颈椎椎弓根内固定系统在枕颈融合术中的应用

[目的]探讨颈椎椎弓根内固定系统在枕颈融合术中的应用价值. [方法]回顾性研究了2004年1月～2007年1月本院应用颈椎椎弓根内固定系统行枕颈融合术的21例患者,男12例,女9例,平均45.3岁(28～61岁).其中上颈椎肿瘤患者14例,颈椎先天性发育畸形3例,齿状突骨折伴寰枢椎脱位4例.术后采用临床观察、影像学评价及统计学方法分析疗效. [结果]全部患者均获随访,随访时间平均21个月(6～40个月).16例患者术后3个月X线片显示植骨愈合,5例患者术后6个月X线片显示植骨愈合;无脊髓损伤加重等并发症,术前JOA 17分法评定脊髓功能,平均12.6分(5～17分),术后平均15.8分(8～17分),改善率72%;21例患者术后旋转功能均有部分丢失,17例患者旋转约达100°,3例患者旋转约达80°,1例患者旋转约达50°. [结论]颈椎椎弓根内固定系统具有经三柱固定的万向螺钉以及与之相连的可塑形棒,可以达到坚强的固定、有利于植骨的融合以及术后颈椎生理曲度的维持,是一种有效、可靠的重建上颈椎稳定的方法.     

Occipitocervical fixation with a single occipital clamp using inverted hooks

A simple occipitocervical osteosynthesis technique using cervical CCD (compact Cotrel-Dubousset) material is described in a clinical case. The originality of this technique consists in the occipital fastening used, involving the simultaneous insertion of two hooks into a single burr-hole. This greatly facilitated the positioning of the osteosynthesis rods, reduced surgical time, and provided immediate stability. These criteria are of considerable importance since this difficult surgical procedure is often performed in patients in a frail condition. Received: 2 August 1996 Accepted: 16 September 1996     

枕颈植骨融合内固定术治疗枕颈畸形

2008年1月～2011年1月,我科对16例枕颈畸形患者采用枕颈植骨融合内固定术,取得良好效果,报道如下. 1材料与方法 1.1病例资料本组16例,男9例,女7例,年龄26 ～58岁.患者术前均行颈椎X线、CT三维重建及MRI检查,诊断为枕颈畸形.其中颅底凹陷并寰椎枕化7例,寰椎后弓缺如4例,C2～3先天融合4例,C4～5先天融合合并寰枢关节不稳1例.合并症:10例脊髓空洞,8例小脑扁桃体下疝,1例脑积水.     

Occipitocervical fusion

The evolution of occipitocervical fixation and new rigid universal screw-rod construct technology has allowed secure anchorage at each level of the occipitocervical junction with the elimination of rigid external orthoses. Rigid occipitocervical instrumentation constructs have achieved higher fusion rates and less postoperative immobilization-associated complications. Outcomes have improved compared with former nonrigid instrumentation techniques; however, with advances of rigid occipitocervical stabilization capability have come new challenges, risks, and operative techniques. A thorough understanding of the relevant cervical bony and soft tissue anatomy is essential for safe implantation and a successful outcome.     

Occipitocervical Injuries

There is a wide spectrum of injuries that occur at the occipitocervical junction. Although a majority of the injuries can be treated nonoperatively, a combination of fractures and ligamentous injuries to this region can lead to the need for surgical intervention, to provide stabilization of this critical region. The increased use of advanced imaging studies, such as computed tomography and magnetic resonance imaging, has led to an increased recognition of these injuries, with improvement in classification and treatment recommendations.     

Occipitocervical arthrodesis in children

A technique for occipitocervical arthrodesis was used in seven patients whose ages ranged from three to thirteen years. The indication for the arthrodesis was occipitocervical instability secondary to various forms of dysplasia. There were no non-unions, and internal fixation was used in only one patient. Six patients were immobilized postoperatively with halo fixation. There was only slight limitation of cervical motion after fusion; we believe that the limitation was due to increased motion in the vertebral segments caudad to the level of fusion. Six patients had full flexion, and only three patients had decreased rotation. We found that, in young patients, occipitocervical arthrodesis by means of the described procedure was both safe and effective.     

新的枕颈中立位影像学参数：枕颈倾斜度

目的通过枕颈倾斜度(occipitocervical inclination,OCI)与枕颈矢状位各参数间的相关性研究,评价枕颈倾斜度的临床应用价值。方法通过北京大学首钢医院骨科门诊招募无颈肩部症状的416名志愿者,其中男性177例,女性239例;年龄18-85岁,平均(49.44±14.54)岁。运用PACS系统在标准侧位颈椎X线片上测量OCI、枕颈角(occipitocervical angle,OCA)、颈椎前凸角(cervical lordosis,CL)、C2-7矢状位平衡(C2-7sagittal vertical axis,C2-7SVA)、T1椎体倾斜角(T1slope,T1S)等矢状位参数,运用SPSS 20.0进行统计分析。结果 OCI、OCA、CL、T1S、SVA分别为(111.14±8.68)°、(22.97±8.02)°、(17.02±11.32)°、(26.47±6.90)°、(19.08±9.48)mm,其中OCA、CL、T1S男女性别之间比较差异有统计学意义(P<0.05);OCI与OCA、SVA之间的Pearson相关系数r分别为0.623(P<0.001)、0.433(P<0.001)。结论枕颈倾斜度是一个测量简便、稳定可靠的枕颈部矢状位参数;我们推荐中国人正常的OCI值为110°,可为术中快速有效的确定枕颈部中立位以及评价颈椎矢状位平衡提供临床参考。     

儿童颈枕融合

目的：研究儿童颈枕融合的适应证、融合方法及预后。方法：分析12例行颈枕融合的儿童患者，其中先天性颈椎畸形2例，寰枢椎半脱位6例，寰枢椎骨折脱位4例，采用“U”形金属棒固定结合自体髂骨植骨融合；评价其治疗效果并进行随访3-5年。结果：12例患者术后融合的时间为8-12个月，对生长发育无明显影响，无并发症，结论：应用“U”形金属棒固定结合植骨行颈枕融合治疗儿童先天性颈椎畸形，寰枢椎骨折脱位等疾病是一种安全、价廉、效果理想的方法。     

枕骨板障间螺钉固定枕颈融合术治疗伴寰椎枕化寰枢椎脱位的颅底凹陷症

目的:探讨应用枕骨板障间螺钉固定行枕颈融合术治疗伴寰椎枕化、寰枢椎脱位的颅底凹陷症的效果与安全性.方法:2004年1月～2012年6月收治9例伴寰椎枕化、寰枢椎脱位的颅底凹陷症患者,男6例,女3例;年龄36～58岁(45.4±7.8岁).患者均有脊髓受压症状,术前脊髓功能JOA评分为7～12分(9.6±1.9分).寰齿间隙(ADI)为3.5 ～ 14.2mm(8.4±3.2mm),齿状突顶部超出Chamberlain线的垂直距离(DDCL)为4.5～14.2mm(8.9±3.3mm),脑干延髓角(CMA)为118°～152°(135.4°±11.3°),脊髓有效空间(SAC)为4.3～9.2mm (6.3± 1.7mm).所有患者术前均行改良Halo-vest支架头颅-双肩撑开牵引复位1～2周;均应用枕骨板障间螺钉-棒-椎弓根螺钉系统进行枕颈融合术.记录手术时间、手术出血量等,观察并发症发生情况.术后复查影像学评价寰枢椎脱位复位和脊髓压迫改善情况;术后每3个月复查颈椎正侧位X线片及CT扫描直至植骨融合,采用JOA评分对脊髓功能改善情况进行评价.结果:手术均顺利完成,手术时间90～195min(132.2±33.9min);出血量80～200ml(122.2±43.4ml).1例术后出现切口皮下感染,经局部换药伤口愈合;1例出现脑脊液漏,经局部换药、腰椎蛛网膜下腔穿刺置管引流1周后愈合.术后ADI 2.5±1.5mm,DDCL 0.9±1.7mm,CMA 154.4°±9.2°,SAC16.3±1.98mm,与术前比较均有显著性差异(P＜0.01).板障间螺钉位置均满意,没有螺钉穿透枕骨内板,2枚C2椎弓根钉进入横突孔,但未发生椎动脉损伤与压迫.患者均获随访,随访时间6～18个月(11.7±4.7个月),患者临床症状均较术前有明显改善,末次随访时JOA评分12～16分(14.3±1.4分);术后3～9个月(5.0±2.1个月)植骨均获得骨性融合,无断钉、断棒及内固定松动发生.结论:应用枕骨板障间螺钉固定行枕颈融合术具有固定牢靠、操作简单、方便植骨等优点,是治疗伴寰椎枕化、寰枢椎脱位的颅底凹陷症的有效方法.     

Occipitocervical neutral position. Possible surgical implications

STUDY DESIGN: The study defines the occipitocervical neutral position using cervical radiographs from 30 subjects. OBJECTIVE: To identify reproducible radiographic measures of the occipitocervical neutral position that can be used during surgery to optimize fusion position. SUMMARY OF BACKGROUND DATA: When performing rigid internal fixation of the occiput to the cervical spine, the ability to determine that the occiput is in a neutral position in relation to the cervical spine is important. Currently, no objective radiographic measures for the occipitocervical neutral position exist. METHODS: Thirty flexion, extension, and neutral lateral cervical spine radiographs radiographs interpreted as normal by an experienced radiologist were studied. The occipitocervical angle and occipitocervical distance were defined and calculated. Two investigators, an orthopedic resident and an experienced orthopedic spine surgeon, measured the occipitocervical angle and occipitocervical distance independently on all radiographs in a blinded manner. Correlation coefficients were obtained to determine interobserver reliability. RESULTS: The mean occipitocervical angles were 24.2 degrees, 44.0 degrees, and 57.2 degrees in flexion, neutral, and extension, respectively. The mean occipitocervical distances were 21.5 mm in neutral, 28.0 mm in flexion, and 14.8 mm in extension. The differences in the occipitocervical angle and occipitocervical distance in neutral, flexion, and extension were statistically significant (P < 0.05 and < 0.001, respectively). There were no significant interobserver differences in any of the measurements. CONCLUSIONS: The radiographic measures of the occipitocervical neutral position reported in this study are reliable, repeatable, and simple to determine on routine lateral radiographs. These measurements should be a valuable intra-operative tool for achieving occipitocervical fusion in appropriate alignment.     

Axis系统枕颈固定融合术

为探讨和评估Axis内固定系统在枕颈融合中的临床效果,作运用Axis系统固定融合治疗4例严重的创伤性枕颈不稳患,并就术后并发症及融合、固定效果进行随访观察。结果显示4例均无神经系统并发症,固定牢固,3个月已获骨性融合,神经症状得以解除。作认为熟悉枕骨及颈椎解剖学特点是安全使用钉板行枕颈固定的保障。Axis内固定系统具较好的可折曲性,钉孔匹配好,方便枕颈部固定时钢板调整和选择最佳进钉位置,固定效果好。     

Occipitocervical fusion in patients with rheumatoid arthritis

Instability and deformity of the cervical spine caused by rheumatoid arthritis is a well known entity. Operative intervention is indicated for patients with progressive deformity and when pain is resistant to conservative treatment. In a series of 39 patients who underwent posterior occipitocervical fusion with a Y plate, 22 patients were observed clinically and radiographically at average 41.5 months after surgery. In 35 of the 39 patients the main indication for surgery was pain, and in 30 of the 39 patients additional neurologic deficit (radiculopathy or myelopathy) was present. Thirty-one of the 39 patients had atlantoaxial instability. The atlantoaxial instability was associated with cranial migration of the dens in 19 patients. According to the classification of Conaty and Mongan 77.3% patients had satisfactory results and 22.7% had unsatisfactory results. Of the 30 patients with neurologic deficit, nine patients had a significant improvement. No patient had a worse result after surgery. Solid fusion was seen in all 22 patients at followup. Seven patients experienced complications directly related to the surgical procedure. Posterior fixation combined with anterior decompression in the presence of spinal stenosis represents a useful and safe method to treat instability and deformity caused by rheumatoid arthritis. Early surgical procedures may reduce the complication rate.     

枕颈内固定系统在枕颈融合术中的应用

目的：探讨枕颈内固定系统在枕颈融合术中的应用价值。方法：对23例因先天性发育畸形、陈旧性骨折脱位及肿瘤所致的上颈椎不稳者在行枕颈融合术同时应用枕颈内固定系统行枕颈部内固定术。术后进行6～24个月(平均22个月)随访。结果：术后症状缓解，神经功能改善者占91％(21／23)，术后9个月植骨融合率达到100％。无内固定棒钉断裂及脱钩现象，仅有1例术后3个月出现枕骨部螺钉松动。结论：在行枕颈融合时应用枕颈内固定具有可获得术后枕颈部即刻稳定，防止植骨块移位，术后无需卧石膏床和提高植骨融合率等优点。