外伤性寰椎横韧带断裂的治疗策略

目的探讨外伤性寰椎横韧带断裂治疗策略。方法回顾性分析一组24例寰椎横韧带断裂病例,其中单纯横韧带断裂15例,合并有寰椎骨折7例,合并齿状突骨折2例。急性损伤20例,陈旧性损伤4例。手术行寰枢椎融合术14例,枕颈融合6例,非手术治疗3例,入院后当天死亡1例。结果23例获得随访,平均随访时间为46个月。20例手术治疗患者中15例完全恢复正常,3例仍有局部症状,2例颈脊髓神经损害改善,无术后神经损害加重病例。3例接受非手术治疗患者中有2例出现寰枢椎不稳及迟发性脊髓损害。结论寰椎横韧带是维持寰枢椎正常解剖关系不可或缺的重要结构,横韧带断裂必然导致寰枢椎不稳定。无论是急性或陈旧性损伤,一旦诊断明确即应在早期行寰枢椎或枕颈融合术。     

寰椎横韧带损伤的治疗策略

[目的]探讨寰椎横韧带在各种损伤状态下的治疗策略。[方法]本组共收治寰椎横韧带损伤患者26例，分析X线、CT及MRI资料，根据是否合并寰椎（或）齿状突骨折、损伤节段的稳定性及脊髓的损伤情况，4例行枕颈融合术，17例行寰枢椎融合术，5例行保守治疗。[结果]26例患者获6～36个月（平均18个月）随访，21例手术治疗患者疗效满意，5例保守治疗，其中4例效果满意，1例远期效果不佳行手术治疗。[结论]对于寰枢椎脱位、横韧带严重损伤，采用枕颈融合或寰枢椎融合术；对于横韧带部分损伤、寰枢椎稳定的患者采用保守治疗，但必须密切随访，出现不稳症状尽早手术治疗。     

创伤性寰椎横韧带断裂

目的：探讨创伤性寰椎横韧带断裂的诊断和治疗。方法：回顾性分析２３例创伤性寰椎横韧带断裂,其中急性损伤９例,陈旧性损伤１４例。所有患者均有颈部症状。１７例有神经损害。Ｘ线检查显示寰齿间距（ＡＤＩ）为６￣１４ｍｍ。本组有５例行非手术治疗,其余１８例行枕颈融合术或寰枢椎融合术。结果：随访１￣１７年（平均７年）,５例接受保守治疗患者中有４例出现寰枢椎不稳及迟发性脊髓损害,１８例手术治疗患者中４例完全恢复正     

寰椎Jefferson''''s骨折伴横韧带损伤的诊治策略

寰椎是枕-寰-枢复合体的重要一环。其损伤后致枕颈部的不稳对患者的影响很大。寰椎Jefferson’s骨折伴有横韧带损伤临床上罕有，对其临床诊断和外科治疗策略的研讨已成为上颈椎损伤研究和临床实践中的新热点。本文结合近年来相关文献从寰椎Jefferson’s骨折伴横韧带损伤的应用解剖、致伤原理、临床表现和诊断、治疗策略四个方面对其进行了文献总结和讨论     

寰椎骨折治疗进展

长期以来,寰椎骨折的治疗存在多种争议.该文在对单纯寰椎骨折机制、分型和稳定性进行文献复习的基础上,重点介绍寰椎骨折的治疗进展:对于稳定型寰椎骨折,通常采用保守治疗;对于不伴有横韧带断裂的不稳定型寰椎骨折,可依病情采取保守治疗、寰椎单节段复位固定术及寰枢、枕颈融合术;对于伴有横韧带断裂的不稳定型寰椎骨折,寰枢椎融合术或枕颈融合术是经典术式,寰椎单节段固定术的内固定效果亦受到关注,但是否可用于伴横韧带断裂的不稳定型寰椎骨折,目前仍未有令人信服的临床报道.     

急性外伤性寰椎横韧带损伤程度的评价与治疗探讨

目的对急性外伤性寰椎横韧带损伤程度进行评价,并探讨其治疗。方法回顾性分析2002年6月～2004年12月12例急性外伤性寰椎横韧带损伤病例。5例为单纯性损伤,7例为合并有寰椎和/或齿状突骨折的横韧带损伤。8例行寰枢椎或枕颈融合术,4例保守治疗。结果12例患者均获平均20个月随访。8例手术治疗患者效果均满意。4例保守治疗患者中3例获得满意结果,1例欠佳。结论寰椎横韧带是维持寰枢椎正常解剖关系不可或缺的重要结构,横韧带损伤常导致寰枢椎不稳定,但对一些损伤较轻者仍可采取保守治疗并获得满意效果。因此,正确评价外伤性横韧带损伤程度对治疗策略的选择和疗效至关重要。     

成人寰椎骨折的治疗策略

目的 :探讨成人寰椎骨折的治疗策略。方法 :2013年5月~2015年12月我科共收治成人单纯寰椎骨折患者58例,男31例,女27例;年龄18~72岁(45.3±14.0岁)。7例稳定寰椎骨折患者采用硬颈围固定;22例不伴横韧带断裂的不稳定寰椎骨折患者,采用头颈胸支具固定20例,halo支具固定2例;29例伴横韧带断裂的不稳定寰椎骨折患者,采用后路寰枢椎内固定融合术20例,后路寰椎单椎节内固定术9例。对患者进行常规随访,记录美国脊髓损伤协会(ASIA)分级、疼痛视觉模拟评分(VAS)以及治疗相关并发症。采用CT评估骨折愈合情况和植骨融合情况,采用颈椎动力位X线片评估寰枢椎稳定性。结果:所有患者随访12~24个月(14.3±4.0个月)。随访CT示,采用硬颈围固定的7例稳定寰椎骨折及采用头颈胸支具或halo架固定的22例不伴横韧带断裂的不稳定寰椎骨折均获得骨性愈合。20例行后路寰枢椎内固定融合术的伴有横韧带断裂的不稳定寰椎骨折有18例获得骨性融合,2例未融合但内固定仍牢靠。颈椎动力位X线片示9例行后路寰椎单椎节内固定术的患者均无寰枢椎失稳征象。治疗前ASIA分级D级4例,E级54例;末次随访ASIA分级均为E级(Z=-2.000,P=0.046)。治疗前VAS评分为4~8分(6.6±1.0分),末次随访为0~2分(0.4±0.7分)(Z=-6.682,P0.001)。保守治疗者有2例枕部发生皮肤压疮;手术者术中均无神经血管损伤,术后2例发生切口感染。结论:对于稳定的寰椎骨折,采用硬颈围固定即可;对于不伴横韧带断裂的不稳定寰椎骨折,采用头颈胸支具或halo架固定可取得良好疗效;对于伴有横韧带断裂的不稳定寰椎骨折,采用后路寰枢椎内固定融合术或后路寰椎单椎节内固定术均可获得较满意的疗效。     

后路钉板寰枢关节、枕颈固定融合术

目的报告后路寰枢椎侧块、枕颈钉板固定融合术治疗寰枢椎不稳定的疗效。方法2006年1月至2007年12月,用特制螺钉及连接板固定寰枢椎、枕骨枢椎,治疗12例寰枢关节不稳定的患者。其中横韧带松弛3例,先天性齿突不连3例,寰椎骨折2例,齿状突粉碎骨折2例,寰枢椎脱位2例。结果本组12例获得5-28个月随访,平均16.3个月,均获得了骨性融合。没有神经、血管损伤和断钉、断板的病例。结论后路使用螺钉、固定板的寰枢关节、枕颈固定融合术具有短节段固定作用,不仅疗效可靠,而且便于寰枢关节复位。     

创伤性寰枢关节旋转脱位的诊断与外科治疗(附32例报告)

目的 探讨创伤性寰枢关节旋转脱位的诊断与外科治疗.方法 自1997年1月～2008年12月收治创伤性寰枢关节旋转脱位32例,其中15例入院前被漏诊或误治.18例采取非手术治疗;14例接受手术治疗:手术包括Summit枕颈融合术内固定2例,Cervifax枕颈融合术内固定1例,Maged寰枢椎融合术2例,C1、2侧块关节螺钉固定结合Apofix椎板夹固定4例,C1侧块、C2椎弓根钉棒固定系统内固定5例.结果 27例(14例手术和13例非手术治疗)获得随访,平均4.5年.斜颈、疼痛症状消失15例,明显缓解7例,部分缓解4例,无变化1例.14例合并神经系统损伤,经治疗后神经症状均有明显好转.手术治疗的14例均获得骨性愈合.结论 外伤病人如诉头颈或枕部疼痛伴头颈偏斜,要考虑寰枢关节旋转脱位的可能,并常规行上位颈椎CT薄层扫描,必要时CT三维重建.对于寰枢关节陈旧性旋转脱位或合并寰椎横韧带断裂、寰椎爆裂骨折等难复性骨折脱位,应及时进行手术治疗.     

枕颈CD内固定在枕颈融合术中的应用

目的：研究枕颈CD内固定在枕颈融合术中的价值和作用。方法：对13例上颈椎不稳患者行枕颈部自体植骨融合枕颈CD内固定术。其中包括寰枢椎肿瘤4例,陈旧性寰枢椎骨折脱位4例,枕寰枢椎复合性畸形4例,陈旧性横韧带断裂伴寰椎前脱位1例。结果：13例患者均获随访5－27个月,平均10个月。所有病例植骨均完全愈合,无一例发生枕颈CD椎板钩及螺钉松动等并发症。结论：枕颈CD可提供有效的节段固定,适用于枕颈不稳的治疗。     

寰枢椎不稳的颈后路手术治疗

目的 对寰枢椎不稳的颈后路手术治疗进行探讨。方法 共78例患者,男57例,女21例;年龄3－78岁,平均42岁。其中齿突骨折（新鲜骨折、陈旧骨折、骨不连）38例,齿突游离小骨15例,寰椎横韧带断裂8例,寰枢椎肿瘤6例,枕颈部发育畸形6例,寰椎椎弓陈旧性骨折5例。78例均行颈后路手术,包括枕颈融合术32例,其中单纯植骨融合11例,辅以CD－Cervical内固定11例,Cervifix内固定10例;寰枢椎融合术46例,其中钢丝钛缆内固定37例（9例同时行寰枢椎经关节间隙螺钉内固定术）,Apofix椎板夹内固定9例。结果 78例均获随访,时间6个月－18年,平均38．4个月。骨性愈合75例,不愈合3例。术前合并神经系统症状38例,术后症状消失或基本消失20例,明显改善11例,轻度改善3例,无改善2例,加重2例。结论 对于由寰枢椎骨折脱位、畸形、肿瘤及横韧带断裂等引起的寰枢椎不稳,应早期进行后路融合术。充分控制寰枢椎活动,精心准备植骨床是保证手术成功的关键。     

Bilateral atlas laminar hook combined with transarticular screw fixation for an unstable bursting atlantal fracture

Introduction  The unstable atlas burst fracture (“Jefferson fracture”) is a fracture of the anterior and posterior atlantal arch with rupture of the transverse atlantal ligament and an incongruence of the atlanto-occipital and the atlanto-axial joint facets. The posterior atlantoaxial fusion is frequently used to reconstruct the stability of atlantoaxial joint. Conventional posterior atlantoaxial fixations are associated with high rates of pseudoarthrosis and chronic atlantoaxial instability. As a modified three-point fixation the bilateral C1-2 transarticular screws combined with C1 laminar hook and bone grafts can provide best biomechanical stability, but no standard protocol has been reported for the use of this fusion technique. A retrospective review of clinical series should be conducted to evaluate the clinical outcome of bilateral atlas laminar hook combined with transarticular screw fixation for unstable bursting atlantal fracture. Materials and methods  From March 2002 to March 2006, there were total 12 cases of unstable atlantal bursting fractures, 10 males and 2 females, age ranging 18–54, with mean of 36 years old. All patients were operated on posterior atlantoaxial fusion using bilateral atlas laminar hook combined with transarticular screw fixation after atlantoaxial joint were reduced and followed up for 12–24 months. The medical records and radiographs of the 12 patients were reviewed. Each patient underwent a complete cervical radiograph series including lateral flexion-extension view and a computed topographic scan. The Frankel grades and ASIA scores were applied to assess the neurologic status. Results  In all patients, a good bony fusion of the atlanto-axial segment was achieved. All patients showed significant improvement of the neurologic defect and no instability on their follow-up plain radiographs and computerized tomography in follow-up interval. Conclusions  For the patients who suffer from the unstable bursting atlantal fracture, the nonoperative methods could carry some clinical complications including infection, nerve injury, etc. and is frequently failure, Posterior atlantoaxial fusion using bilateral atlas laminar hook combined with transarticular screw fixation is an effective treatment. Xiang Guo and Bin Ni contributed equally to the article.     

后路融合术治疗不稳定寰椎爆裂性骨折

目的 评价后路融合术(枕颈融合或寰枢椎融合术)治疗不稳定寰椎爆裂性骨折的临床疗效.方法 从2005年10月～2008年10月,共收治不稳定寰椎爆裂性骨折20例.所有患者均早期行后路融合术,回顾治疗过程,分析随访结果.结果 术后均随访24个月.13例临床症状完全消失;7例有神经损伤的患者获得明显改善.术后3个月颈椎X线片及CT三维重建片提示内固定位置良好,寰枢关节无不稳征象;18例在术后3个月内植骨块已完全融合,2例植骨块在术后6个月也获得完全融合.各个随访时间点未见并发症出现.患者术后3个月ASIA评分与人院时比较明显提高,差异具有统计学意义(P＜0.05).结论 颈椎后路融合术是一种安全有效的治疗不稳定寰椎爆裂性骨折的方法.术式首选寰枢椎融合术,慎重选择枕颈融合术.     

Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability

Twenty normal human subjects and 14 patients with upper cervical spine pathology were studied with axial high-field magnetic resonance (MR) imaging to examine the transverse atlantal ligament. Gradient-echo MR imaging pulse sequences provided reliable visualization of the transverse ligament, which exhibited low signal intensity and extended behind the dens between the medial portions of the lateral masses of C-1. The MR imaging characteristics of the transverse ligament were verified in clinical studies and in postmortem specimens. The clinical MR examinations defined 27 normal ligaments, three ligament disruptions, and four stretched rheumatoid ligaments. Atlantoaxial instability associated with transverse ligament rupture or ligamentous laxity required internal fixation. In contrast, fractures of C-1 or C-2 or atlantoaxial rotatory dislocations associated with an intact transverse ligament healed without instability or nonunion. The transverse ligament is the primary stabilizing component of C-1. The treatment of atlantoaxial instability has previously been based on criteria drawn from computerized tomography or plain radiographic studies, which only indirectly assess the probability of rupture of the transverse ligament. It is concluded that MR imaging accurately depicts the anatomical integrity of the transverse ligament. After transverse ligament failure, the remaining ligaments of the craniovertebral junction are inadequate to maintain stability. The presence of ligament disruption should be considered as a criterion for early fusion.     

陈旧性寰椎横韧带断裂的手术治疗

目的探讨陈旧性寰椎横韧带断裂的后路手术治疗。方法回顾性分析12例陈旧性寰椎横韧带断裂病例,患者病程为伤后3个月~2年,平均为12个月,患者均有程度不等的神经损伤表现。X线检查显示寰齿间距(ADI)为6~12mm。所有患者均接受Apofix固定并寰、枢椎融合术。本组患者术前均施行颅骨牵引,以获得寰枢关节复位或接近解剖复位。结果随访6个月~3年,所有患者术后均未出现寰、枢椎不稳定的表现。结论陈旧性寰椎横韧带断裂是导致寰、枢椎不稳定的重要原因之一。其诊断依赖于ADI测量及MRI检查。一旦诊断明确,后路寰枢椎融合术是一种有效的治疗方法。术前牵引复位是施行后路寰枢椎融合术的前提。     

Surgical treatment of nonunited fractures of the odontoid process, with special reference to occipitocervical fusion for unreducible atlantoaxial subluxation or instability

Fifty-seven consecutive patients treated surgically for nonunited fractures of the odontoid process were reviewed. All patients presented late, exhibiting neurological deficits subsequent to nonunion. Delay in presentation was between ¶6 and 120 months (mean 32 months) after the original injury, due to missed diagnosis or inappropriate management. Seven patients who were reduced in traction underwent a Gallie atlantoaxial fusion. In the remaining 50 patients who were unreducible, an occipitocervical arthrodesis was performed. They were followed up for a minimum of 2 years, except one who died from postoperative respiratory failure. All patients obtained a solid bony union, including two in whom nonunion occurred following atlantoaxial fusion, and occipitocervical fusion was added as a rescue. Thirty-eight patients achieved excellent neurological recovery, nine still had some disability, five retained their neurological deficits and two reported a deterioration. In two patients, a recurrence in a traumatic episode was experienced long after a resolution. Our findings demonstrate that occipitocervical arthrodesis is preferable for unreducible subluxation or instability of atlantoaxial articulation in nonunion of odontoid fractures.     

Traumatic atlantal anterior arch fracture with associated avulsion fracture of the transverse ligament attachment: a previously undescribed combined entity

A case of an atlantal anterior arch burst fracture combined with an avulsion fracture of the transverse ligament attachment is presented. Similar cases have dealt with either isolated transverse ligament ruptures and avulsions or with Jefferson fractures associated with transverse ligament ruptures and avulsions. This case probably represents an entity in the spectrum of injury patterns to the atlanto-axial articulation.