后路寰枢椎固定融合治疗陈旧性寰枢椎损伤

目的 探讨后路寰枢椎固定融合治疗陈旧性寰枢椎损伤继发寰枢椎脱位的临床疗效. 方法 回顾性分析2008年3月-2012年3月采用寰枢椎后路固定融合术治疗的陈旧性寰枢椎损伤继发寰枢椎脱位患者16例,其中男14例,女2例.受伤至手术时间3～36个月,平均10.5个月.其中采用寰枢椎后路椎弓根钉板系统治疗13例,包括陈旧性齿状突骨折10例,陈旧性创伤性寰椎横韧带断裂合并寰枢椎脱位3例.采用经寰椎后弓椎弓根钉板联合枢椎椎板螺钉固定治疗3例,均为陈旧性齿突骨折合并寰枢关节脱位.全部患者在复位固定的同时行椎板间自体骨植骨.比较术前、术后日本骨科学会(JOA)评分变化,术后随访X线片及CT,观察寰枢椎复位及融合情况. 结果 所有患者均获随访,随访时间9 ～18个月,平均13个月.全组患者无一例发生脊髓或椎动脉损伤.复查CT显示2例一侧枢椎椎弓根螺钉部分进入横突孔,但无神经或血管损伤并发症,临床症状得到不同程度改善.术后JOA评分13 ～16分,平均14.8分,术前、术后JOA评分改善率为71％ ～92％,平均82％.复查X线片、CT显示骨性融合好,未见寰枢椎失稳或复位丢失征象,固定螺钉位置良好,无松动或断钉发生. 结论 后路寰枢椎固定融合可有效重建寰枢椎稳定性,并能改善脊髓神经功能,疗效可靠.     

CT analysis of the axis for transarticular screw fixation of rheumatoid atlantoaxial instability

Objective To investigate the morphological characteristics of the axis of rheumatoid arthritis (RA) patients with atlantoaxial instability and to determine, by means of sagittal reconstructed computed tomography (CT), the suitability for atlantoaxial transarticular screw fixation.Design and patients Twenty-seven patients, who had undergone reconstructed cervical spine CT scanning preoperatively and posterior atlantoaxial arthrodesis for atlantoaxial instability, were identified from a database for inclusion in this study. The isthmus height and internal height of the lateral mass of the axis were measured using digital imaging software.Results The mean isthmus height and internal height of the lateral mass of the axis in RA patients (n=14) were significantly lower than in non-RA patients (n=13) (P<0.01). A high-riding vertebral artery (VA) was present in 54% (15 joints, 9 patients) of the 28 atlantoaxial joints in the RA group and in 12% (3 joints, 2 patients) of the 26 atlantoaxial joints in the non-RA group (P<0.01).Conclusions In RA patients, the axis showed more extensive thinning of the isthmus and lateral mass than in non-RA patients. A precise preoperative evaluation of screw trajectory using reconstruction CT imaging may be useful in atlantoaxial transarticular fixation, particularly for RA patients with atlantoaxial instability.     

前路经寰枢关节螺钉内固定治疗寰枢椎不稳

目的 评估前路经寰枢关节螺钉内固定治疗寰枢椎不稳的临床疗效. 方法 选择2004年3月-2009年6月收治的寰枢椎不稳患者32例,其中男21例,女11例;年龄22～64岁,平均49岁.寰枢椎不稳的原因:齿状突陈旧性骨折10例,游离齿状突畸形16例,横韧带损伤2例,类风湿关节炎4例.32例患者均在皮层体感诱发电位(cortical somatosensory evoked potential,CSEP)监测下行前路经寰枢关节螺钉内固定术.记录手术时间、失血量及并发症情况,采用日本骨科协会(JOA)评分评估术前和术后1年神经功能情况. 结果 32例患者平均手术时间98 min,平均出血量110 ml,术中无食管、神经、椎动脉损伤或脑脊液漏.术后所有患者均获随访,时间12 ～31个月,平均19个月.JOA术前评分为9.8分,术后1年为15.8分,改善率为83％.所有患者均植骨融合,内固定位置良好.2例患者术后出现舌下神经损伤症状,术后2个月恢复. 结论 前路经寰枢关节螺钉固定是治疗寰枢椎不稳的有效方法之一.     

Quantification of C2 cervical spine rotatory fixation by X-ray,MRI and CT

Atlanto-axial rotatory displacement is known to be a cause of childhood torticollis and may as well be responsible for chronic neck pain after rear-end automobile collisions. The objective was to determine whether quantification of C2 malrotation is possible by plain radiographs in comparison to CT as the golden standard. MR imaging was evaluated as to whether it was of equal value in the detection of bony landmarks. C2 vertebra of five human cadaveric cervical spine specimens, ligamentously intact, were rotated using a Steinmann pin in steps of 5° up to 15° right and 15° left. Plain radiographs, CT and MRI images were taken in each rotational step. Data were analyzed for quantification of C2 rotation by three independent examiners. A rotation of 5° led to a spinous process deviation (SPD) from the midline of 3 mm as measured on an a.p. plain radiograph. A coefficient of rotation was calculated (1.62° mm^–1). Data analyzed by three examiners revealed a small coefficient of variation (0.03). MRI and CT measurements showed comparable results for the quantification of rotation; however, in both techniques the 15° rotation was underestimated. Quantification of upper cervical spine malrotation was possible on plain radiographs using the SPD and a rotation coefficient. MRI and CT were equally successful in the assessment of C2 malrotation.     

四点内固定技术治疗创伤性寰枢椎不稳

目的 探讨对创伤性寰枢椎不稳患者行后路四点内固定术（联合Apofix椎板夹和C1-C2关节突螺钉固定）的临床疗效和应用价值。方法 对16例创伤性寰枢椎不稳经牵引已达复位的可复型及经口前路松解后牵引复位的难复型寰枢椎脱位患者，经颈后路使用Apofix椎板夹和C1～C2关节突螺钉内固定联合自体髂骨植骨。结果 所有患者症状均有所改善，无神经症状加重表现，无神经血管损伤等并发症发生。16例随访8～26个月，平均16个月，均在3～6个月获得骨性融合。本组术后脊髓功能改善为优5例（占31％），良8例（占50％），有效2例（占13％），无变化1例（占6％），无加重患者。内置物无松动、断裂。结论 Apofix椎板夹和C1～C2关节突螺钉内固定确实起到了四点固定作用；对已复位或接近复位的寰枢椎脱位患者，只要寰枢椎后部结构完整即可行力学稳定性最佳的四点内固定术。本术式可使寰枢椎复合体获得三维稳定，为骨性愈合提供良好的力学环境。     

后路钉棒系统术中复位内固定治疗寰枢椎脱位

目的 分析后路钉棒系统术中复位内固定治疗在寰枢椎脱位的临床效果.方法 回顾分析2007年1月-2009年5月治疗的寰枢椎脱位患者27例,男18例,女9例;年龄13～51岁,平均31岁.其中,陈旧性齿状突骨折11例,齿状突游离小骨5例,寰椎横韧带断裂7例,类风湿性寰枢椎脱位4例.所有患者术前均难以获得良好复位,寰齿间距(atlantodens interval,ADI)8～15 mm,平均11mm.术中采用后路寰枢椎椎弓根螺钉固定,利用弯棒提拉进行复位,并行椎板间植骨.治疗前按美国脊髓损伤协会(ASIA)分级:B级8例,C级15例,D级4例.结果 随访时间6～24个月,平均13个月.所有患者枕颈部症状得到改善,均获得骨性融合.术后ADI为2～4 mm,平均2.8 mm.术后ASIA脊髓神经功能分级:C级4例,D级12例,E级11例.无椎动脉及脊髓神经损伤患者.无内固定脱落、断裂、退钉等并发症.结论 后路钉棒系统能够对寰枢椎脱位进行有效的术中复位,具有操作简单、并发症少、疗效确切的优点.     

CT三维成像诊断寰枢关节不全脱位的临床价值

目的 评价CT三维成像对寰枢关节不全脱位的显示及诊断价值，探讨最佳三维成像方法。方法回顾性分析41例寰枢关节不全脱位的CT影像学表现，比较横断面图像、多层面重建(multiplanar reformatting，MPR)法、表面遮盖(surface shade display，SSD)法、最大强度投影(maximum intensity projection，MIP)法及容积重建(volume rendermg，VR)法三维图像显示的病变情况。结果寰枢关节不全脱位41例，其中旋转型脱位31例，前脱位5例，后脱位5例。影像学表现为上、下关节面错位41例，其中错位2～5mm 29例、5～9mm 12例；齿突侧距不对称15例；寰齿间隙增宽合并骨折8例。SSI)法三维影像直观显示移位的寰枢关节上、下关节面，齿突侧距不对称及寰齿间隙增宽；横断面图像和MPR、MIP及VR法三维图像显示移位的上、下关节面差、不直观。结论运用CT三维成像能准确显示及诊断寰枢关节不全脱位，并以SSD法三维成像最佳。     

Pitfalls in the CT diagnosis of atlantoaxial rotary subluxation

CT was used to examine six patients with clinically evident atlantoaxial rotary fixation, two patients with torticollis, and six normal subjects who had turned their heads to the side as far as voluntarily possible. The CT appearances of the atlantoaxial complex were identical in all three groups. To differentiate these groups, we propose a functional scan through C1-C2 in which patients are scanned initially as they present, with their heads fixed in lateral rotation. Subsequent scans are obtained with their heads turned to the maximum contralateral rotation. CT scans in patients with atlantoaxial rotary fixation demonstrate no motion at C1-C2 during this maneuver, while those in patients with transient torticollis show a reduction or reversal of the rotation of C1 on C2.     

Condylus tertius with atlanto-axial rotatory fixation: an unreported association

The “condylus tertius” or the “third occipital condyle” is an embryological remnant of the proatlas sclerotome. Anatomically, it is attached to the basion and often articulates with the anterior arch of the atlas and the odontoid apex; hence, it is also called the “median occipital condyle”. It is a rare anomaly of the cranio-vertebral junction (CVJ) that can lead to instability and compression of important surrounding neurovascular structures. We report a case of a 16-year-old boy who presented with suboccipital neck pain, torticollis and right sided hemiparesis. Plain radiographs revealed an increased atlanto-dental interspace (ADI) with a retroflexed odontoid. Open mouth view showed asymmetry of the articular processes of the atlas with respect to the dens. Computed tomography (CT) of the CVJ delineated the third occipital condyle. Furthermore, on dynamic CT study, a type 3 atlanto-axial rotatory fixation (AARF) was clearly demonstrated. Magnetic resonance imaging (MRI) of the CVJ revealed severe right-sided spinal cord compression by the retroflexed and rightward deviated dens. It also revealed disruption of the left alar and transverse ligaments. The patient was treated with 8 weeks of cranial traction and reasonable alignment was obtained. This was followed by C1–C2 lateral mass screw fixation and C1?C2 interlaminar wiring to maintain the alignment. A review of the literature did not reveal any cases of condylus tertius associated with non-traumatic AARF. An accurate knowledge of the embryology and imaging features of this rare CVJ anomaly is useful in the prompt diagnosis and management of such patients.     

寰枢椎后路三种组合固定技术治疗寰枢关节不稳的临床评估

Objective To assess clinical curative effect of three types of combined posterior atlantoaxial internal fixation techniques in treatment of atlantoaxial instability. Methods The study involved 68 patients with atlantoaxial instability treated with different fixation techniques from August 2002 to March 2008. ( 1 ) Transpedicular fixation was performed in 32 patients including 20 patients with Anderson Ⅱ odontoid fractures (seven with old odontoid fracture and 13 with fresh fractures), six with type Anderson Ⅲ fresh odontoid fractures, four with disrupt of transverse ligament of the atlas and two with congenital loose odontoid process combined with atlantoaxial instability. (2) Transpedicular internal fixation with screws of atlas incorporating C2 laminar screws was performed in 20 patients with upper cervical injury including eight with type Ⅱ odontoid process fractures combined with atlantoaxial backward dislocation,four with type Ⅱ odontoid process fractures combined with atlantoaxial forward dislocation, two with nonunion of odontoid process fractures, three with type Ⅲ odontoid process fractures combined with atlantoaxial unsteadiness and three with atlantoaxial dislocation combined with disrupt of transverse ligament of atlas. (3)A total of 16 patients with traumatic atlantoaxial instability, reducible atlantoaxial dislocation and irreducible atlantoaxial dislocation were treated with four-point internal fixation technique using autologous iliac bone grafts. Results (1) A total of 120 screws were implanted in 32 patients, with no spinal cord or vertebral artery injury after surgery. Atlas lateral mass fixation was adopted in three patients because of broken posterior arch of the atlas. Postoperative CT showed that two screws were inserted into the vertebral artery hole and that one screw was inserted medially into the spinal canal and caused medial correx rupture, but both with no clinical symptoms. All 32 patients were followed up for 6-42 months ( average 26 months), which showed solid fusion in all patients. The postoperative JOA scores ranged from 13.2 points to 16.8 points (average 14. 8 points). (2) Thirty-two screws were implanted in 20 patients,with no spinal cord or vertebral artery injury. The patients were followed up for mean six months ( range 6-14 months). Postoperative X-ray showed sound bone fusion, with no cervical instability, loosening or breakage of the screws. (3) The symptoms of all the patients were improved at different degrees, with no neurological deterioration or severe complications, such as nerve blood vessel injury. All 16 patients were followed up for 8-26 months ( average 16 months), which showed bony fusion in all patients at 3-6 months after surgery. The spinal cord function was improved markedly in five patients, good in eight, mild in two but unchanged in one. Conclusions Three types of combined posterior atlantoaxial internal fixation techniques have advantages of rigid, short-segmental and three-dimensional fixation and hence are effective methods for treatment of upper cervical injuries. The combination mode can be varied according to specific condition of the patients.     

寰枢椎后路三种组合固定技术治疗寰枢关节不稳的临床评估

Objective To assess clinical curative effect of three types of combined posterior atlantoaxial internal fixation techniques in treatment of atlantoaxial instability. Methods The study involved 68 patients with atlantoaxial instability treated with different fixation techniques from August 2002 to March 2008. ( 1 ) Transpedicular fixation was performed in 32 patients including 20 patients with Anderson Ⅱ odontoid fractures (seven with old odontoid fracture and 13 with fresh fractures), six with type Anderson Ⅲ fresh odontoid fractures, four with disrupt of transverse ligament of the atlas and two with congenital loose odontoid process combined with atlantoaxial instability. (2) Transpedicular internal fixation with screws of atlas incorporating C2 laminar screws was performed in 20 patients with upper cervical injury including eight with type Ⅱ odontoid process fractures combined with atlantoaxial backward dislocation,four with type Ⅱ odontoid process fractures combined with atlantoaxial forward dislocation, two with nonunion of odontoid process fractures, three with type Ⅲ odontoid process fractures combined with atlantoaxial unsteadiness and three with atlantoaxial dislocation combined with disrupt of transverse ligament of atlas. (3)A total of 16 patients with traumatic atlantoaxial instability, reducible atlantoaxial dislocation and irreducible atlantoaxial dislocation were treated with four-point internal fixation technique using autologous iliac bone grafts. Results (1) A total of 120 screws were implanted in 32 patients, with no spinal cord or vertebral artery injury after surgery. Atlas lateral mass fixation was adopted in three patients because of broken posterior arch of the atlas. Postoperative CT showed that two screws were inserted into the vertebral artery hole and that one screw was inserted medially into the spinal canal and caused medial correx rupture, but both with no clinical symptoms. All 32 patients were followed up for 6-42 months ( average 26 months), which showed solid fusion in all patients. The postoperative JOA scores ranged from 13.2 points to 16.8 points (average 14. 8 points). (2) Thirty-two screws were implanted in 20 patients,with no spinal cord or vertebral artery injury. The patients were followed up for mean six months ( range 6-14 months). Postoperative X-ray showed sound bone fusion, with no cervical instability, loosening or breakage of the screws. (3) The symptoms of all the patients were improved at different degrees, with no neurological deterioration or severe complications, such as nerve blood vessel injury. All 16 patients were followed up for 8-26 months ( average 16 months), which showed bony fusion in all patients at 3-6 months after surgery. The spinal cord function was improved markedly in five patients, good in eight, mild in two but unchanged in one. Conclusions Three types of combined posterior atlantoaxial internal fixation techniques have advantages of rigid, short-segmental and three-dimensional fixation and hence are effective methods for treatment of upper cervical injuries. The combination mode can be varied according to specific condition of the patients.     

寰枢椎后路三种组合固定技术治疗寰枢关节不稳的临床评估

目的 评估寰枢椎后路三种组合固定技术治疗C1～2不稳的临床疗效和应用价值.方法 2002年8月至2008年3月,采用不同方法治疗寰枢关节不稳68例.(1)采用寰枢椎后路椎弓根螺钉技术治疗32例,其中AndersonⅡ型齿状突骨折20例(陈旧骨折7例,新鲜骨折13例),Ⅲ型新鲜齿状突骨折6例,寰椎横韧带断裂4例,先天性游离齿突并寰枢椎不稳2例;(2)采用经寰椎后弓椎弓根螺钉联合枢椎椎板螺钉固定治疗20例,其中AndersonⅡ型齿状突骨折伴寰枢关节向后脱位8例,向前脱位4例,齿状突骨折不愈合2例,Ⅲ型齿状突骨折伴寰枢关节不稳3例,寰枢关节前脱位伴横韧带断裂3例;(3)对16例创伤性寰枢椎不稳经牵引已达复位的可复型及经口前路松解后牵引复位的难复型寰枢椎脱位患者,采用经颈后路Apofix椎板夹和C1～2关节突螺钉内固定联合自体髂骨植骨治疗.结果 (1)采用寰枢椎后路椎弓根螺钉技术治疗32例患者共置入寰枢椎椎弓根螺钉120枚,其中有3例在置入寰椎椎弓根螺钉时,因后弓细小发生破裂,改用寰椎侧块固定.术中无一例发生脊髓和椎动脉损伤.术后CT显示2例一侧枢椎椎弓根螺钉部分进入椎动脉孔,另1例枢椎螺钉偏内致椎弓根内侧皮质破裂,均无症状,未发现与螺钉有关的神经血管损伤并发症.32例患者均获随访6～42个月,平均26个月.术后JOA评分13.2～16.8分,平均14.8分.无内固定松动或断钉现象,均已达到骨性融合.(2)采用寰椎经后弓椎弓根螺钉联合枢椎椎板螺钉固定治疗20例患者共置入枢椎椎板螺钉32枚,枢椎椎板螺钉位于椎板中,无偏斜.术中无一例发生脊髓和椎动脉损伤.20例随访6～14个月,平均11.2个月.术后X线片未见明显颈椎不稳、无内固定松动或断钉现象,均获得了良好的骨性愈合.(3)16例难复型寰枢椎脱位患者症状均有所改善,无神经症状加重表现.无神经血管损伤等并发症发生.16例随访8～26个月,平均16个月,所有患者在3～6个月均获得骨性融合.术后脊髓功能改善优5例,良8例,有效2例,无变化1例,无加重患者.内置物无松动、断裂.结论 寰枢椎后路三种组合固定技术是治疗上颈椎疾患的有效方法,具有固定牢固、固定节段短和三维固定的优点,在临床应用可根据患者的具体病情组合固定.     

CT of untreated occipitoatlantal rotatory subluxation (OARS)

We report the first case of occipitoatlantal rotatory subluxation (OARS) in which computed tomography (CT) images at initial presentation and at follow-up when still untreated are included. In addition, we report the first images of traumatic OARS to include 3-D CT reformations. The fact that the diagnosis was missed initially underscores the need for familiarity with the radiologic findings. The clinical and radiologic imaging including 3-D CT are discussed.     

Magerl和Brooks联合内固定术治疗寰枢椎不稳

目的 探讨和评估Magerl和Brooks联合内固定治疗寰枢椎不稳的临床疗效和应用价值。方法 对18例寰枢椎不稳或经牵引已达复位的可复型及经口前路松解后牵引复位的难复型寰枢椎脱位患者，进行Magerl和Brooks联合内固定植骨融合术。结果 平均随访18个月，1例螺钉疑误打入椎动脉；1例术中导针误穿过C1前弓皮质约3．5cm，进入咽部，未发生脊髓损伤及伤口感染并发症。本组术后脊髓功能改善为优3例，良9例，有效4例，无变化2例，无加重病例。内置物无松动，无断裂。结论 Magerl和Brooks联合固定确实起到了三点固定作用；本术式能在术中完善复位效果；对已复位或接近复位的寰枢椎脱位患者，只要C1.2后部结构完整，有必要行力学稳定性最佳的该联合内固定术。     

寰枢椎椎弓根内固定技术的解剖学与临床研究进展

1910年,Mixter等[1]用丝线固定寰椎后弓和枢椎棘突,开创了寰枢椎内固定技术的先河.此后,学者们创建了一系列寰枢椎内固定技术,按入路分为前路技术和后路技术.     

寰枢椎椎弓根内固定技术的解剖学与临床研究进展

1910年,Mixter等[1]用丝线固定寰椎后弓和枢椎棘突,开创了寰枢椎内固定技术的先河.此后,学者们创建了一系列寰枢椎内固定技术,按入路分为前路技术和后路技术.     

寰枢椎椎弓根内固定技术的解剖学与临床研究进展

1910年,Mixter等[1]用丝线固定寰椎后弓和枢椎棘突,开创了寰枢椎内固定技术的先河.此后,学者们创建了一系列寰枢椎内固定技术,按入路分为前路技术和后路技术.