 Revised: 30 January 1998 Accepted: 9 February 1998     

The characteristics of bony ankylosis of the facet joint of the upper cervical spine in rheumatoid arthritis patients

This study investigated the bony ankylosis of the upper cervical spine facet joints in patients with a cervical spine involvement due to rheumatoid arthritis (RA) using computed tomography (CT) and then examined the characteristics of the patients showing such ankylosis. Forty-six consecutive patients who underwent surgical treatment for RA involving the cervical spine were reviewed. The radiographic diagnoses included atlanto-axial subluxation in 30 cases, vertical subluxation (VS) in 10 cases, VS + subaxial subluxation in 3 cases and cervical spondylotic myelopathy in 3 cases. The patients were classified into two groups, those developing bony ankylosis or not and then the differences in the patient characteristics between the two groups was investigated. Furthermore, cervical spine disorders and surgeries were also evaluated in patients who demonstrated such bony ankylosis. The CT reconstruction image demonstrated bony ankylosis in 12 patients (group BA), and the remaining 34 cases (group NB) showed no bony ankylosis. The level at which bony ankylosis occurred was atlanto-occipital joint (AOJ) in eight cases, atlanto-axial joint (AAJ) in two cases and AOJ, AAJ in two cases. No differences were observed between the two groups (age P > 0.54, gender P > 0.39, duration of RA P > 0.72). There was a significant difference between two groups in the patients showing obvious neurological impairment (P = 0.017). In BA group, arthrodesis or decompression was adapted for a caudal region of bony ankylosis. In conclusion, bony ankylosis of the facet joint of the upper cervical spine was detected in 12 of 46 RA patients with involvement of the cervical spine who thus required surgery. These findings showed that the patients demonstrating such ankylosis showed severe cervical myelopathy. In addition, we suggest that the occurrence of bony ankylosis was a risk factor for instability of AAJ, and subaxial instability or stenosis.