难复性寰枢关节脱位的手术治疗

目的探讨难复性寰枢关节脱位的手术治疗方法。方法54例难复性寰枢关节脱位患者,男32例,女22例;年龄7～63岁,平均32岁。其中齿突不连18例,寰椎枕骨化畸形22例,齿突骨折畸形愈合5例,寰椎横韧带松弛9例。40例有脊髓病或脊髓损伤的症状、体征。先行经口咽入路的寰枢关节松解复位术,术中横断挛缩的椎前肌、前纵韧带和侧块关节囊,借助于牵引和器械撬拨的力量使寰枢关节复位;同期行后路寰枢或枕颈固定植骨融合术,后路固定方法包括经寰枢侧块关节螺钉固定5例、寰枢侧块钉板固定12例和借助于枢椎椎弓根螺钉与枕颈固定板的枕颈固定37例。术后不用外固定。结果41例获得解剖复位;13例部分复位,其中2例行部分齿突切除,另11例术前颈髓角平均104.1°,术后120.2°。48例随访4～40个月,平均15.7个月,全部病例均获骨性融合。术前有脊髓症状的38例术后功能评价(Odom标准)为优15例,良14例,可8例,差1例。术中出现硬膜破裂1例,椎弓根钉切割1例;术后出现呼吸衰竭1例,发音不正常3例,吞咽不利1例,术后2周发生败血症脊髓炎致瘫痪1例,术后2个月内固定松动1例。结论经口咽入路寰枢关节松解复位结合后路坚强内固定及植骨融合,对难复性寰枢关节脱位有良好的治疗效果。

A novel surgical treatment of irreducible atlantoaxial dislocation

Objective To explore a novel operative management for irreducible atlantoaxial dislocation. Methods Fifty-four patients, which as 32 males and 22 females aged from 7 to 63 years old with a mean of 32 years, were diagnosed with irreducible atlantoaxial dislocation, including 18 patients with os odontoideum, 22 occipitalization, 5 malunion of odontoid fracture and 9 relaxation of transverse ligament of atlas. Forty patients presented signs and symptoms of myelopathy or spinal cord injury. All of the patients underwent the operation of open reduction and release by transoral approach. The longus collies muscles, longus capitis muscles, anterior longitudinal ligament, atlantoaxial articular capsules, the apical odontoid ligament and alar odontoid ligaments may be included, were transected, followed by arthrodesis via posterior approach in one stage. Different methods of posterior arthrodesis were conducted as followed: C1,2 transarticular screw fixation in 5 cases, occipitocervical fixation using pedicle screws of axis and occipitocervical plate in 37 cases, and C1,2 joint fixation with plates and screws in the lateral masses of the atlas and axis in 12 cases. Results A complete reduction was achieved in 41 cases, and the other 13 patients obtained partial reduction. Forty-eight patients were followed up from 4 to 40 months, 15.7 months at the average. All of them achieved solid arthrodesis. According to Odom's scoring system, among the 38 patients with preoperative upper cervical myelopathy, 15 patients were assessed as excellent, 14 good, 8 fair and 1 poor. During the operation, cerebral spinal fluid leakage occurred in 1 case, and pedicle screwing failed in 1 case. After the operation, respiratory failure was found in 1 case, nasal sound in 3 cases, dysphagia in 1 case. One patient became quadriplegia due to myelitis caused by septicemia at two weeks after the operation. The internal fixation loosened in 1 case at 2 months postoperatively. Conclusion Transorally surgical release for reduction and posterior arthrodeses could achieve satisfactory outcomes in patients with irreducible atlantoaxial dislocation.