寰枢椎不稳及脱位的外科治疗

目的总结和分析寰枢椎不稳及脱位的外科治疗结果，并对其手术方法的选择进行探讨。方法自1998年1月至2004年5月对15例寰枢椎不稳及13例寰枢椎脱位患进行手术治疗，15例寰枢椎不稳均行后路寰枢椎植骨融合内固定术；13例寰枢椎脱位病例中，8例经颅骨牵引寰椎完全或大部分复位，系采用后路寰枢椎植骨融合内固定术，5例牵引后不能复位，行寰椎后弓切除减压枕颈融合术。结果1例寰枢椎脱位病例术后1周死亡，1例寰枢椎脱位病例术后复发，给予颅骨牵引复位后头颈胸石膏外固定3个月，其余病例随访3～24个月，所有病例枕颈部疼痛症状减轻或消失，四肢及躯体感觉恢复接近正常，肌力及肌张力明显改善，寰枢椎及枕颈部植骨在半年左右均达骨性融合，未出现内固定物断裂、脱落。结论术前应熟悉寰枢椎不稳及脱位的各自影像特点，并对其解剖特点、发生机制及其临床特点认识清楚，正确地选择手术方法，术中仔细操作，便能达到满意的治疗效果。     

Ransford环在枕颈融合术中的应用

目的 评价Ransford环在枕颈融合术中的固定作用。方法 9例陈旧性寰枢椎骨折接脱位，5例枕颈区畸形行后路枕颈减压，髂骨植骨，用自制Ransford环颅骨下和椎板下钢丝固定，术后X线片观察枕颈植骨融合。结果 13例随访6个月-4年，神经功能明显恢复，12例枕颈区骨性融合。结论 Ransford环在枕颈融合术中能提供较强的固定作用。     

钢板螺钉内固定在枕颈融合中的应用

目的探讨钢板螺钉内固定在枕颈融合中应用的疗效。方法1999年3月-2003年7月，应用钢板螺钉内固定枕颈融合治疗难以复位的寰枢椎脱位并脊髓压迫11例，其中齿突陈旧性骨折并寰椎前脱位7例，齿突发育不良并寰椎后脱位4例。结果寰枢椎脱位获得不同程度的复位，脊髓压迫解除，神经功能明显改善，枕颈部3～5个月骨性融合。结论对于难以复位的寰枢椎脱位应用钢板螺钉内固定枕颈融合术，不但固定较牢固可靠、简便，有利于植骨融合，而且还有一定的复位作用。     

经C1、2关节突螺钉治疗寰枢椎创伤和不稳的疗效及手术策略

目的 探讨经C1、2关了突螺钉治疗寰枢椎创伤和不稳的疗效及手术策略.方法 11例寰枢椎骨折或不稳需行寰枢椎融合患者,经颅骨牵引基本复位后行C1、2关节突螺钉联合Gallie手术,观察术后近期疗效、植骨融合及并发症.结果 术中和术后无神经、椎动脉损伤表现.术后枕颈部冬痛消失7例,明显缓解4例.1例双上肢麻木术后明显好转.过伸过屈侧位X线片示寰枢椎稳定性好.平均随访7.8个月,11例植骨均融合,无内固定并发症.颈椎前屈、后伸、左右侧屈活动度未见明显减少,旋转活动平均丧失34.6%.结论 经C1、2关节突螺钉固定寰枢椎生物力学稳定性好,植骨融合率高,并发症发生率低,是一种安全、疗效可靠的手术方法.     

枕颈融合Cervifix内固定术

目的：研究Cetwifix内固定在枕颈融合术中的价值和作用。方法：对47例上颈椎不稳患者行枕颈部自体植骨融合Cervifix内固定术，其中陈旧性寰枢椎骨折脱位14例，枕寰枢椎复合性畸形13例，寰枢椎肿瘤10例(其中原发性寰枢椎肿瘤6例，转移性寰枢椎肿瘤4例)，寰枢椎类风湿性关节炎伴寰椎前脱位8例，寰枢椎结核2例。结果：47例患者均获随访，时问3～38个月，平均9个月。46例植骨愈合，1例植骨块部分吸收骨不连。31例颈髓神经压迫症状均有不同程度的改善。无一例发生Cetwifix内固定螺钉松动等并发症。结论：Cervifix内固定可提供坚强有效的节段性固定，适用于枕颈不稳的治疗。     

枕颈CD内固定在枕颈融合术中的应用

目的：研究枕颈CD内固定在枕颈融合术中的价值和作用。方法：对13例上颈椎不稳患者行枕颈部自体植骨融合枕颈CD内固定术。其中包括寰枢椎肿瘤4例,陈旧性寰枢椎骨折脱位4例,枕寰枢椎复合性畸形4例,陈旧性横韧带断裂伴寰椎前脱位1例。结果：13例患者均获随访5－27个月,平均10个月。所有病例植骨均完全愈合,无一例发生枕颈CD椎板钩及螺钉松动等并发症。结论：枕颈CD可提供有效的节段固定,适用于枕颈不稳的治疗。     

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。     

枕颈钢板固定融合治疗齿突骨折伴脊髓损伤

目的　探讨齿状突骨折与迟发性脊髓损伤关系及外科治疗方法选择。方法　对 7例齿突骨折伴迟发性脊髓损伤患者全部施行槽式钢板内固定及取髂骨植骨融合术。随访 6个月～ 48个月 ,平均 2 8个月。结果　 7例枕颈植骨全部融合 ,功能评价 :优 6例 ,良 1例。结论　认为陈旧性齿突骨折 ,造成寰枢椎不稳 ,最终导致寰枢椎脱位及脊髓压迫 ,应积极选择牵引复位 ,后方减压 ,坚强内固定及枕颈融合术。     

创伤陈旧性寰枢椎脱位的诊断与手术治疗

目的　探讨创伤性陈旧性寰枢椎脱位的诊断与手术治疗。方法　自 1994年 1月～ 2 0 0 2年 12月收治创伤性陈旧性寰枢椎脱位 2 6例 ,全部病例入院前均被漏诊或误诊。采用枕颈融合 10例 ,寰枢融合 16例。结果　症状完全缓解 2 3例 ,部分缓解3例 ,神经功能明显改善 9例 ,无改善 1例。骨性融合时间 3～ 10个月。结论　外伤病人如有诉头颈或枕部疼痛 ,要考虑寰枢椎脱位的可能 ,常规摄颈椎正侧位片和张口位X线片 ,必要时加摄应力位片。对于难复性陈旧性寰枢椎脱位 ,采用后路枕颈融合。可复性的寰枢椎脱位将采用寰枢融合 ,经C1、2 关节突侧块螺钉固定是目前寰枢椎融合固定中较好的方法之一。     

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。     

Occipitocervical stabilization for myelopathy in patients with rheumatoid arthritis. Implications of not bone-grafting

BACKGROUND: Approximately 0.9 percent of the white adult population of the United States and 1.1 percent of the adult population in Europe are affected by seropositive rheumatoid arthritis. As many as 10 percent of those patients may need an operation for atlantoaxial subluxation. Severe instability, especially when associated with vertical subluxation of the odontoid process, can result in progressive cervical myelopathy. Typically, occipitocervical fixation has been performed for these patients with use of autograft bone to achieve long-term stability through a solid fusion. Harvesting the bone graft increases the operative risk to the patient and may result in increased morbidity. In our experience, patients who have had no clear radiographic evidence of fusion following use of occipitocervical instrumentation seemed to have done as well as those who have had obvious fusion. One assumption is that the clinical improvement might be attributable simply to stabilization of the joint rather than to osseous fusion. A longitudinal study was performed on patients with rheumatoid arthritis who required an operation because of craniocervical or upper cervical instability. METHODS: The results of clinical, radiographic, functional, and self-evaluations were studied to determine the efficacy of treatment and to compare the outcomes of bone-grafting with those of procedures done without bone-grafting in a group of 150 patients who underwent posterior occipitocervical stabilization with use of a contoured metal implant (a Ransford loop) that was affixed by sublaminar wires. Internal fixation was performed in 120 patients without bone-grafting and in thirty patients with use of autogenous bone-grafting. Preoperatively, 23 percent (thirty-five) of the 150 patients had mild neurological involvement (class II, according to the system of Ranawat et al.), 45 percent (sixty-eight) had objective findings of weakness and long-tract signs but were able to walk (class III-A), and 29 percent (forty-three) were quadriparetic and unable to walk (class III-B). The age of the patients at the time of the operation ranged from twelve to eighty-three years (mean, sixty-two years). RESULTS: There were significant improvements in postoperative Ranawat classes at all time-periods (range, p < 0.00005 to p = 0.0066) and in patient ratings of neck pain (range, p < 0.00005 to p = 0.0044) compared with preoperative scores. With the numbers available, there were no significant differences between the patients managed with a graft and those managed without grafting with respect to survival after the operation, Ranawat class, head or neck-pain rating, presence of subaxial abnormalities, radiographic craniovertebral motion, or vertical subluxation. Overall mortality at one month was 10 percent (fifteen of 150), although this value varied directly with the degree of preoperative disability. A second cervical spine operation was required in 11 percent (sixteen) of the 150 patients. CONCLUSIONS: While patients who have rheumatoid disease with anterior atlantoaxial subluxation should be treated with posterior atlantoaxial arthrodesis with use of bone-grafting and internal fixation, we believe that those who present with vertical instability and multi-level involvement can be treated with posterior occipitocervical stabilization with use of a contoured occipitocervical loop and sublaminar wire fixation without bone-grafting. Furthermore, we believe that the use of preoperative traction, bone cement, or a postoperative halo vest is unnecessary. Avoiding the harvesting of autogenous bone for grafting reduced the morbidity of this operation without compromising the outcome in these already sick patients.     

寰枢椎不稳的颈后路手术治疗

目的 对寰枢椎不稳的颈后路手术治疗进行探讨。方法 共78例患者,男57例,女21例;年龄3－78岁,平均42岁。其中齿突骨折（新鲜骨折、陈旧骨折、骨不连）38例,齿突游离小骨15例,寰椎横韧带断裂8例,寰枢椎肿瘤6例,枕颈部发育畸形6例,寰椎椎弓陈旧性骨折5例。78例均行颈后路手术,包括枕颈融合术32例,其中单纯植骨融合11例,辅以CD－Cervical内固定11例,Cervifix内固定10例;寰枢椎融合术46例,其中钢丝钛缆内固定37例（9例同时行寰枢椎经关节间隙螺钉内固定术）,Apofix椎板夹内固定9例。结果 78例均获随访,时间6个月－18年,平均38．4个月。骨性愈合75例,不愈合3例。术前合并神经系统症状38例,术后症状消失或基本消失20例,明显改善11例,轻度改善3例,无改善2例,加重2例。结论 对于由寰枢椎骨折脱位、畸形、肿瘤及横韧带断裂等引起的寰枢椎不稳,应早期进行后路融合术。充分控制寰枢椎活动,精心准备植骨床是保证手术成功的关键。     

重建钛板枢椎椎弓根螺钉及颗粒状植骨枕颈融合术

目的 探讨重建钛板螺钉及颗粒状自体松质骨植骨在枕颈融合中的应用。方法 2002年4月～2005年1月，选择枕颈区不稳定患者19例，年龄31～67岁；病程3个月～2年。其中枕寰枢椎复合畸形8例，陈旧性寰枢椎骨折脱位8例，类风湿性关节炎所致寰椎前脱位2例，枢椎齿状突肿瘤1例。JOA脊髓功能评分平均9．8分。使用重建钛板和枢椎椎弓根螺钉固定枕颈部，同时枕骨与枢椎后弓间颗粒状自体松质骨植骨。结果 术中、术后无并发症发生，切口Ⅰ期愈合。19例均获随访6个月～2年8个月，平均16个月，均获得了骨性融合。无神经血管损伤，无断钉、断板及内固定松脱。JOA脊髓功能评分平均达14．4分。结论 重建钛板枢椎椎弓根螺钉固定可靠，置入方便，自体颗粒状松质骨具有较高的融合率，在枕颈融合中效果满意。     

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。     

Posterior occipitocervical reconstruction using cervical pedicle screws and plate-rod systems.

STUDY DESIGN: This retrospective study was conducted to analyze the clinical results in 26 patients with lesions at the craniocervical junction that had been treated by occipitocervical reconstruction using pedicle screws in the cervical spine and occipitocervical rod systems. OBJECTIVES: To evaluate the effectiveness of pedicle screw fixation in occipitocervical reconstructive surgery and to introduce surgical techniques. SUMMARY OF BACKGROUND DATA: Many methods of occipitocervical reconstruction have been reported, but there have been no reports of occipitocervical reconstruction using pedicle screws and occipitocervical rod systems for reduction and fixation. METHODS: Twenty-six patients with lesions at the craniocervical junction underwent reconstructive surgery using pedicle screws in the cervical spine and occipitocervical rod systems. The occipitocervical lesions were atlantoaxial subluxation associated with basilar invagination, which was caused by rheumatoid arthritis in 19 patients and other disorders in 7. The lowest cervical vertebra of fusion in 16 patients was C2, and the remaining 10 patients underwent fusion downward from C3 to C7. Flexion deformity of the occipitoatlantoaxial complex was corrected by application of extensional force, and upward migration of the odontoid process was reduced by application of combined force of extension and distraction between the occiput and the cervical pedicle screws. RESULTS: Solid fusion was achieved in all patients except two with metastatic vertebral tumors who did not receive bone graft for fusion. Correction of malalignment at the craniocervical junction was adequate, and postoperative magnetic resonance imaging showed improvement of anterior compression of the medulla oblongata. There were no neurovascular complications of cervical pedicle screws. CONCLUSIONS: Occipitocervical reconstruction by the combination of cervical pedicle screws and occipitocervical rod systems provided the high fusion rate and sufficient correction of malalignment in the occipitoatlantoaxial region. Results of this study showed the effectiveness of cervical pedicle screw as a fixation anchor for occipitocervical reconstruction.     

Craniocervical fusion for rheumatoid arthritis: comparison of sublaminar wires and the lateral mass screw craniocervical fusion

The majority of rheumatoid arthritis patients with C1/2 instability causing neck pain and neurological compromise can be treated with unisegmental fusion. However, a minority will require decompression and more extensive craniocervical fusion. Two cohorts of patients with rheumatoid arthritis requiring decompression and craniocervical fusion were included in a retrospective study comparing sublaminar wiring (Ransford Loop, n = 10, follow-up = 36 +/- 9.5 months) and lateral mass screws (Cervifix system, n = 11; follow-up = 39.7 +/- 7.9 months). Both cohorts of patients experienced significant improvements in high cervical pain scores [McGill 5-point score; preop = 4.5 +/- 0.75 for Cervifix and 4.5 +/- 0.75 for Ransford loop; postop = 1.17 +/- 0.9 (p = 0.003) for Cervifix (at 39.7 months +/-7.9) and 2.8 +/- 1.6 (p = 0.011) for Ransford loop (at 36 +/- 9.5 months)]. Lateral mass screws for craniocervical fusion (seven out of 11 pain free) appear to produce better early results for rheumatoid arthritis patients suffering high cervical neck pain than sublaminar wire techniques (three out of 10 pain free).     

寰枢关节360°松解在经口寰枢椎复位钢板内固定术治疗僵硬难复性寰枢椎脱位中的应用

目的探讨在经口寰枢椎复位钢板(TARP)内固定术中采用寰枢关节360°松解技术治疗僵硬难复性寰枢椎脱位的临床疗效。方法 2005年1月—2014年12月,对23例常规方法不能彻底松解的僵硬难复性寰枢椎脱位患者采用寰枢关节360°松解TARP内固定术治疗。通过术前、术后影像学检查(X线、CT三维重建和MRI)判断寰枢椎复位、内固定器位置及脊髓受压改善情况。采用日本骨科学会(JOA)评分评估患者临床症状改善情况。结果所有患者手术均顺利完成,术后颈椎局部症状和肢体麻木无力均不同程度改善,术后影像学资料显示内固定位置满意,脊髓压迫均彻底解除。所有患者术后随访6~12个月(平均9.3个月),末次随访时JOA评分由术前(8.5±3.2)分提高至(13.2±2.1)分;所有患者均获骨性融合。除1例患者因术中硬膜破裂,二期拆除TARP改为后路枕颈固定,其他患者未发生感染、神经血管损伤、钉板松脱等并发症。结论按常规方法不能完成充分松解的由陈旧性骨痂和瘢痕等因素造成的僵硬难复性寰枢椎脱位,采用寰枢关节360°松解技术可以获得彻底松解,再行TARP内固定术即可完成寰枢关节的完全复位,彻底解除脊髓压迫。     

Marginal indications for the Magerl method of fixation of C1-C2 (case report)

The authors present a 4-year old girl who had a car accident as a passenger and hurt her head, chest and limbs as well as upper cervical spine. The patient with multiple injuries was taken to the FTN Centre of Children's traumatology, Prague. Here the basic vital functions were ensured and a diagnosis was made of contusion of the brain with quadriparesis and inhibition of the respiratory centre, contusion of the chest, epiphysiolysis of the distal femur and later also instability of C1-C2. A censor for measuring or intracranial pressure was immediately inserted with a subsequent reduction of the distal femur and elastic fixation. External lumbar drainage was performed in the next week instability of C1-C2 was not found out and therefore not treated. Three months after the injury a ventriculoperitoneal shunt for intracranial hypertension was inserted. MRI showed stenosis in the region of occipitocervical passage and dorsal decompression of craniocervical passage was performed which consisted in the removal of the posterior arch of C1 and a significant extension of foramen magnun dorsally and laterally to both sides. Due to persisting ligamentous instability of C1-C2 with a spastic quadriparesis and inhibition of the respiratory centre a surgical atlantoaxial stabilization was indicated, i.e. causal treatment of instability. Seven months after the injury Magerl fixation of C1-C2 was performed by 2.7 mm titanicum screws (Synthes). Preoperative stability of C1-C2 in the reduced position was satisfactory but with regard to iatrogenic instability the C0-C1 fixation was combined with occipitocervical fussion by Ransford loop extending over C0-C3. Further, the triangular flap of periost was overturned from the external occipital protuberance to C3 and all this was bridged by cortical cancellous bone grafts from iliac crest. After two months a check simple and functional x-ray examination showed a stable fusion of C0-C2. The neurological finding remained the same even after one year, i.e. a severe quadriparesis with the inhibition of the respiratory centre requiring artificial lung ventilation.     

内窥镜辅助下经颈动脉三角区前路松解治疗难复性寰枢关节脱位(附12例初步报告)

目的：探讨内窥镜辅助下经颈动脉三角前路松解治疗难复性寰枢关节脱位的手术方法。方法：12例难复性寰枢关节脱位患者，男性4例，女性8例，年龄16～48岁，平均31．6岁；病程24～48个月。平均20个月。其中陈旧性齿状突骨折5例，齿状突不连3例，横韧带松弛症3例，齿状突短小合并寰枕融合畸形1例。术前颈脊髓功能JOA评分平均9．3分。在内窥镜辅助下经颈动脉三角区前路C1、C2松解，清除寰枢椎前方挛缩瘢痕组织(或骨)连接，颅骨牵引复位，一周后行后路内固定融合手术。结果：前路平均手术时间70min，出血量150ml。松解后11例获得解剖复位，行寰枢椎固定；1例部分复位，行枕颈融合。术后随访3～12个月，无手术切口感染和内固定失败。术后JOA评分平均15．2分，术后功能改善率76．6％。结论：内窥镜辅助下经颈动脉三角区前路松解治疗难复性寰枢关节脱位创伤小、术野清晰、安全有效。