经口咽入路治疗上颈椎损伤围手术期护理

经口咽入路治疗上颈椎损伤手术风险很高,病情复杂多变,围手术期需要严密的观察与护理。2006年7月～2008年12月,我科对经口咽入路治疗的上颈椎损伤12例患者实施了系统的围手术期护理及康复训练指导,有效地防止了各类并发症。     

下颈椎骨折脱位并脊髓损伤的前路手术治疗

目的:探讨颈椎前路手术在治疗下颈椎骨折脱位并脊髓损伤中的复位率及临床疗效.方法:2006年1月～2011年1月,我院采用前路手术治疗下颈椎骨折脱位伴脊髓损伤患者196例,168例患者资料完整并获得随访,男123例,女45例,年龄18～71岁,平均38.7岁.ASIA分级A级21例,B级46例,C级60例,D级41例;按脱位程度Ⅰ度79例,Ⅱ度42例,Ⅲ度31例,Ⅳ度16例.所有患者术前先行小重量颅骨牵引(2～4kg),随后在全麻下行颈椎前路手术进一步复位,先行损伤节段椎间盘切除,以Caspar撑开器撑开复位;不能复位者,行脱位椎体次全切除,再次复位;仍不能复位者,则一期行后路松解,再行前路手术.结果:168例中经颈前路手术复位者为88.1％(148/168),其余11.9％(20/168)则通过前路-后路-前路手术获得复位.89.9％(151/168)获得了完全复位,10.1％(17/168)获得了90％以上的复位.平均随访30.7个月,死亡19例,失访9例,140例仍在随访中.术后6个月均获得骨性融合,颈椎椎间高度和生理曲度维持良好,无钢板螺钉并发症.术后发生声音嘶哑4例,咽喉疼痛17例,髂骨取骨区麻木18例,给予对症治疗后均好转.术后153例脊髓损伤者神经功能获得改善.结论:下颈椎骨折脱位并脊髓损伤,可通过前路手术治疗使颈椎获得即刻的稳定,防止继发性脊髓损伤,改善脊髓的功能状况.     

下颈椎骨折脱位并脊髓损伤的前路手术治疗

目的：探讨颈椎前路手术在治疗下颈椎骨折脱位并脊髓损伤中的复位率及临床疗效。方法：2006年1月～2011年1月,我院前路手术下颈椎骨折脱位伴脊髓损伤196例,168例患者资料完整,并得以随访,男123例,女45例,年龄18。71岁,平均38．7岁。所有患者术前先行小重量颅骨牵引（1．5～4．5kg）,随后在全麻下行颈椎前路手术进一步复位,先行损伤节段椎间盘切除,以Caspar撑开器撑开复位;不能复位者,行脱位椎体次全切除,再次复位;仍不能复位者,则一期行后路松解,再行前路手术。结果：168例中经颈前路手术复位者88．1％（148／168）,其余19．9％（20／168）则通过前路一后路一前路手术获得复位。89．9％（151／168）获得了完全复位,10．1％（17／168）获得了90％以上的复位。平均随访30．7,术后6个月均获得骨性融合,颈椎椎间高度和生理曲度维持良好,无钢板螺钉并发症。术后153例脊髓损伤者神经功能获得改善。结论：下颈椎骨折脱位并脊髓损伤,多可通过前路手术治疗,该入路可使颈椎获得即刻的稳定,防止继发性脊髓损伤,改善脊髓的功能状况。     

The anterior approach and plates in lower cervical posttraumatic lesions

Between 1949 and 1982, 290 patients were operated on for lesions of the lower cervical spine. Since 1970 the combined use of the anterior approach and more and more sophisticated osteosynthesis equipment has led us to revise our therapeutic policy with regard to 160 patients. The results, advantages, and disadvantages of this policy are discussed hereafter.     

Complications during and after surgery of the lower cervical spine by isolated anterior approach with CSLP implant

Background  The merits of different operative approaches in the management of spinal injury is debated. The aim of this study was to assess, retrospectively, the outcome of treatment of injuries of the lower cervical spine by an anterior approach, in terms of fusion rate and complications. Materials and methods  Between 1995 and 2004, 270 patients with an injury of the lower cervical spine were operated on by an anterior approach in our hospital. There were 67 females and 203 males. Using the Aebi and Nazarian classification, 22% of patients had a type A injury, 23% of patients had a type B injury and 55% of patients had a type C injury. All had an anterior approach with monocortical stabilisation using a cervical spine locking plate [Synthes]. Results  Radiological evidence of fusion was found in all but one patient at 6 months. Complications occurred in a small proportion of the series. Recurrent laryngeal nerve injury was noted in seven patients, an abscess in the wound in one patient, a haematoma requiring re-operation for evacuation in two patients. The cervical locking plate broke in one patient and this patient went on to develop a pseudoarthrosis from failure to fuse. In another patient there was release of the plate osteosynthesis. Conclusions  Treatment of the injured lower cervical spine by an anterior operation and plate fixation was successful in achieving bone fusion in almost every patient and was followed by a complication in only a small proportion of our series. Similar results in other reports indicate that this approach is a safe and effective procedure.     

前路手术治疗严重下颈椎骨折脱位

目的：探讨前路手术在治疗严重下颈椎骨折脱位中的价值。方法：32例严重下颈椎骨折脱位均在全麻下行颈前路减压、复位、自体髂骨植骨及AO颈椎带锁钢板固定。结果：完全复位17例,复位90%以上15例,平均随访28个月,颈椎椎间高度和生理曲度维持良好,无钢板螺钉并发症,21例脊髓不完全损伤者神经功能获得改善。结论：严惩下颈椎骨折脱位选择前路手术治疗可获得满意的复位和即刻稳定性的重建。     

Anterior endoscopically assisted transcervical reconstruction of the upper cervical spine

Anterior decompression and/or reconstruction can be an effective method for the surgical treatment of ventral spinal cord compression in the upper cervical spine. Options for traditional surgical approaches include transoral, transnasal, and extraoral. The risk and complex anatomy with the aforementioned approaches induces surgeons to use the transcervical route to expose the upper cervical spine. A traditional transcervical approach, however, carries the disadvantages of a deep operative field and steep trajectory. We performed a new endoscopically assisted method of anterior reconstruction for the treatment of ventral lesions in upper cervical spine. Six patients were treated from January 2005 to December 2007. Among those six patients, three patients were diagnosed with fixed atlantoaxial dislocations, two with plasmacytomas, and one with a giant cell tumor. All patients were treated by combined endoscopically assisted anterior reconstruction and posterior fusion. One patient with a fixed atlantoaxial dislocation sustained a cerebrospinal fluid leak in the immediate postoperative period, which spontaneously resolved 7 days after surgery. None of the patients had any neurologic deterioration following surgery, nor did any require admission to the intensive care unit for any reason. At the final follow-up, all patients were found to have evidence of a successful clinical outcomes and radiographic fusion. There were no implant failures or radiographic signs of implant migration or loosening. In conclusion, this study demonstrates that an anterior transcervical decompression using endoscopic visualization combined with a posterior arthodesis can achieve good clinical and radiographic outcomes.     

单纯前路手术治疗下颈椎脱位

目的探讨早期单纯前路手术治疗下颈椎脱位的临床疗效;方法对2005—06—2011—08收治的41例下颈椎脱位患者,采用颅骨牵引下复位或术中复位,单纯行前路减压,钛网或自体髂骨块植骨融合,前路钢板固定治疗。结果所有病例均得到良好复位,根据x线片定期检查结果,颈椎生理弧度及椎间隙高度良好,植骨融合确切,未出现内固定失用。术后随访10～28个月,Frankel分级显示,绝大部分患者术后神经功能得到不同程度的改善;结论早期行单纯前路手术治疗下颈椎脱位,可获得良好的解剖学复位,能有效地解除脊髓压迫,使脊柱获得即刻稳定。     

对经颈侧方入路行脊髓腹侧减压治疗寰枢关节前脱位的评价

目的：对经颈侧方入路行脊髓腹侧减压治疗寰枢关节前脱位的手术方法进行评估。方法：9例难复性寰枢关节前脱位患者采用经颈侧方入路进行脊髓腹侧减压，术前未做枕颈融合或融合失败的患者在术后2～6周进行枕颈融合术，对脊髓腹侧减压术中情况进行总结和术后效果进行随访，并复查颈椎CT和MRI。结果：手术时间平均7h．平均出血量2300ml；椎动脉损伤3例；舌下神经损伤3例。9例患者术后早期均无明显效果，3例6个月后出现改善，其中2例效果明显；6例无效，其中1例术后6个月北于长期卧床并发症，1例在术后1年冉次行经口咽入路脊髓减压手术，北于蛛网膜下腔感染。结论：经颈侧方入路进行脊髓腹侧减压治疗寰枢关节前脱位显露困难，减胀不充分，并发症多．不宜采用。     

Axis系统治疗下颈椎不稳的解剖研究和临床应用

目的：研究下颈椎侧块的解剖特点,评估Axis颈椎后路内固定系统的应用价值。方法：选16具成人正常下颈椎防腐标本。观察解剖特点。探查并测量改良Magerl法进针点和进针角度,深度以及与血管、神经的关系。临床应用Axis系统治疗下颈椎不稳18例。结果：改良Magerl法进针点选在术中可视侧块中点内下1-2mm处,深度13.2-16.4mm,进针角度分别为矢状面角度45℃,水平面角度29℃。距动脉和神经根的距离分别约为4.1mm和1.9mm。临床应用18例,平均随访8个月,无并发症,15例获骨性融合,脊髓功能除1例无改善外,余均有不同程度恢复,结论：改良进行针法更适合于国人,Axis系统适用于各种原因引起的需后路减压的下颈椎不稳,侧块固定有一定风险,但只熟悉解剖特点,规范操作,使用是安全的。     

经前方咽后入路脊髓减压治疗上颈椎后路融合术后畸形愈合并脊髓压迫

目的:探讨寰枢椎后路融合术后畸形愈合并脊髓压迫症的治疗方法。方法:2002年1月￣2004年5月收治8例上颈椎后路融合术后畸形愈合患者,均有不同程度的脊髓压迫症表现,JOA评分9.6±2.34分。影像学均显示C2椎体后上与C1后弓形成钳夹压迫脊髓。均行经前方咽后入路C2椎体次全切除减压融合术。结果:术中喉上神经牵拉损伤1例,术后4周恢复,无其它并发症。8例患者术后神经功能均有恢复。平均随访时间22个月,JOA评分平均13.8±0.97分。结论:经前方咽后入路C2椎体次全切除减压治疗寰枢椎后路融合术后畸形愈合并脊髓压迫症能取得较好的显露与减压效果。