关于寰枢关节骨性关节炎的认识

枕颈部疼痛在临床是一种非常多见的症状。引起枕颈部疼痛有许多疾病,包括风湿性关节炎、感染、原发性和转移性肿瘤、创伤和各种形式的颈部退变和枕颈不稳。近年来,人们已经注意到骨性关节炎也可累及寰枢椎,引起枕颈部疼痛。由于寰枢椎关节骨性关节炎的病理、症状和体征与下颈椎相比有着不同特点,对寰枢关节的骨性关节炎较少引起人们注意,但寰枢椎关节骨性关节炎在临床上并不少见,占枕颈部疼痛的6%~10%,因缺乏足够认识常被忽略。1寰枢关节解剖学及生物学特性寰枢关节由4个关节组成,包括位于正中的2个寰齿关节和左右侧块的2个外侧关节。寰齿关…     

后路经寰枢椎侧块关节螺钉固定融合治疗类风湿性寰枢椎不稳

目的 探讨对类风湿性寰枢椎不稳患者行后路经寰枢椎侧块关节螺钉固定融合治疗的手术方法总总结初步疗效。方法 对１５例类风湿性寰枢椎不稳的患者采用后路经关节突侧块螺钉固定的方法,行寰枢椎（Ｃ１,２）即刻牢固固定。为保证确切的三点固定和植骨融合,同时辅以寰枢间植骨与钛丝固定。结果 患者寰枢椎间稳定性得到恢复,无并发症发生;随访６～１４个月（平均１０个月）,１５例患者均获骨融合。结论 经后路寰枢椎侧块关节螺     

类风湿性关节炎继发寰枢椎脱位的手术治疗进展

寰枢椎解剖结构脆弱,先天畸形、创伤、肿瘤、炎症等因素都可破坏其稳定性,威胁延髓和椎基底动脉安全。类风湿性关节炎是寰枢椎脱位的重要原因之一,为避免不可逆的神经损害,应尽早手术治疗,而寰枢椎融合是首选手术方式。近年来寰枢椎内固定技术不断完善,医生的选择日益丰富,但如何进一步规避手术风险、增强固定稳定性、最大程度保留寰枢椎功能、减少术后并发症成为现阶段努力的方向。本文就近五年类风湿性关节炎继发寰枢椎脱位的手术治疗进展作一综述。     

寰枢椎椎弓根钉系统固定治疗寰枢关节不稳的疗效评估

目的 探讨寰枢椎椎弓根钉系统固定治疗寰枢关节不稳的临床效果.方法 总结2003-06-2008-12运用寰枢椎椎弓根钉系统固定治疗寰枢关节不稳38例.其中,男32例,女6例,年龄18～76岁,平均45.3岁.横韧带损伤3例,Jefferson骨折3例,齿状突骨折伴寰枢关节脱位29例,齿状突发育异常伴寰枢关节不稳3例.结...     

颈后路手术治疗类风湿性寰枢椎不稳

目的：对类风湿性寰枢椎不稳患者颈后路植骨融合、内固定手术进行探讨。方法：对21例类风湿性寰枢椎不稳患者采用颈后路植骨融合、内固定手术，其中7例可复性寰枢椎半脱位行寰枢椎间植骨钛缆或Apofix固定术；14例难以复位者行枕颈间植骨cervifix固定术。结果：随访6～28个月(平均18个月)。21例均无并发症发生，X线显示均获骨性融合，19例患者神经功能获不同程度改善，2例虽无改善但无神经损害发展。结论：颈后路植骨融合、内固定术可为类风湿性寰枢椎不稳的患者提供牢固的融合固定，且以早期手术为佳。     

类风湿性关节炎继发寰枢椎脱位的手术治疗

目的:总结手术治疗类风湿性关节炎(rheumatoid arthritis,RA)继发寰枢椎脱位的临床疗效。方法:2010年1月~2018年12月收治57例RA继发寰枢椎脱位的患者,男14例,女43例;年龄46~79岁(61.8±12.4岁)。类风湿性关节炎病史2.5~36.8年(17.5±3.7年),诊断RA后出现上颈椎相关症状时间为1.5~19.4年(8.9±2.4年)。患者均有不同程度的枕颈部疼痛、颈部姿势异常和活动受限。术前神经功能ASIA分级:B级3例,C级12例,D级20例,E级22例;JOA评分4~14分(8.7±1.8分),VAS 4~10分(7.4±1.5分)。寰椎前向脱位44例,其中寰齿前间距(anterior atlantodental interval,AADI)>10mm者8例;寰椎后向脱位9例;寰椎前后向脱位4例。6例合并下颈椎不稳,10例合并枕颈部其他畸形。13例枕寰关节先天性融合及骨性融合无枕寰关节活动度者采用枕颈固定融合术治疗(A组);44例有枕寰关节活动度的患者采用寰枢椎融合固定融合术治疗,其中16例寰枢椎脱位牵引不能复位的患者先行前路经下颌下寰枢椎关节松解术再一期后路行寰枢椎融合术治疗(B组),28例寰枢椎脱位牵引能复位的患者直接采用后路寰枢椎融合内固定术治疗(C组)。定期随访患者的临床症状和神经功能改善情况,影像学观察寰枢椎复位和植骨融合情况。结果:患者均顺利完成手术,A组手术时间100~130min(118.2±13.5min),术中出血量100~300ml(190.5±42.8ml);B组手术时间180~240min(221.4±20.3min),术中出血量100~260ml(157.3±36.1ml);C组手术时间100~130min(109.4±12.1min),术中出血量100~200ml(124.1±32.7ml)。术中均未发生椎动脉和脊髓损伤。所有患者随访期间复查颈椎CT及MRI显示寰枢椎序列重建满意,齿状突区域脑脊液线清晰,脊髓无压迫,术后AADI为2~3mm(2.4±0.4mm)。患者均获随访,随访时间12~84个月(34.4±10.3个月),术后12个月随访时,2例ASIA分级B级患者恢复至C级,C级患者6例恢复至D级、3例恢复至E级,9例D级患者恢复至E级,其余患者无变化;JOA评分改善至10~17分(14.6±3.5分),VAS评分降至1~5分(3.6±1.4分),与术前比较均有显著性差异(P<0.05)。1例患者植骨块发生自发性部分吸收,随访1年半时植骨块吸收停止并部分融合,未再次行植骨术;其余患者植骨均融合。随访期间均未发现螺钉松动、移位、断裂和寰枢椎再脱位、失稳现象。结论:RA累及上颈椎时会造成寰枢椎脱位导致脊髓受压,依据枕寰关节活动度情况采用寰枢椎融合术或枕颈融合术治疗可获得良好的临床效果。     

前路经枢椎体寰椎侧块螺钉固定术

目的 建立一种新的寰枢椎内固定术式,用来治疗难以实施后路内固定的病例。方法 使用纯钛制成的固定螺钉,做颈前路暴露,经枢椎针两枚螺钉分别拧人左、右寰椎侧块,达到区椎的即刻稳定。结果 １０例手术患者,平均随访１９个月,其中７例螺钉固定位置良好,寰枢椎达到稳定,死亡１例。结论 经枢椎体寰椎愉螺钉固定术是一种比较可犊的寰枢椎内固固定方法,尤其适用于难以施行后路内豁达一术的病例。     

寰枢椎畸形并不稳的治疗（附73例分析）

目的：探讨寰枢椎畸形并不稳的临床及其治疗方法。方法;对73例因寰枢椎先天性畸形导数上颈椎不稳患者分别施行保守及手术治疗,其中保守治疗21例,手术治疗52例。结果：保守治疗患者随访3个月至2年,其中14例患者症状缓解或无加重,另7例因症状加重行手术治疗。手术治疗患者随访3个月至10年,效果均满意。结论：对于有症状的寰枢椎畸形并不稳患者可采取积极手术治疗,复位、减压及重建稳定性是治疗之原则。     

CT扫描寰枢关节对诊断类风湿关节炎价值的探讨

目的分析40例确诊为类风湿关节炎的寰枢关节及其附近骨质软组织改变，为临床治疗提供重要资料。方法CT扫描从枢椎至枕骨底部逐层薄层扫描，显示枢椎、寰椎、枕骨底部及周围组织类风湿关节炎的各种征象。结果40例类风湿关节炎患者中寰枢关节改变，Ⅰ期9例，Ⅱ期12例，Ⅲ期10例，Ⅳ期9例。结论利用CT薄层扫描，可清晰显示寰枢关节类风湿关节炎的各种征象，使临床能全面掌握类风湿关节炎病情而作出更好治疗措施。     

后路内固定融合手术治疗类风湿性寰枢椎不稳

目的 :评估后路内固定融合节段对治疗类风湿性寰枢椎不稳临床疗效的影响。方法 :2008年1月~2015年3月收治类风湿性寰枢椎不稳患者24例,其中女15例,男9例;年龄37~64岁(50.8±4.3岁)。21例患者入院前已经诊断为类风湿性关节炎(RA),病程2~30年(15.6±7.8年);3例患者本次入院确诊为RA并且伴有寰枢椎不稳。侧位X线片示寰枢椎脱位(AAS)13例;寰枢椎垂直脱位(VS)5例;AAS+VS 2例;AAS+下颈椎半脱位(SAS)1例;后路钢丝固定术后3年钢丝断裂合并下颈椎SAS 1例;寰枢关节破坏无脱位表现2例。均行后路固定融合手术,13例AAS患者10例行后路寰枢椎(C1-2)融合内固定术,2例因C2椎弓根细小行C1-C3固定融合,1例因寰椎后弓细小及骨质疏松行枕颈融合术(O-C2);7例VS/AAS+VS患者及2例严重枕颈部疼痛的患者行枕颈融合术,O-C2融合3例,O-C3融合6例,其中1例行寰椎后弓切除减压;2例合并SAS的患者行枕颈椎/胸椎(O-C7 1例,O-T1 1例)固定融合,包括1例翻修手术。比较患者术前、术后及末次随访时的Ranawat神经功能分级、VAS和JOA评分。结果 :24例患者手术均顺利完成,无术中并发症;术后伤口浅表感染2例,经换药和使用敏感抗菌素治愈。24例患者均获得随访,随访时间12~45个月(24.1±10.3个月)。VAS评分由术前的6.6±1.2分下降到术后的2.6±0.9分,末次随访时1.8±0.7分(P0.05)。JOA评分由术前的平均11.5±1.9分增加到术后的平均13.6±2.0分,末次随访时14.5±1.1分(P0.05)。Ranawat神经损伤分级:3例术前Ⅰ级无恢复;5例Ⅱ级者4例恢复至Ⅰ级,1例无恢复;15例Ⅲa级恢复至Ⅰ级13例,Ⅱ级2例;1例Ⅲb级恢复至Ⅲa级。术后3个月植骨融合率为29%(7例),术后6个月为79%(19例),术后12个月为100%(24例)。术后继发SAS 3例,脱位部位:C3/4 2例,C4/5 1例。结论:类风湿性寰枢椎不稳患者行后路内固定融合手术治疗效果满意,应根据病变累及范围、脱位类型、骨密度和钉道情况选择固定融合范围。     

Subaxial subluxation after atlantoaxial transarticular screw fixation in rheumatoid patients

The most common cervical abnormality associated with rheumatoid arthritis (RA) is atlantoaxial subluxation, and atlantoaxial transarticular screw fixation has proved to be one of the most reliable, stable fixation techniques for treating atlantoaxial subluxation. Following C1–C2 fixation, however, subaxial subluxation reportedly can bring about neurological deterioration and require secondary operative interventions. Rheumatoid patients appear to have a higher risk, but there has been no systematic comparison between rheumatoid and non-rheumatoid patients. Contributing radiological factors to the subluxation have also not been evaluated. The objective of this study was to evaluate subaxial subluxation after atlantoaxial transarticular screw fixation in patients with and without RA and to find contributing factors. Forty-three patients who submitted to atlantoaxial transarticular screw fixation without any concomitant operation were followed up for more than 1 year. Subaxial subluxation and related radiological factors were evaluated by functional X-ray measurements. Statistical analyses showed that aggravations of subluxation of 2.5 mm or greater were more likely to occur in RA patients than in non-RA patients over an average of 4.2 years of follow-up, and postoperative subluxation occurred in the anterior direction in the upper cervical spine. X-ray evaluations revealed that such patients had a significantly smaller postoperative C2–C7 angle, and that the postoperative AA angle correlated negatively with this. Furthermore, anterior subluxation aggravation was significantly correlated with the perioperative atlantoaxial and C2–C7 angle changes, and these two changes were strongly correlated to each other. In conclusion, after atlantoaxial transarticular screw fixation, rheumatoid patients have a greater risk of developing subaxial subluxations. The increase of the atlantoaxial angel at the operation can lead to a decrease in the C2–C7 angle, followed by anterior subluxation of the upper cervical spine and possibly neurological deterioration.     

Atlantoaxial instability in a patient with neck pain and rheumatoid arthritis

Context: The purpose of this report is to describe the clinical decision-making process for a patient with rheumatoid arthritis with neck pain with underlying atlantoaxial instability.Findings: The patient was evaluated for worsening upper neck pain that began insidiously 1 year prior. The patient denied numbness or tingling in her upper or lower extremities, dizziness or lightheadedness, difficulty maintaining balance with walking, or muscle weakness. Cervical spine range of motion was limited in all planes due to pain and apprehension. The patient’s neurological examination was unremarkable. Prior flexion and extension radiographs of the cervical spine were interpreted as unremarkable with alignment preserved in flexion and extension. However, upon further inspection, the cervical spine flexion radiograph was concerning for inadequate cervical motion, which may have limited the diagnostic utility of these radiographs. Additionally, a Sharp-Purser test was performed, which was positive for excessive motion. Flexion and extension radiographs of the cervical spine were then repeated ensuring the patient adequately flexed and extended during the imaging. Severe anterior subluxation of C1 relative to C2 with cervical flexion was noted, as C1 moved as much as 8–9 mm anterior to C2 with cervical flexion. Given the degree of atlantoaxial instability, the patient subsequently underwent successful posterior fusion from the occiput to C2.Conclusion/Clinical Relevance: This case report demonstrates the importance of properly screening for upper cervical spine instability in patients with rheumatoid arthritis and neck pain and understanding the importance of obtaining adequate and appropriate diagnostic imaging.     

Periodontoid pannus migration into the spinal canal with reduction of rheumatoid atlantoaxial subluxation: a case report

 We report a patient with rheumatoid arthritis in whom periodontoid pannus migrated into the spinal canal with reduction of atlantoaxial subluxation. In this case, magnetic resonance imaging in the extension position was valuable for determining the therapeutic strategy. Received: February 5, 2002 / Accepted: June 18, 2002 Offprint requests to: H. Ishihara     

Relationship between the morphology of the atlanto-occipital joint and the radiographic results in patients with atlanto-axial subluxation due to rheumatoid arthritis

The upper cervical spine is a common focus of destruction from rheumatoid arthritis (RA). Atlanto-axial subluxation (AAS) presents with marked frequency among patients with instability. However, there are occasional patients who show no motion between the occipital bone and atlas on a dynamic cervical radiograph in AAS patients. This study investigated the morphology of the atlanto-occipital joint (AOJ) in AAS patients due to RA using computed tomography, and examined the relationship between its morphology and other radiographic results. Twenty-six consecutive patients with AAS due to RA treated by surgery were reviewed. The subjects included 18 females and 8 males. The average patient age was 59.3 years. The mean duration of RA was 14.3 years. In all the patients, the AOJ was morphologically evaluated using sagittal reconstruction view on computed tomography before surgery. Moreover, the ADI value was investigated at the neutral and maximal flexion position, and atlanto-axial angle (AAA) at the neutral position in preoperative lateral cervical radiographs. The morphology of the AOJ on a CT sagittal reconstruction view was classified into three types as follows: a normal type which showed a maintenance of the joint space, a narrow type which showed a disappearance of the joint space and a fused type which showed the fusion of the AOJ. The pre-operative CT sagittal reconstruction image of the AOJ demonstrated a normal type bilaterally in six cases (Group A). In 15 cases (Group B), CT image demonstrated narrowing on at least one side of the AOJ. In five cases (Group C), CT images demonstrated fusion on at least one side of the AOJ. The average ADI value at the flexion position was 10.7 mm in Group A, 11.7 mm in Group B, and 12.6 mm in Group C. There was no significant difference among those groups. The average ADI value at the neutral position before surgery was 2.8 mm in Group A, 5.9 mm in Group B, and 10.4 mm in Group C. There was no significant difference between Group A and B (P > 0.105), and Groups B and C (P > 0.032), however, there was a significant difference between Groups A and C (P < 0.004). The average AAA value was 25.3° in Group A, 19.3° in Group B and 3.4° in Group C. There was no significant difference between Groups A and B (P > 0.230), however, there was a significant difference between Groups A and C (P < 0.002), and Groups B and C (P < 0.007). This study showed that fusion or ankylosis of the AOJ induced an enlargement of the ADI and anterior inclination of the atlas in the neutral position, despite the fact that normal findings of AOJ showed a slight displacement of the atlas to axis in RA patients showing AAS involvement. This morphology may progress to SAS and VS due to AOJ after atlanto-axial arthrodesis. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.     

Atlantoaxial immobilization in rheumatoid arthritis: a prophylactic procedure?

Timing of surgical intervention in atlantoaxial instability due to rheumatoid arthritis is still controversial. An aim of this study was to investigate whether atlantoaxial fusion can prevent progression of instability and upward migration of the dens. Thirty-two patients with rheumatoid arthritis, who underwent posterior atlantoaxial fixation due to instability, were clinically and radiologically examined after a minimum follow-up of 5 years. The radiological measurements focussed on the extent of cranial vertical migration after atlantoaxial fusion. In none of the 20 patients available for follow-up examination was a vertical cranial migration observed, in spite of the ongoing course of the disease. These findings are in concordance with findings in the literature, and strongly suggest that, with atlantoaxial stabilization, the inflammatory process with destruction of the lateral masses of the atlas is able to prevent further deterioration with vertical cranial ¶migration.     

游离齿突小骨的影像学征象(附23例报告)

目的 经影像学研究探讨游离齿突小骨的影像学特征。方法 回顾分析23例游离齿突小骨患者，其中10例有明确的外伤史。明确游离小骨的诊断后，须经影像学检查来明确寰枢关节的不稳定程度和颈脊髓的压迫。1例无症状的患者行保守治疗，22例行手术治疗。结果 随访2～4年(平均2年8个月)，23例患者的临床和影像学结果均较满意。结论 对游离齿突小骨患者，无论有无寰枢椎不稳、有无症状和脊髓损伤的体征，均可成功进行影像学评估。建议对此类患者宜常规行颈椎正侧位、开口位、屈．伸侧位摄片和CT平扫，并根据实际情况尽可能行三维CT重建和MRI检查。     

Safety of atlantoaxial fusion using laminar and transarticular screws combined with an atlas hook in a patient with unilateral vertebral artery occlusion (case report)

Objective and importance  A disadvantage of transarticular and C2 pedicle screws is vertebral artery (VA) injury as a result of screw misplacement. If unilateral occlusion of the VA is present, VA injury of the dominant side will cause fatal complications as a result of collateral flow insufficiency. Several authors have recently reported the usefulness of C2 laminar screws because of their safety on VA injury. We used transarticular and C2 laminar screws combined with the atlas hook in a patient with C1-2 instability and unilateral VA occlusion, in order to reduce the risk of further VA injury. Clinical presentation  A 64-year-old woman with rheumatoid atlantoaxial subluxation complained of cervical myelopathy and neck pain. Preoperative MR angiography showed a left side VA occlusion. Technique  The patient underwent atlantoaxial, posterior fusion using a transarticular screw on the side of the occlusion and a C2 laminar screw on the dominant side combined with a bilateral atlas hook. The transarticular screw was inserted using a navigation system and image intensifier, and the laminar screw was inserted free hand. Bone grafting from the iliac crest was performed. Conclusion  Transarticular and C2 laminar screws fixation combined with the atlas hook in a patient with unilateral VA occlusion is a useful technique, in order to reduce the risk of further VA injury.