经咽后入路行高位颈椎前路减压内固定术

目的 探讨经咽后入路行高位颈椎前路减压内固定的显露效果。方法 本组7例，年龄12－56岁，C1、2椎体结核3例，第二颈椎骨折（Hangman Ⅲ型）3例，C2、3、C3、4椎间盘突出症1例。经高位前方咽后入路显露C1－C3，结核行病灶清除，Hangman骨折复位后行C2、3椎间植骨融合，自锁钛板内固定，高位颈椎间盘突出症患者行椎间盘切除，C2、3植骨自锁钛板内固定。结果 7例患者均成功显露出C1前弓－C3椎体，并完成病灶清除、减压融合内固定。无颈部重要血管神经损伤，无伤口感染，1例不全瘫有部分恢复。结论 前方高位咽后入路是显露上颈椎较理想的入路，具有显露充分、损伤小、切口并发症少等优点。     

经咽后入路行高位颈椎前路减压内固定术

目的　探讨经咽后入路行高位颈椎前路减压内固定的显露效果。方法　本组 7例 ,年龄 12～ 5 6岁 ,C1、2 椎体结核 3例 ,第二颈椎骨折 (HangmanⅢ型 ) 3例 ,C2、3 、C3、4 椎间盘突出症 1例。经高位前方咽后入路显露C1～C3 ,结核行病灶清除 ,Hangman骨折复位后行C2、3 椎间植骨融合 ,自锁钛板内固定 ,高位颈椎间盘突出症患者行椎间盘切除 ,C2、3 植骨自锁钛板内固定。结果　 7例患者均成功显露出C1前弓～C3 椎体 ,并完成病灶清除、减压融合内固定。无颈部重要血管神经损伤 ,无伤口感染 ,1例不全瘫有部分恢复。结论　前方高位咽后入路是显露上颈椎较理想的入路 ,具有显露充分、损伤小、切口并发症少等优点。     

上位颈椎前路手术咽后人路"窗口"显露技术的临床应用观察

目的:探讨上颈椎前路减压经咽后入路"窗口"显露技术在上颈椎损伤手术中的应用.方法:2000年1月至2008年7月手术治疗上位颈椎损伤患者5例,男4例,女1例;年龄16～68岁,平均35岁.C2椎弓骨折(HangmanⅡ型)2例,C2,3椎间盘突出症2例,C2椎体结核1例.所有患者经高位前方咽后入路舌下神经、喉上神经、咽和颈动脉之间的"窗口"成功获得显露.Hangman骨折复位后行C2,3椎间盘切除椎闻植骨融合内固定.C2,3椎间盘突出症患者行相应椎间盘切除,减压植骨融合内固定.C2椎体结核行病灶清除并植骨等.结果:5例患者均成功在舌下神经、喉上神经、咽和颈动脉之间的"窗口"显露出C1前弓一C3椎体.随访5～26个月,平均13.5个月.无伤口感染,无颈部重要血管神经损伤.患者的神经症状恢复良好,所有患者植骨都获得了融合.结论:前方咽后入路的"窗口"显露技巧可使上颈椎获得理想的显露,创伤小,切口并发症少,有相关经验后也比较安全.     

上位颈椎前路手术咽后入路“窗口”显露技术的临床应用观察

目的：探讨上颈椎前路减压经咽后入路＂窗口＂显露技术在上颈椎损伤手术中的应用。方法：2000年1月至2008年7月手术治疗上位颈椎损伤患者5例,男4例,女1例;年龄16～68岁,平均35岁。C2椎弓骨折（HangmanⅡ型）2例,C2,3椎间盘突出症2例,C2椎体结核1例。所有患者经高位前方咽后入路舌下神经、喉上神经、咽和颈动脉之间的＂窗口＂成功获得显露。Hangman骨折复位后行C2,3椎间盘切除椎间植骨融合内固定。C2,3椎间盘突出症患者行相应椎间盘切除,减压植骨融合内固定。C2椎体结核行病灶清除并植骨等。结果：5例患者均成功在舌下神经、喉上神经、咽和颈动脉之间的＂窗口＂显露出C1前弓-C3椎体。随访5～26个月,平均13.5个月。无伤口感染,无颈部重要血管神经损伤。患者的神经症状恢复良好,所有患者植骨都获得了融合。结论：前方咽后入路的＂窗口＂显露技巧可使上颈椎获得理想的显露,创伤小,切口并发症少,有相关经验后也比较安全。     

经咽后入路手术治疗Hangman骨折

目的探讨Hangman骨折经咽后入路减压融合内固定的临床疗效。方法对7例Hangman骨折患者行颅骨牵引大致复位后择期手术。全麻下采用高位前方咽后入路显露C2-3椎体，切除C2-3椎间盘组织，充分减压，C2-3椎间植骨钢板内固定。术后颈围保护6～8周。结果7例均获随访，时间4—42个月。患者术后3个月内均获骨性愈合，无一例出现椎体再位移和成角畸形，无伤口感染及其他并发症发生，不全瘫患者均有不同程度恢复。结论C2-3前路减压融合内固定治疗Hangman骨折，内固定疗效确切，并能有效维持理想的复位。     

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。     

前方经咽后入路切口治疗上颈椎病变

目的探讨颈椎前方经咽后入路切口治疗上颈椎病变的临床疗效。方法 9例上颈椎病变患者,均采用前方经咽后入路切口实施颈椎前路手术,其中包括前后路手术1例,术前JOA评分平均（8.6±1.2）分,枢椎椎弓骨折2例,颈椎肿瘤3例,颈椎结核1例,颈椎间盘突出2例,颈椎畸形1例。结果 9例患者术中均清楚显露C1~C3椎体前方,完成减压复位、病灶清除、融合内固定等操作;有脊髓压迫者术后脊髓神经功能得到一定程度的改善。全部伤口于2周后获甲级愈合,无伤口感染病例。1例术后出现口轮匝肌瘫痪,1周左右自行缓解,1例出现术后呛咳,3周左右自行缓解,其余病例未出现颈部重要神经血管损伤与相应节段的颈髓损伤。9例患者均经平均12（10~16）个月随访,JOA评分术后平均（13.4±1.6）分,与术前比较有显著差异（P〈0.01）。结论经高位前方咽后入路可充分显露上颈椎前方,进行直接有效的手术操作,创伤小,并发症少,是理想的显露途径。     

前路松解复位后路融合治疗游离齿突继发环枢椎脱位

目的: 探讨经高位咽后入路前路松解、后路融合治疗游离齿突继发的难复性环枢椎脱位。方法: 本组 3例, 均为男性, 年龄 17~36岁, 无明显创伤史, 颅骨牵引 2~3周, 采用高位咽后入路显露C1~3, 行环枢前方松解复位, Ⅰ期后路环枢融合, Brooks法钛缆内固定。结果: 3例游离齿突继发的难复性环枢椎脱位, 术前颅骨牵引不能复位, 经前路手术松解达到良好复位, 后路环枢融合良好, 内固定无松脱, 无伤口感染。3例患者神经症状均明显改善。结论: 经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环枢椎脱位, Ⅰ期后路环枢融合可获良好的植骨融合。     

肩胛下高位经胸入路行上胸椎前路减压融合术

目的探讨前路肩胛下高位经胸入路行上胸椎减压内固定的显露效果。方法本组 8例 ,男 6例 ,女 2例 ,年龄2 6 - 5 5岁 ,平均 37岁。病变范围胸3 ～胸5椎体 ,其中胸3 ,4结核 3例 ,胸3 ～胸5转移性肿瘤 3例 ,胸4,5骨折 2例。采用肩胛下高位经胸入路显露胸1～胸5椎体 ,结核行病灶清除 ;肿瘤行病椎切除 ,骨水泥充填 ,Z -plate内固定 ;骨折行侧前方减压、植骨、Z -plate内固定。结果 8例均良好地显露出胸1～胸5椎体 ,并完成病灶清除、减压、内固定 ,无重要血管神经损伤 ,无 1例出现神经症状加重 ,伤口均一期愈合 ,仅 1例发生胸导管损伤 ,经对症治疗 1周后痊愈。结论肩胛下高位经胸入路是显露上胸椎较理想的入路 ,便于行侧前方减压 ,并有充分的空间行内固定。     

累及枢椎椎体的Hangman骨折七例报告

目的 探讨特殊Hangman骨折的损伤病理、诊断及治疗方法.方法 收治累及枢椎椎体的Hangman骨折7例,患者均有C2、3不稳定,2例同时累及C1、2,损伤脊髓神经.均行C2、3前路融合术,加前路经寰枢关节螺钉内固定2例,减压2例.结果 随访1～5.5年,骨折及C2、3或C1～3椎间均骨性愈合.除C1、2固定者头颈部旋转部分受限外,其他颈椎活动正常,神经功能恢复明显.结论 累及枢椎椎体的Hangman骨折具有自身伤情特点,CT及三维重建可明确诊断.如未波及C1、2其治疗同典型骨折,否则需酌情加寰枢关节融合术或齿状突骨折螺钉内固定术,前路手术值得推荐.     

颈前路植骨融合内固定治疗Ⅱ、ⅡA型Hangman骨折

目的观察颈前路植骨融合钢板内固定治疗Ⅱ、ⅡA型Hangman骨折的临床疗效。方法对16例Ⅱ、ⅡA型Hangman骨折患者术前颅骨牵引后行颈前路植骨融合钢板内固定术。结果 16例均获随访,时间12~24个月。均未出现脊髓、神经损伤,无椎动脉损伤及脑脊液等并发症,无切口感染,未发生咽喉疼痛、吞咽困难。术后3个月患者均获骨性愈合。颈椎生理曲度恢复,屈伸及旋转活动良好,无内固定系统松动、断裂现象。4例脊髓神经D级者全部恢复到E级。枕颈部疼痛均较术前明显改善。7例行取髂骨术者切口愈合良好,术区无遗留疼痛。结论颈前路植骨融合钢板内固定治疗Ⅱ、ⅡA型Hangman骨折能获得即时稳定,减压彻底,固定确实,融合满意。     

One stage anterior-posterior approach for traumatic atlantoaxial instability combined with subaxial cervical spinal cord injury

Objectives

To explore the clinical features of traumatic atlantoaxial instability combined with subaxial cervical spinal cord injury (CSCI), and to analyze the feasibility, indication and therapeutic effects of anterior-posterior approach in such cases.

Methods

From March 2004 to September 2009, 16 cases with this trauma were admitted and surgically treated in our department. Before surgery, skull traction was performed. Posterior atlantoaxial pedicle screw internal fixation and bone graft fusion were conducted to manage traumatic atlantoaxial instability. As for subaxial CSCI, anterior cervical corpectomy or discectomy decompression, bone grafting and internal fixation with steel plates were applied.

Results

All operations were successful. The average operation time was 3 hours and operative blood loss 400 ml. Satisfactory reduction of both the upper and lower cervical spine and complete decompression were achieved. All patients were followed up for 12 to 36 months. Their clinical symptoms were improved by various levels. The Japanese Orthopaedic Association (JOA) scores ranged from 10 to 16 one year postoperatively, 13.95±2.06 on average (improvement rate=70.10%). X-rays, spiral CT and MRI confirmed normal cervical alignments, complete decompression and fine implants' position. There was no breakage or loosening of screws, nor exodus of titanium mesh or implanted bone blocks. The grafted bone achieved fusion 3-6 months postoperatively and no atlantoaxial instability was observed.

Conclusions

Traumatic atlantoaxial instability may combine with subaxial CSCI, misdiagnosis of which should be especially alerted and avoided. For severe cases, one stage anterior-posterior approach to decompress the upper and lower cervical spine, together with reposition, bone grafting and fusion, as well as internal fixation can immediately restore the normal alignments and stability of the cervical spine and effectively improve the spinal nervous function, thus being an ideal approach.     

High anterior cervical approach to the upper cervical spine

BACKGROUND: Surgical exposure of the upper cervical spine is challenging, and optima approaches are subjects of debate. The high anterior cervical approach to the upper cervical spine is a favorable method that provides direct and wide exposure for fusion and anterior decompression of the upper cervical spine. The authors present their experiences with 15 patients in whom fusion and instrumentation on the upper cervical spine were performed via the prevascular extraoral retropharyngeal approach. METHODS: A series of 15 patients who were surgically treated using the high anterior cervical retropharyngeal approach was reviewed. These cases involved a C2 hangman's fracture with significant angulation and translation (11 patients), C2 EDH (1 patient), C2 chordoma (1 patient), C3-4 metastasis (1 patient), and C2-3-4 OPLL (1 patient). RESULTS: Twelve patients underwent C2-3 fusion followed by instrumentation. C2-5 fusion with instrumentation was performed in 2 patients. One patient experienced occipitocervical fusion after anterior removal of a C2 chordoma. A solid fusion was achieved in 13 patients. However, 1 patient needed additional posterior fusion because of fusion failure, and the other died due to ischemic heart disease. There was 1 patient who developed permanent dysphagia related to the hypoglossal nerve and 2 who had transient dysphagia. No complications occurred related to the marginal branch of the facial nerve or submandibular gland. CONCLUSIONS: The high anterior cervical approach is a useful surgical technique for an upper cervical lesion without severe morbidity, which allows direct anterior access to C2 and C3 while allowing extension to the lower cervical spine.     

Os odontoideum with bipartite atlas and segmental instability: a case report

We report on the case of a 15-year-old adolescent who presented with a transient paraplegia and hyposensibility of the upper extremities after sustaining a minor hyperflexion trauma to the cervical spine. Neuroimaging studies revealed atlantoaxial dislocation and ventral compression of the rostral spinal cord with increased cord signal at C1/C2 levels caused by an os odontoideum, as well as anterior and posterior arch defects of the atlas. The patient underwent closed reduction and posterior atlantoaxial fusion. We describe the association of an acquired instability secondary to an os odontoideum with an anteroposterior spondyloschisis of the atlas and its functional result after 12 months. The rare coincidence of both lesions indicates a multiple malformation of the upper cervical spine and supports the theory of an embryologic genesis of os odontoideum.

     

多节段颈椎骨折脱位的诊治分析

目的 探讨颈椎多节段骨折脱位的临床特点和诊治方法。方法 对1988～2001年43例(男38例,女5例)多节段颈椎骨折脱位患者的影像学资料及临床表现进行回顾分析。结果 连续多节段损伤为36例,其中32例损伤位于下颈椎;不连续多节段损伤为7例,其中有5例为上颈椎伴下颈椎损伤;损伤部位为椎体31例,椎板25例,棘突9例,椎弓4例,横突5例,关节突5例;多见的受累节段为C4、C5、C6和C7;屈曲压缩型占60．5％。行颈前路椎体大块切除脊柱稳定重建21例,后路椎板减压加关节突钢板内固定10例,前、后路联合减压颈椎稳定重建2例;保守治疗10例。结论 颈椎多节段损伤多为屈曲压缩型,连续型损伤多见,不连续型损伤少见;连续型多节段损伤多为下颈椎损伤;不连续型多节段损伤多数为寰、枢椎损伤合并下颈椎损伤;多节段颈椎损伤中不稳定节段及脊髓受损平面均位于下颈椎;手术应在减压的同时重建脊柱的稳定性。     

Upper cervical spine instability in pseudoachondroplasia

BACKGROUND: Pseudoachondroplasia (PSACH) is a rare autosomal dominant skeletal dysplasia associated with os odontoideum and atlantoaxial instability. This study aims to define the characteristics of upper cervical spine instability in patients with PSACH and analyze the relation between the incidence of upper cervical instability and os odontoideum. METHODS: Fifteen patients (10 women and 5 men) with PSACH of Korean ethnicity with mean age of 23.7 years (range, 3-44 years) at presentation to our hospital with varied complaints, including short stature, limb deformity, neck pain, and neurological symptoms, were evaluated clinicoradiologically for upper cervical spine instability. The patients were separated into group 1 (n = 9) with os odontoideum and group 2 (n = 6) without os odontoideum. Comparisons were made using parameters such as instability index, rotational instability, atlantodens interval and space available for cord, and analysis done to correlate cervical instability with age and Japanese Orthopedic Association (JOA) score. RESULTS: Significant differences were found statistically when the 2 groups were compared on the basis of the space available for the cord (SAC), JOA scoring, and rotational instability. Linear relationship was found between instability and age and JOA score. Incidence of os odontoideum was 60% in our study group. CONCLUSIONS: Os odontoideum led to an increase in the incidence of upper cervical spine instability. Instability increased with the age. The presence of os odontoideum and atlantoaxial instability did not warrant for surgery because no signs of cervical myelopathy developed or progressed in our patients during the follow-up period, but these patients should undergo regular clinical and radiological evaluation. LEVEL OF EVIDENCE: Level IV prognostic study.