单侧双通道内镜辅助下难复性寰枢椎脱位经口松解的临床疗效

寰枢椎脱位的手术治疗是临床难题,手术方式包括前路手术、后路手术以及前后路联合手术,不同手术方式各自具有优缺点,对于寰枢椎脱位手术方式的选择一直存在争议,但目前临床中针对全麻下术中牵引无法复位的难复性寰枢椎脱位（irreducible atlantoaxial dislocation,IAAD）,普遍采用前路经口松解的手术方案。经口松解能够较好地显露C1、C2节段,为松解寰枢椎关节囊、去除瘢痕及骨赘组织、截骨等操作提供充分条件,但经口入路存在术野深、操作困难、感染及助手配合困难等缺点。微创技术的发展为脊柱外科的手术治疗提供更多选择,单侧双通道内镜技术（unilateral biportal endoscopy,UBE）,近年来成功运用于多种脊柱手术,包括颈椎手术和腰椎手术等,其本质是水介质下的内镜技术。目前该技术在寰枢椎脱位经口松解中的应用国内外尚未见报道,笔者团队采用UBE技术的思路,将该技术应用于IAAD经口松解,结合文献探讨内镜辅助下寰枢椎脱位经口松解的运用及优缺点。     

寰枢椎脱位的诊疗现状及争议

寰枢椎脱位的外科学分类主要用于指导治疗策略,历史上较为著名的是1968年的Greenburg分类：可复性及不可复性,即通过动力位X线片判断寰枢椎的关系。在20世纪七八十年代前,针对可复性寰枢椎脱位行后路固定融合,不可复性寰枢椎脱位行后方骨性减压、原位固定,但临床观察发现不可复性寰枢椎脱位的后方减压效果不佳。20世纪60年代我国香港方心让等及80年代Menezes等报告经口入路腹侧切骨减压,大幅提高了寰枢椎不可复性脱位的临床疗效,但此方法仍然无法实现“复位”。临床上医生们发现颅骨牵引可将某些以往判断为“不可复性”寰枢椎脱位转化为“可复性”。21世纪初开始,以北京大学第三医院、南部战区总医院为代表的中国学者们发表了系列文章,使用颅骨牵引下的经口松解术可以将绝大多数不可复性脱位转变为可复性脱位,并实施了解剖复位下的经口或后路固定融合。这一由我国学者提出的“不可复性向可复性转化”理论,获得了国际承认和应用。另外,Goel、Chandra等及国内陈赞等报告了经后路侧块关节松解术,使寰枢椎复位后行固定融合。然而后路松解无法实现前方挛缩韧带或骨性结构的松解,部分病例的复位效果不如经口松解术。目前寰枢椎脱位的当代治疗理念已经形成,即经过颅骨牵引结合松解术达到寰枢椎解剖复位、并实行植骨融合。绝大多数情况下不需要切骨减压。从前述的寰枢椎外科发展史可见,我国同道做出了很大贡献。     

一期前路松解后路固定治疗难复性寰枢椎脱位

[目的]介绍一期颈前咽后入路松解后路复位固定融合治疗难复性寰枢椎脱位的手术技术与初步疗效。[方法] 2016年3月～2019年1月应用颈前咽后入路寰枢松解后路复位固定融合治疗难复性寰枢椎脱位患者38例。患者首先取仰卧位,经Smith-Robinson入路显露寰枢关节腹侧结构,去除寰枢关节周围瘢痕韧带等实现寰枢松解;然后,在石膏床保护下改为俯卧位,行寰枢椎后路钉棒复位固定及植骨融合。[结果]本组患者均顺利完成手术,所有患者均获得满意复位,无神经、血管损伤等严重并发症。平均随访(32.54±7.63)个月,所有病例均实现骨性融合,无内固定失效及再脱位。末次随访时JOA评分、寰齿前间距和延髓脊髓角均较术前显著改善(P0.05)。[结论]颈前咽后入路松解联合后路钉棒复位固定融合是治疗难复性寰枢椎脱位的可靠手术方法。     

后路松解复位、固定融合术治疗难复性寰枢椎脱位的远期疗效

目的:探讨后路松解复位、固定融合术治疗难复性寰枢椎脱位的远期疗效。方法:回顾性分析2005年1月至2016年6月接受单纯后路松解复位、固定融合术治疗难复性寰枢椎脱位患者的病历资料,男13例、女18例,年龄为（39.1±13.5）岁（范围9~72岁）。临床评价指标为颈椎功能障碍指数（neck disability ind...     

进一步提高复杂寰枢椎脱位的治疗水平

<正>近20年来,寰枢椎脱位的临床治疗水平不断提高。目前根据临床分型,有以下治疗方式可供选择:可复性寰枢椎脱位一般采取后路寰枢椎椎弓根钉棒内固定;难复性寰枢椎脱位采用Ⅰ期经口前路松解+后路复位内固定术或前路经口寰枢     

寰枢椎脱位的外科治疗原则

寰枢椎脱位（atlanto-axial dislocation）常累及延髓生命中枢与椎-基底动脉,导致严重残疾,甚至威胁生命。寰枢椎是颈椎中活动度最大的节段,其旋转活动占整个颈椎旋转活动度（120°~160°）的50%以上。因此,合理的寰枢椎脱位外科分型和治疗原则对其治疗的效果、安全性和颈椎功能的保留具有重要意义。自从Zileli等[1]2002年报道前后路联合手术治疗难复性寰枢椎脱位以来,其基础和临床研究进步很快,例如：前路经口腔寰枢椎病灶清除、螺钉钢板复位内固定术[2],经口腔或内窥镜下行寰枢椎前方软组织松解、后方寰枢椎椎弓根螺钉复位固定术[3],以及各类后路钉板和钉棒内固定系统[4~6]等技术已在国内广泛开展。但随着寰枢椎脱位外科治疗的报道增多,需要再次手术翻修病例也有上升的趋势,应该引起临床高度重视。在此,笔者针对寰枢椎脱位的外科治疗原则,谈谈自己的管见,与同道商榷。     

我国上颈椎外科已跨入国际先进行列

上颈椎位于头颈交界部,毗邻生命中枢,部位狭小,解剖复杂,是外科治疗难度高、风险大的高危区.20世纪末,我国对寰枢椎脱位多采用保守治疗(如颅骨牵引、Halo支架固定)或Brooks钢丝[1]、Halifax椎板夹[2]、Apofix夹等非螺钉固定技术治疗,而对陈旧性难复性寰枢椎脱位几乎缺少良好对策.1986年刘景发等[3]采用经口咽寰椎前弓和枢椎齿状突切除行前路减压复位术治疗难复性寰枢椎脱位,后于1998年报道经口咽前路寰枢椎松解,术后持续牵引缓慢复位后,行头颈胸石膏外固定或后路枕颈或寰枢椎固定融合术来治疗难复性寰枢椎脱位[4].     

寰枢椎脱位前路手术治疗——TARP内固定手术 寰枢椎脱位系列讲座(四)

<正>寰枢椎脱位是脊柱外科的常见疾患,由于毗邻重要的神经和血管结构,处理不当时死亡率和致残率均较高。经口前路寰枢椎复位钢板(transoral atlantoaxial reduction plate,TARP)内固定手术是近年来开展的寰枢椎脱位前路手术技术,为难复性和不可复性寰枢椎脱位患者提供了新的治疗选择[1]。本文重点介绍TARP内固定手术治疗难复性寰枢椎脱位的设计原理、技术优势、     

合并复杂颅颈交界畸形的寰枢椎脱位应个性化治疗

<正>随着颈椎外科基础研究和相关临床研究的不断深入,寰枢椎脱位的诊治技术在近十年取得了长足的发展[1],不仅寰枢椎脱位的原理、临床分型得以明晰,而且治疗手段也不断丰富,治疗效果不断提高。20世纪80年代初,对可复性寰枢椎脱位采用牵引复位,一般应用后路椎板钢丝固定,但对难复性寰枢椎脱位没有很好的办法。20世纪90年代初,刘景发等[2]采用经口咽前路松解术后牵引缓慢复位后头颈胸外     

Ⅰ期前后路联合手术治疗游离齿突继发的难复性寰枢椎脱位

目的探讨颈高位咽后入路前路松解、Ⅰ期后路融合治疗游离齿突继发的难复性寰枢椎脱位的临床效果。方法本组19例均为游离齿突继发的难复性寰枢椎脱位,X线片动态位不能自行复位,且术前颅骨牵引均未获得满意复位。采用颈高位咽后入路显露C1～C3,行寰枢椎前方松解复位,Ⅰ期后路寰枢融合内固定。结果 19例患者采用颈高位前方咽后入路均成功显露C1前弓～C3椎体,前路松解后复位良好,Ⅰ期行后路寰枢融合内固定,全组无一例出现脊髓损伤加重、咽喉部阻塞或窒息。1例颈后部伤口积液感染,经换药引流后痊愈;2例出现舌下神经牵拉症状,1例出现面神经刺激症状,均在1个月后恢复正常。脊髓功能正常者无神经功能损害,不全瘫患者神经功能均有部分恢复。随访植骨均获骨性融合,无内固定松脱。结论颈高位咽后入路行前方松解能够复位游离齿突继发的难复性寰枢椎脱位患者,Ⅰ期后路寰枢融合可获良好的植骨融合。     

An unusual intratarsal dislocation: cuneonavicular and calcaneocuboid dislocation

We report a case of tarsal dislocation with cuneonavicular dislocation associated with calcaneocuboidal dislocation. This dislocation is rare and severe because it causes disruption of both the medial and lateral columns of the foot. Early and prompt reduction of this rare injury was successful in this case and appears important.     

Clinical significance and treatment concept of Lisfranc dislocation and dislocation fracture

Dislocations and fracture dislocations of the tarsometotarsal joint are uncommon (only 30 cases have been treated in our hospital in a 20-year period). The late results of tarsometotarsal injuries in 20 patients have been reviewed. The average follow-up was 3.8 years (range 8 months to 20 years). Methods of treatment were either open (n = 15) or closed (n = 5) reduction with (n = 18) or without (n = 2) internal fixation and cast immobilization (n = 10). Late results clearly correlate with the quality of reduction. An open procedure is usually necessary to achieve anatomical reduction. Diagnostic and operative problems are discussed.     

Bipolar dislocation of the forearm: elbow and perilunate dislocation

We report a case of bifocal dislocation of the forearm due to posterior dislocation of the elbow and transcaphocapital retrolunate dislocation of the carpus, Fenton's syndrome, associated with fracture of both bones of the forearm. The emergency procedure achieved reduction of the elbow, plate fixation of the radius and ulna, used a posterior and an anterior access to achieve reduction and osteosynthesis of the radial styloid, the scaphoid, and the capitatum and temporary schapholunate, triquetrolunate, scaphocapitate, and radiolunate pinning. At ten months, the patient only complained of moderate pain for exceptional efforts. Complete amplitude elbow motion was restored. Wrist flexion and extension were 50 degrees and 30 degrees respectively. X-rays demonstrated union of the scaphoid and the capitatum. There was no scapholunate diastasis and the scapholunate angle was normal.     

Transtriquetral perihamate ulnar axial dislocation and palmar lunate dislocation.

Transtriquetral perihamate ulnar axial dislocation associated with palmar lunate dislocation is a rare condition. We could find no other similar cases reported. The mechanism of injury was a combined anteroposterior crushing force that caused axial disruption of the carpus and the metacarpals and wrist hyperextension that caused the transtriquetral lunate dislocation. Our patient was treated with open reduction and internal fixation with good result.     

Occipitoatlantal and atlantoaxial dislocation

Vertical distractive forces at the craniovertebral junction can affect the occipitoatlantal joint or the atlantoaxial joint. These lesions are part of the same spectrum of injuries. They share the same mechanism of injury and high mortality rate. They usually represent a pure ligamentous injury that causes severe instability and requires early fixation.     

Shoulder dislocation and -subluxation

The diagnosis and treatment of shoulder instability require basic differentiation between unidirectional, multidirectional, and voluntary dislocation. Within unidirectional instability primary dislocation, recurrent dislocation, and recurrent subluxation need to be considered separately.--Primary dislocation: In 160 patients with primary dislocation a follow-up was done by questionnaire. In the case of atraumatic primary dislocation the redislocation rate was 100%. Predisposing factors inherent in the bony, cartilaginous, and capsular components of the joint favoured the tendency of primary dislocation. In the case of traumatic primary dislocation the redislocation rate was lower after immobilisation of the joint than without when it had not been immobilised.--Recurrent subluxation: In 52 patients with a clinical diagnosis of recurrent subluxation a tear of the glenoid labrum was found by arthroscopy. In 21 cases the detached labrum was refixed arthroscopically and in 18 cases the repair was done by an open Bankart procedure. Seventy-two percent of the patients who underwent arthroscopic repair showed good to excellent results. In all cases but one in which the Bankart procedure was applied the results were excellent.--Recurrent dislocation: Since 1984 a total of 183 patients were operated on for recurrent shoulder dislocation. All these patients were examined preoperatively by CT scan. The CT findings were used in selection of the appropriate procedure. In 114 patients the Bankart procedure was applied and in 39 cases, a bone-block method. The remaining patients were subjected to various other procedures. Not one of the patients showed postoperative redislocation. (ABSTRACT TRUNCATED AT 250 WORDS)     

Subtalar dislocation

During the period from 1945 to 1972, 30 cases of subtalar dislocation were reported to the Directorate of Industrial Injuries Insurance in Denmark. The lesions were classified according to type of dislocation showing that the medial inward type predominated by far. According to the findings of the present investigation, the long-term prognosis seems to be more serious than has hitherto been assumed. X-ray and clinical examination disclosed that arthrosis of the subtalar joints was demonstrable in 19 patients. Six of these patients had pantalar arthrosis, the causative factor in two cases being avascular necrosis of the talus. Clinical examination showed that walking was associated with some degree of pain in 21 patients and 15 patients had a more or less pronounced limp.