颅颈交界区后路螺钉内固定

目的 报告C2椎弓根螺钉结合C1侧块或枕骨螺钉用于颅颈交界区后路内固定的解剖研究及临床应用结果.方法 福尔马林固定的头颈标本4个,根据解剖标志分别植入C2椎弓根及C1侧块螺钉,然后行CT扫描及重建,观察螺钉位置.2004年5月至2007年1月,利用C2椎弓根一C1侧块/枕骨螺钉内同定9例病人,男4例,女5例,年龄12～68岁,平均38岁;各种原因引起的C1～C2半脱位6例,因颅底凹陷经口腔齿状突切除后1例,斜坡脊索瘤经口腔切除手术前2例;采用C2椎弓根-C1侧块螺钉技术4例,C2椎弓根一枕骨螺钉技术5例,手术后均行CT扫描观察螺钉位置.结果 手术中直接显露C2椎弓根内上缘,并以此确立进钉方向,在椎弓根峡部后缘确定进钉点,可保证C2椎弓根螺钉的安全植入;直接显露C1侧块后正中确立进钉点,可避免螺钉植入过程中的椎动脉损伤.9例病人中,手术后CT复查有2例病人两颗螺钉穿破骨皮质,但末造成血管及神经的压迫,其余螺钉位置均较好;随访4-32个月,1例临床症状较术前无变化,其余8例均改善.结论 C2椎弓根-C1侧块/枕骨螺钉技术可安全有效地用于颅颈交界区内固定.     

颅颈交界后路内固定技术进展

颅颈交界区的后路内固定术通常指寰枢椎内固定术和枕颈内固定术,主要应用于先天畸形、外伤、炎症以及肿瘤破坏等各种原因导致的颅颈交界区失稳。寰枢椎脱位是颅颈交界区失稳的关键病理变化,因此各种内固定技术主要针对寰枢椎加以固定和植骨,即寰枢椎内固定术。有时寰椎或枢椎不     

Surgical treatment of meningiomas of the craniovertebral junction

The results of surgical treatment in 21 patients with meningiomas of the craniovertebral junction are presented. Main clinical diagnostic criteria in relation to the site of a tumor relative to the brain stem are considered. The basic surgical approaches used in the surgical treatment of meningiomas of the craniovertebral junction are described. These include posterior, median, posterolateral, transcondylar approaches. Surgical techniques to remove meningiomas having a matrix of varying areas were concretized, this is also done in relation to the consistency of a tumor. The outcomes of surgical treatment are analyzed. Possible postoperative complications and measures of their prevention and treatment are considered.     

个体化3D打印模型辅助后路螺钉内固定治疗颅颈交界区畸形

目的 研究个体化3D打印模型辅助后路内固定治疗颅颈交界区畸形的方法和效果.方法 对贵州省人民医院神经外科MRI及CT确诊的31例颅颈交界区畸形患者进行回顾性分析.采用3D打印技术建立颅颈交界区个体化3D打印模型,在模型上进行模拟置钉及内固定手术,获得个体化置钉数据,再进一步术中辅助真实手术,采取一期后路减压及内固定治疗.结果 25例建立了个体化3D打印模型辅助术中置钉进行内固定手术,全部置钉成功.术前CT判断,有2例可直接行枢椎椎弓根置钉,但通过3D模型测量以及术中辅助发现不能置钉;术前有3例评估不适合椎弓根置钉的病例,经过3D模型分析,最后仍能行椎弓根峡部置钉.术后随访时间3～ 28个月,平均13.9个月.术后JOA评分显著提高,差异有统计学意义(P=0.000).术后复查MRI及CT,寰枢椎脱位行撑开复位的24例中,完全复位19例,不完全者5例.术后寰椎齿突间隙(ADI)明显缩小,延髓颈髓角(CMA)明显增大,延髓腹侧受压明显减轻或消失,差异有统计学意义(P=0.000).无手术死亡,2例出现呼吸困难.结论 个体化3D打印模型辅助后路螺钉内固定可提高置钉成功率,有效保护椎动脉,提高安全性,值得初学内固定者借鉴和推广;采取螺钉间撑开复位技术治疗寰枢椎脱位短期疗效好.     

Amyloidoma of the craniovertebral junction

We report a rare case of localized amyloidoma of the craniovertebral junction causing severe myelopathy and respiratory distress and death. The clinical features and the natural history of this rare condition are discussed.     

复杂颅颈交界区畸形个体化治疗值得考虑的问题

对于颅颈交界区(CVJ)畸形的描述最早可追溯到18世纪末、19世纪初,但限于技术条件等原因,对其认识有限。直至20世纪70年代末期,随着CT、MRI及三维CT重建术等现代影像学技术的问世,对颅颈交界区畸形的诊断和治疗才日趋准确、合理。     

颅颈交界区畸形

颅颈交界区(CVJ)畸形的发生发展既有先天胚胎发育因素,又有后天病理生理学及生物力学改变的影响。在许多情况下,多种畸形同时存在,错综复杂,如颅底凹陷(BI)、扁平颅底(platybasia)、寰枕融合(AOA)、寰枢椎脱位(AAD,失稳)等,有时还可同时合并小脑扁桃体下疝、脊髓空洞症(SM)等,给疾病的诊断、鉴别诊断带来困难,误诊误治现象时有发生。     

不适合枢椎椎弓根螺钉植入的颅颈交界区后路螺钉固定方法的选择

目的 评价不适合枢椎椎弓根螺钉植入的颅颈交界区后路固定方法的安全性及有效性.方法 回顾性总结分析自2004年5月至2011年8月,32例未采用枢椎椎弓根螺钉固定患者的临床资料,针对性采用枢椎椎板螺钉、枢椎侧块螺钉和延长固定节段至C3侧块的方法.采用问卷调查、电话和门诊复查进行随访,手术前后分别行MRI及CT薄层扫描及重建,评价脊髓受压程度,螺钉位置及脱位复位程度,6个月后复查CT观察骨融合情况.通过比较术前、术后日本骨科协会(JOA)评分评判患者疗效.结果 32例病例均行钉棒固定,共植入枢椎椎板螺钉14枚,枢椎侧块螺钉13枚,C3侧块螺钉36枚.术中未发生椎动脉和脊髓损伤.1枚椎板螺钉突破枢椎椎板外层皮质,但没有影响到固定的稳定性;1枚枢椎侧块螺钉突入横突孔,但未造成椎动脉损伤.32例病例均获得不同程度的复位,随访中1例病例出现复位丢失.结论 根据个体解剖特点,在不适合植入枢椎椎弓根螺钉时,灵活选择不同的替代螺钉固定方式,可以提高手术的安全性和成功率.但其长期有效性仍有待进一步观察研究.     

Fusions at the craniovertebral junction

INTRODUCTION: The surgical management of craniovertebral junction instability in pediatric patients has unique challenges. While the indications for internal fixation in children are similar to those of adults, the data concerning techniques, complications, and outcomes of spinal instrumentation comes from experience with adult patients. Diminutive osseous and ligamentous structures and anatomical variations associated with syndromic craniovertebral abnormalities frequently complicates the approaches and limits the use of internal fixation in children. Cervical arthrodesis in the pediatric age group has the potential for limiting growth potential and causing secondary deformity. Recent advances in image analysis have enabled preoperative planning which is critical to evaluate the size of instrumentation and its relation to the patient's anatomy. Newer techniques have recently evolved and have been incorporated in the management of pediatric patients with requirement for craniocervical stabilization. MATERIALS AND METHODS: Over 750 craniovertebral junction fusions have been reviewed in children. The indications for atlantoaxial arthrodesis were: (a) absent odontoid process, dystopic os odontoideum, absent posterior arch of C1; (b) Morquio's syndrome, Goldenhar's syndrome, Conradi's syndrome, and spondyloepiphyseal dysplasia. The acquired abnormalities of trauma, postinfectious instability, and Down's syndrome completed the indication in children. The indications for occipitocervical fusion were: (a) anterior and posterior bifid C1 arches with instability, absent occipital condyles; b) severe reducible basilar invagination, unstable dystopic os odontoideum, and unilateral atlas assimilation; (c) acquired phenomenon with traumatic occipitocervical dislocation, complex craniovertebral junction fractures of C1 and C2, after transoral craniovertebral junction decompression, cranial settling in Down's syndrome and inflammatory disease such as Grisel's syndrome. Instability was seen in children with clivus chordoma and osteoblastoma. Atlantoaxial fusions were performed mainly with interlaminar rib graft fusion and more recently with the transarticular screw fixation in the older patient. In the teenager, lateral mass screws at C1 and rod fixation were made; C2 pars interarticular screw fixation and C2 pedicle screw fixation. A C2 translaminar screw fixation is described. Occipitocervical fusions were made utilizing rib grafts below the age of 6. A contoured loop fixation was made in children above the age of 7, and recently, rod and screw fixation was also utilized. RESULTS: Abnormal cervical spine growth was not seen in children who underwent craniocervical stabilization below the age of 5. The authors have reserved rigid instrumentation for children above the age of 10 years and dependent on the anatomy.     

经后路椎板内固定术治疗颅颈交界区畸形合并寰枢椎脱位

目的观察经后路椎板内固定术治疗颅颈交界区畸形合并寰枢椎脱位的临床疗效。方法对2010年4月-2011年11月诊断明确的颅颈交界区畸形合并寰枢椎脱位的12例患者进行经后路减压复位螺钉钛棒(板)系统内固定术。应用CT薄层扫描及三维CT重建术测量手术前后寰齿间距(ADI)、硬腭枕骨大孔线(CL)和斜坡枕骨大孔线(ML)上方距离,通过延髓脊髓角(CMA)评价脊髓受压程度,以日本骨科协会(JOA)17分评分系统评价颈脊髓神经功能改善程度;神经电生理学方法监测神经传导功能,同时分析经后路减压复位螺钉钛棒(板)系统内固定术治疗颅颈交界区畸形合并寰枢椎脱位的可行性。结果共随访4~20个月(平均13个月)。与手术前ADI[(4.42±2.91)mm]、CL[(10.31±3.80)mm]、ML[(3.24±2.92)mm]、CMA[(127.83±8.75)°]及JOA评分(9.75±2.59)相比,手术后ADI[(2.96±2.08)mm]、CL[(7.16±3.19)mm]、ML[(0.29±2.36)mm]减小,CMA[(134.10±8.38)°]及JOA评分(14.83±2.94)增加,治疗前后比较差异具有统计学意义(P<0.05或P<0.01)。其中,手术前神经电生理学监测波形异常的10例患者中7例术后完全恢复正常形态。术后MRI检查显示,颅颈交界区减压充分,无一例出现内固定松动或断裂;随访期间植骨获得骨性融合,未出现并发症。结论经后路椎板内固定术治疗颅颈交界区畸形合并寰枢椎脱位临床疗效满意,手术安全、可行。     

经口咽前路寰枢椎复位钢板置入内固定治疗颅颈交界部畸形的MRI评价

背景：颅颈交界部畸形经口咽前路寰枢椎复位钢板置入内固定治疗过程中,X射线、CT对于颅颈交界部病变的检查只能显示其骨性结构,无法显示脊髓情况。 目的：分析颅颈交界部畸形经口咽前路寰枢椎复位钢板内固定前后的磁共振图像,探讨MRI成像对其内固定术式的选择及效果判断的价值。 方法：选择2009-06/2010-04收治的颅颈交界部畸形患者25例,男9例,女16例,术前均行X射线、CT、MRI检查,采用经口咽前路寰枢椎复位钢板置入内固定治疗方式,置入后6个月内行MRI复查。 结果与结论：所有患者均顺利完成内固定,未出现脊髓血管损伤等严重并发症。25例患者置入后MRI成像显示内固定在位,寰枢椎复位,脊髓受压情况改善,11例随访患者中,原上颈椎局部疼痛、活动受限等情况有9例明显改善或消失。提示MRI能够多方位清晰显示颅颈交界部畸形情况,对脊髓及颅内病变的显示更直接,可为颅颈交界部畸形经口咽前路寰枢椎复位钢板置入内固定手术方式的选择、脊髓受压情况及手术效果的判断、术后恢复提供客观依据。     

Anatomy and development of the craniovertebral junction

The occipital bone is the upper end of the somatic spine, limited cranially by the tentorium. The bony craniovertebral junction (caudal occiput, atlas, and axis) is interposed between the unsegmented occipital and the intersegmental spinal sclerotomes, separated from the occiput and C3 by the intrasegmental clefts of O4 and C2 sclerotomes, respectively. It retains a primitive segmental hypocentrum (anterior arch of C1) and is unsegmented from caudal O4 to cranial C2 half-sclerotomes (axis). Its morphology relates to the dual function of providing support and mobility (visual/olfactory/auditory pursuit, oral prehension) to the head. The early notochord passes through the odontoid tip to the basiocciput surface before entering the clivus up to the craniopharyngeal canal; later, the rostralmost chordal remnant is the C2/3 nucleus pulposus. Chondrification starts in the second fetal month and ossification in the fetal or postnatal periods depending on the structure.     

Analysis of the treatment of 576 patients with congenital craniovertebral junction malformations

We aim to report our experience treating craniovertebral junction malformations (CVJM) and to investigate the management of this uncommon condition. Between 2000 and 2009, 629 patients with CVJM underwent surgery in our department. Fifty-three patients were lost to follow-up; therefore 576 patients completed follow-up, for an average period of 3 years and 2 months. All patients were diagnosed on the basis of clinical presentation and imaging features, and we found that anomalies of the occipitocervical junction manifested as four major types. Different microsurgical treatments were carried out in these patients according to disease type, and the effectiveness of individualised treatments was analysed. Categorizing patients with CVJM into these four types to simplify this somewhat unclear area could provide insight into the pathogenesis of the anomaly and a basis for rational surgical treatment.     

合并寰枢椎脱位的复杂颅颈交界区畸形后路减压复位内固定术疗效初步观察

目的 总结合并寰枢椎脱位的复杂颅颈交界区畸形经后路减压复位内固定术的临床经验.方法 回顾分析18 例合并寰枢椎脱位的复杂颅颈交界区畸形患者(先天性寰枢椎脱位15 例、经口腔入路齿状突磨除术后症状加重致枕颈失稳1 例、外伤所致2 例)的临床资料.施行经后路减压复位钉棒内固定术,术中行体感诱发电位及肌电图监测,根据日本骨科协会(JOA)17 分评分系统和影像学改善程度评价手术疗效.结果 术后影像学检查显示,18 例中16 例钉棒内固定系统和寰枢椎复位良好,1 例复位不良;骨性融合良好16 例,欠佳1 例.术后临床表现均不同程度好转,1 例突发呼吸骤停死亡.术后平均随访6.62 个月(3 ~ 28 个月),JOA 平均评分为11.62 ± 3.23,与手术前评分(7.51 ± 3.82)相比,差异具有统计学意义(t = - 5.476,P = 0.004).结论 经后路减压、复位、钉棒内固定术治疗合并寰枢椎脱位的颅颈交界区畸形临床疗效良好,能够减少患者痛苦、避免再次手术,值得临床推广应用.     

Intradural neurenteric cyst at the craniovertebral junction

A case of an intraspinal neurenteric cyst at the craniovertebral junction in a 7-year-old girl is reported. The intermittent progression of her neurological symptoms delayed the diagnosis. The location and cystic nature of the lesion were diagnosed with magnetic resonance imaging. Total surgical excision of the cyst was possible.     

前屈-后伸位MRI对判断颅脊交界区畸形内固定指征的临床价值

目的分析前屈-后伸位MRI对诊断Arnold-Chiari畸形可能合并寰枢椎脱位的作用,以及指导治疗的临床意义。方法回顾分析40例Arnold-Chiari畸形患者的前屈-后伸位MRI影像学资料,测量寰齿间距,通过前屈位和后伸位颈椎椎管狭窄程度分级,判断颅脊交界区稳定性。单纯Arnold-Chiari畸形患者采用枕大孔减压和枕大池扩大成形术,存在寰枢椎脱位者兼行枕颈内固定融合术。结果经前屈-后伸位MRI检查,证实有12例患者存在颅颈失稳,于枕大孔减压的同时行枕颈内固定融合术。手术后第3天颈椎影像学检查,40例中10例脊髓空洞病灶明显缩小;12例兼行枕颈内固定融合术者颅颈复位满意,脊髓压迫解除;手术后3个月随访,脊髓空洞病灶明显缩小(17例),颅脊交界区骨痂形成、骨融合效果良好、颅颈复位无丢失(12例),日本矫形外科评分13.08±1.40,与手术前评分(11.08±1.61)比较,差异有统计学意义(t=5.928,P=0.000)。结论前屈-后伸位MRI对判断颅脊交界区稳定性、选择适宜的手术方式具有重要意义。     

前屈-后伸位MRI对判断颅脊交界区畸形内固定指征的临床价值

目的分析前屈-后伸位MRI对诊断Arnold—Chiari畸形可能合并寰枢椎脱位的作用,以及指导治疗的临床意义。方法回顾分析40例Arnold—Chiari畸形患者的前屈-后伸位MRI影像学资料,测量寰齿间距,通过前屈位和后伸位颈椎椎管狭窄程度分级,判断颅脊交界区稳定性。单纯Arnold．Chiari畸形患者采用枕大孔减压和枕大池扩大成形术,存在寰枢椎脱位者兼行枕颈内固定融合术。结果经前屈．后伸位MRI检查,证实有12例患者存在颅颈失稳,于枕大孔减压的同时行枕颈内固定融合术。手术后第3天颈椎影像学检查,40例中10例脊髓空洞病灶明显缩小;12例兼行枕颈内固定融合术者颅颈复位满意,脊髓压迫解除;手术后3个月随访,脊髓空洞病灶明显缩小（17例）,颅脊交界区骨痂形成、骨融合效果良好、颅颈复位无丢失（12例）,日本矫形外科评分13．08±1．40,与手术前评分（11．08±1．61）比较,差异有统计学意义（t=5．928,P=0．000）。结论前屈．后伸位MRI对判断颅脊交界区稳定性、选择适宜的手术方式具有重要意义。     

Embryology and bony malformations of the craniovertebral junction

Background  

The embryology of the bony craniovertebral junction (CVJ) is reviewed with the purpose of explaining the genesis and unusual configurations of the numerous congenital malformations in this region. Functionally, the bony CVJ can be divided into a central pillar consisting of the basiocciput and dental pivot and a two-tiered ring revolving round the central pivot, comprising the foramen magnum rim and occipital condyles above and the atlantal ring below. Embryologically, the central pillar and the surrounding rings descend from different primordia, and accordingly, developmental anomalies at the CVJ can also be segregated into those affecting the central pillar and those affecting the surrounding rings, respectively.     

枢椎椎板螺钉用于颅颈交界区后路固定的疗效评价

目的 评价枢椎(C2)椎板螺钉固定的安全性及有效性.方法 2004年5月至2010年8月,回顾性总结分析14例C2:椎板螺钉固定患者的临床资料.手术前后分别行MRI及CT薄层扫描及重建,评价脊髓受压程度,螺钉位置及脱位复位程度,3-6个月后复查CT观察骨融合情况.结果 14例患者的28枚螺钉中,27枚位置良好,仅1枚突破C2椎板外层皮质,但没有影响到固定的稳定性;11例脱位患者均获得满意的复位及脊髓减压.随访中13例6个月时骨融合,1例3个月时出现复位丢失.结论 C2椎板螺钉植入简单、安全,但其长期有效性及能否替代C2椎弓根螺钉仍有待进一步观察研究.

Abstract：

Objective To appreciate the safety and efficacy of C2 intralaminar screw fixation.Methods From May 2004 to August 2010,clinical data of 14 patients in which C,intralaminar screw fixation was USed was retrospectively collected and analyzed.MRI and CT were used to evaluate the preand postoperative degree of spinal cord compression,size of the C2 laminae,position of the screws,and degree of dislocation and reduction.CT scan 3-6 months after the operation was repeated to assess the bone fusion.Results Among 28 screws of 14 patients.27 screws were well placed but 1,in which lateral outer cortex breach of the C2 lamina occurred,without influencing the stability of the fixation.Satisfactory reduction and decompression of the spinal cord were achieved in all 11 dislocated patients.Bone fusion was confirmed in 13 of 14 patients 6 months postoperatively.Loss of reduction occurred in 1 patient 3 months after the operation.Conclusions C,intralaminar screw insertion is a simple and safe technique:its long term efficacy needs to be obserred,and further study is necessary to decide whether the technique Can be used as a substitute for C,pedicle screw fixation.     

Quantitative analysis of the effect of brainstem shift on surgical approaches to anterolateral tumors at the craniovertebral junction

Many anterolateral craniovertebral junction (CVJ) tumors can safely be resected using a simple posterolateral approach given the surgical corridor provided by brainstem shift. We sought to study how increasing anterolateral CVJ lesion size affects exposure in the posterolateral and far lateral approaches. Six cadaveric heads were used. A posterolateral approach was performed on one side and a far lateral with one-third condyle resection on the other side. Clival and brainstem exposure and surgical freedom were measured. A balloon catheter was used to simulate 10, 15, and 20 mm anterolateral mass lesions. Mean clival exposure was significantly greater with the far lateral approach (197.4 versus [vs] 135.0 mm², p = 0.03) with no balloon, but this difference disappeared with lesion sizes of 10 mm (246.8 vs 237.9 mm², p = 0.79), 15 mm (306.7 vs 262.4 mm², p = 0.25), and 20 mm (360.0 vs 332.7 mm², p = 0.64). Mean brainstem exposure was significantly greater with the far lateral approach for 0 mm (127.8 vs 65.8 mm², p < 0.01), 10 mm (129.5 vs 87.5 mm², p = 0.045), and 15 mm (140.1 vs 97.8 mm², p = 0.01) lesions. There was no difference at 20 mm (146.7 vs 147.8 mm², p = 0.97). Medial-lateral surgical freedom was greater with the far lateral approach for all sizes. The results of this study provide insight on one important variable in the decision-making process to select the optimal approach for anterolateral CVJ tumors.