不稳定性Hangman骨折手术入路选择

目的:探讨前路或后路手术治疗不稳定性Hangman骨折的影响因素及临床疗效。方法:回顾性分析我院2004年5月~2011年5月收治的65例不稳定性Hangman骨折患者,术前采用颅骨牵引C型臂X线机透视观察椎间盘和韧带损伤程度,X线片、CT和MRI观察合并存在的骨折和畸形情况。对椎间隙增宽、C2关节突间部粉碎、C2关节突间部发育细小、C2椎动脉高切迹、C3椎弓根发育细小或无髓腔、C3椎体骨折者采用前路手术;对椎间隙无增宽、C2-C3关节突交锁牵引不能复位、C3椎弓根骨折者采用后路手术。通过临床和影像随访观察两组患者临床疗效。结果:本组患者除C2关节突间部骨折伴C2/C3不稳定外,合并存在的严重损伤和畸形包括:椎间隙增宽9例、C2椎弓根发育细小1例、C2椎动脉高切迹2例、C2关节突间部粉碎骨折3例、C2-C3关节突脱位6例、C3椎体骨折3例、C3椎弓根骨折3例、C3椎弓根细小2例、C3椎弓根无髓腔2例。前路手术15例:椎间隙増宽3例、伴C2关节突间部粉碎骨折2例、C3椎体骨折+C3椎弓根细小1例、C3椎体骨折+C2-C3后方关节突交锁牵引复位1例、C2椎动脉高切迹1例;椎间隙未增宽也需行前路手术者包括C2椎弓根发育细小1例、C3椎体骨折+C2-C3关节突交锁牵引复位1例、C2-C3关节突交锁牵引复位又不能判断C2/3椎间盘和韧带复合体损伤程度1例、C3椎弓根无髓腔2例、C2椎动脉高切迹+C3椎弓根细小1例、关节突间部粉碎骨折+C2-C3关节突交锁复位1例。后路手术50例:其中椎间隙增宽1例、C2-C3关节突脱位交锁牵引不能复位2例、C3椎弓根骨折3例。前、后路手术分别出现并发症7例次(47%)和8例次(16%),手术并发症发生率前路高于后路。结论:根据不稳定Hangman骨折合并C2/3椎间盘韧带结构损伤程度、合并存在的骨折和畸形情况选择前后路手术有利于提高临床疗效。

Option of anterior or posterior approach for unstable Hangman fracture

Objectives: To investigate the risk factors and clinical outcome of anterior or posterior approaches for unstable hangman fracture.Methods: 65 patients with hangman fracture from May 2004 to May 2011 in our hospital were reviewed retrospectively.Preoperative and intraoperative skull traction was applied and C-arm fluroscopy was used to evaluate the condition of C2-C3 disc and paravertebral ligaments.The fracture morphology of the involved cervical vertebrae was evaluated by X-rays,computed tomography and magnetic resonance images.Patients with the following conditions underwent anterior approach: C2-C3 disc space increase,comminuted fracture of pars interarticularis of C2,narrowed C2 pedicle,high notch of vertebral arteries of C2,C3 body fracture and C3 pedicle deformity.Patients without C2-C3 disc space increase or irreducible interlocking of posterior facets of C2-C3,or pedicle fracture of C3 underwent posterior approach.The clinical outcomes and rediograph results were reviewed.Results: Except for C2 pars fracture combined with C2/3 instability,severe injury and deformity included: completely rupture of C2-C3 intervertebral discs and ligamentous structure in 9 cases,narrowed C2 pedicle in 1 case,high notch of vertebral arteries of C2 in 2 cases,comminuted fracture of pars interarticularis of C2 in 3 cases,C3 body fracture in 3 cases,C3 pedicle fracture in 3 cases,C3 pedicle narrowing in 2 cases,and C3 pedicle sclerosis in 2 cases.Fifteen patients underwent anterior surgery,which included intervertebral disc space increase in 3 cases,fracture of C2 pars interarticularis in 2 cases,C3 body fracture and C3 pedicle narrowing in 1 case,C3 body fracture and reduced interlocking of posterior facets of C2-C3 in 1 case,C2 high notch of vertebral arteries in 1 case.Seven other cases without C2-C3 disc space increase also underwent anterior surgery,which included narrowing of C2 pedicle in 1 case,fracture of C3 body and reduced interlocking of posterior facets in 1 case,uncertain injuries of C2-C3 intervertebral discs and ligamentous structure in 1 case,C3 pedicle sclerosis in 2 cases,C2 high notch of vertebral arteries and C3 pedicle narrowing in 1 case,comminuted fracture of C2 pars interarticularis and irreducible facets interlocking in 1 case.Fifty patients received posterior surgery: no disc space increase in 44 cases,disc increase in 1 case,failure of reduction of C2-C3 in 2 cases,fracture of C3 pedicle in 3 cases.Anterior and posterior approach was noted 7 and 8 complications respectively.Conclusions: Unstable Hangman fracture complicated with C2/3 dislocation,injury to disc-ligament complex,complicated fracture and deformity can be used to guide the surgical approach.