经口单开门小钛板复位固定治疗寰椎前后弓骨折

目的探讨利用单开门小钛板经口复位固定治疗寰椎前后弓骨折的临床疗效。方法 2012年11月—2015年11月,应用经口单开门小钛板复位固定术治疗寰椎前后弓骨折患者13例,其中寰椎前弓1处骨折合并后弓1处骨折6例,寰椎前弓2处骨折合并后弓1处骨折3例,寰椎前弓1处骨折合并后弓2处骨折和寰椎前弓2处骨折合并后弓2处骨折各2例。记录手术前后美国脊髓损伤协会(ASIA)分级及视觉模拟量表(VAS)评分,术后定期随访复查X线片、CT以评价寰椎骨折复位、骨折愈合和内固定情况以及寰枢椎的稳定性。结果 13例患者均顺利完成手术,术中未发生脊髓及椎动脉损伤。术前ASIA分级D级2例,E级11例,术后均为E级;VAS评分由术前的(6.2±1.8)分降低至术后的(2.0±0.8)分。随访3~24个月,X线片、CT复查示小钛板固定良好、无松动,骨折均获骨性愈合,无寰枢椎失稳、脱位发生。结论经口单开门小钛板复位固定是治疗寰椎前后弓骨折的有效方法,初步临床应用效果满意。     

上颈椎骨折脱位的外科治疗

目的探讨上颈椎骨折脱位的诊断及治疗方法。方法2005年1月—屯009年9月收治16例创伤性上颈椎骨折脱位患者。其中齿状突骨折7例,寰枢椎脱位5例,Hangman骨折2例,Jefferson骨折2例。9例伴有神经功能障碍者脊髓神经功能按ASIA分级：B级3例,c级4例,D级2例。除7例采用颈椎牵引及支具固定外,齿状突中空螺钉固定术2例,Apofix寰枢椎后路固定＋植骨融合2例,枕颈融合术1例,寰枢椎后路经椎弓根螺钉固定术4例。所有患者术后均行头颈胸支具外固定3个月。结果16例患者术后获6—36个月随访。所有病例未出现脊髓损伤、椎动脉破裂等并发症。经6个月以上随访骨折或植骨获愈合,未见内置物断裂或感染等并发症发生。1例患者枕颈融合术后2年因呼吸道感染并发症死亡。9例神经功能障碍患者中均有不同程度改善。上颈椎不稳均获得有效治疗。结论上颈椎外伤性失稳的诊断和治疗方式选择取决于骨折类型和移位状况。AndersonI、Ⅲ型齿状突骨折和LevineI、Ⅱ型Hangman骨折经保守治疗可获得满意的临床疗效。齿横韧带损伤合并寰枢关节脱位及不稳定的Jefferson骨折和Hangman骨折应手术治疗。寰枢椎后路组合固定技术是治疗上颈椎外伤性失稳的有效方法,具有固定可靠、短节段固定、三维固定、融合率高、可早期功能锻炼的优点。     

经口咽入路内固定治疗孤立性寰椎骨折临床疗效分析

目的评价应用经口咽入路内固定治疗孤立性寰椎骨折的临床疗效及安全性。方法 2008年7月～2010年12月,应用经口咽入路钢板内固定治疗10例孤立性寰椎骨折患者,其中3例双侧寰椎前弓骨折（前1/2 Jefferson骨折,Landells typeⅠ）、5例单侧寰椎前后弓双骨折（半环Jefferson骨折,Landells typeⅡ）、2例寰椎前弓骨折合并寰椎后弓发育不良。结果所有病例术后随访10～24个月,平均15个月。患者的临床症状均得到不同程度的改善。平均手术时间为100 min（80～120 m in）;平均出血量为200 mL（100～300 mL）;平均透视时间60 s;10例患者术均未发生神经、椎动脉和其他手术相关并发症。随访复查X线片和CT,未发现患者上颈椎失稳或复位丢失,螺钉位置良好,无松动、断钉。结论经口咽入路采用C1侧块螺钉固定钢板重建寰椎前环是治疗不稳定性寰椎骨折的一种新的技术方法。它既保持了C1/C2关节的旋转运动功能,同时又恢复了寰枕关节和寰枢关节的协调运动。     

后路寰椎有限内固定治疗寰椎不稳定性骨折

目的:探讨后路寰椎钉棒系统有限内固定治疗寰椎不稳定性骨折的疗效。方法:2008年4月~2010年10月采用后路寰椎钉棒系统内固定治疗寰椎不稳定性骨折10例,男7例,女3例;年龄20~60岁,平均37.5岁。患者均有不同程度的枕颈部疼痛、僵硬和颈部活动受限,均无神经损伤表现。双侧寰椎后弓并单侧寰椎前弓骨折(后3/4 Jefferson骨折,LandellsⅡ型)6例,单侧寰椎前后弓骨折(半环Jefferson骨折,LandellsⅡ型)4例;横韧带完整7例,横韧带附着处骨折和撕脱(DickmanⅡ型)3例。术前均行颅骨牵引稳定骨折块。结果:共置入螺钉20枚,其中1例在置入寰椎椎弓根螺钉时后弓破裂,1例术前进钉点处后弓破裂,直接将螺钉固定在侧块上;1例患者寰椎后弓进钉点处的高度小于4mm,无法行椎弓根螺钉固定而改为侧块螺钉固定;其余7例均行寰椎椎弓根螺钉固定。手术时间为60~90min,平均70.5min;术中出血量为100~300ml,平均150ml。术中1例患者在剥离寰椎后弓下缘时损伤静脉丛,用明胶海绵压迫止血;未发生脊髓和椎动脉损伤。术后X线片及CT示1例一侧寰椎椎弓根螺钉部分进入椎动脉孔,1例一侧螺钉偏内致椎弓根内侧皮质破裂,但均无血管神经损伤症状,未处理;其余螺钉位置良好。随访12~36个月,平均20.2个月,术后3~6个月枕颈部疼痛缓解,颈部活动范围基本接近伤前水平;术后6个月复查骨折断端达到骨性融合;随访期间颈椎序列良好,未见内固定松动、断裂,无C1-2失稳。结论:在严格选择适应证的前提下,寰椎后路钉棒系统有限内固定是治疗寰椎不稳定性骨折的较好方法,能保留枕颈部活动功能。     

Jefferson骨折的治疗

Jefferson骨折可致颈椎严重不稳,如未能早期发现,及时治疗,骨折不愈合或延迟愈合,可致寰椎迟发性前脱位或迟发性四肢瘫等严重后果。我科采用颅骨牵引头颈胸石膏固定治疗Jefferson骨折2例,疗效满意。1　材料与方法1.1　病例资料　本组2例,均为女性。例1,4 0岁。因车祸致枕颈部疼痛,活动受限2d就诊。查体:神志清楚,颈椎生理弯曲变直,颈部压痛(+)。颈椎正侧位及寰枢椎开口正位X线片示寰枢椎半脱位(图1)。CT示寰椎Jefferson骨折(图2 )。例2 ,31岁。从2m高处跌落致颈部疼痛,活动受限30min就诊。X线片示寰枢椎半脱位,CT示寰椎Jef ferson骨折。…     

手术治疗7例变异型Jefferson骨折

目的 探讨变异型Jefferson骨折的手术治疗效果.方法 对7例变异型Jefferson骨折行寰枢椎椎弓根螺钉内固定术.结果 平均随访18个月,7例寰枢椎骨折脱位基本复位.术后1年神经功能JOA评分平均16.1分.结论 对于变异型Jefferson骨折手术可有效复位固定骨折,促进骨折愈合,重建颈椎的稳定性.     

颈枕套治疗4岁儿童寰椎前弓骨折合并齿状突骨折1例

<正>寰椎骨折占急性颈椎骨折的7%,孤立的寰椎骨折大多是两处或多处前、后弓骨折,44%的寰椎骨折合并有枢椎骨折,孤立性前弓骨折较少,小儿的寰椎骨折多发生在骨、软骨结合处,寰椎前结节、前弓水平骨折较为罕见[1],易被漏诊、误诊,应注意分析鉴别。查阅国内外文献未对此类骨折进行报道。云南省德宏州人民医院于2014年1月10日收治1例4岁儿童寰椎前弓骨折合并齿状突骨折,报告如下。     

经口咽JeRP内固定治疗不稳定型Jefferson骨折的生物力学和初期临床研究

目的 :评估Jefferson骨折复位钢板(Jefferson fracture reduction plate,Je RP)内固定治疗不稳定型Jefferson骨折的生物力学实验结果及临床应用效果。方法:(1)2012年5月~2014年3月于郑州市骨科医院收集人体上颈椎尸体标本6例,2014年6月模拟不稳定型Jefferson骨折中的前弓双骨折类型,以Je RP内固定系统模拟进行复位内固定术,并以三维运动实验机对标本C0-3节段在正常、骨折、内固定3种状态的负载(前屈、后伸、左侧屈、右侧屈加载的水平方向载荷为20N,左旋转、右旋转采用的载荷为2.0N·m的力矩)六向运动中性区及运动范围(ranges of motion,ROM)进行检测及分析。(2)2008年4月~2014年1月广州军区广州总医院收治不稳定型Jefferson骨折患者8例,男6例,女2例;年龄29~67岁,平均39岁;均以颈项部疼痛、活动受限为主,其中7例无脊髓及神经损伤症状,1例合并脊髓损伤,Frankel分级为D级,寰椎环3处骨折5例,单侧前后弓骨折3例;术前MRI均显示寰椎横韧带完整。8例均采用经口咽Je RP内固定手术治疗,术后定期随访并应用CT扫描及颈椎过伸过屈位X线片观察骨折愈合情况及评估寰枢椎稳定性。结果:骨折组中性区与正常组中性区在屈伸、侧屈、旋转3个运动维度的差异均有统计学意义(P0.05),骨折组的三维中性区值均明显大于正常组;固定组的中性区与正常组中性区在3个运动维度的差异均无统计学意义(P0.05),固定组的ROM与正常组ROM在3个运动维度的差异均无统计学意义(P0.05)。8例患者术后随访6~15个月,平均7.2个月,所有患者术后枕颈部疼痛不适症状均获得改善,1例合并脊髓损伤的患者术后6个月Frankel分级由D级改善至E级。所有患者口咽后壁切口愈合良好,无感染发生,术后CT示骨折均达良好复位;术后6个月CT示骨折均骨性愈合,未见寰枢椎失稳及活动受限,初期临床应用效果良好。结论:Je RP内固定系统固定在实现对不稳定型Jefferson骨折复位及固定的基础上保留了上颈椎活动度,为不稳定型Jefferson骨折的临床手术治疗提供了更多选择。     

经口咽入路钢板内固定治疗不稳定性寰椎骨折

目的:分析应用经口咽入路钢板内固定治疗不稳定性寰椎骨折的临床疗效及安全性。方法:2007年7月至2011年6月,应用经口咽入路钢板内固定治疗不稳定性寰椎骨折8例,男6例,女2例;年龄23～48岁,平均39.5岁;高处坠落伤5例,交通伤3例。双侧寰椎前弓骨折(前1/2 Jefferson骨折,Landells type Ⅰ)3例,单侧寰椎前后弓双骨折(半环Jefferson骨折,Landells typeⅡ)3例,双侧寰椎前后弓双骨折伴单侧侧块骨折(Landells typeⅢ)2例。结果:所有患者获得随访,时间6～24个月,平均13个月。患者的临床症状均得到不同程度的改善。平均手术时间为98min(80～140min);平均出血量为200ml(100～300ml);平均透视时间55s;术中术后均未发生神经、椎动脉损伤和其他手术相关并发症。复查X线片及CT,未发现患者上颈椎失稳或复位丢失,螺钉位置良好,无松动、断钉。结论:经口咽入路采用寰椎侧块螺钉固定钢板重建寰椎前环是治疗不稳定性寰椎骨折的一种可靠及安全的方法。它既保持了寰枢关节的旋转运动功能,同时又恢复了寰枕关节和寰枢关节的协调运动。     

前弓分离移位的Gehweiler Ⅲa型寰椎骨折非手术与手术治疗的疗效比较

目的 比较前弓分离移位的Gehweiler Ⅲa型寰椎骨折非手术与手术治疗的疗效。方法 回顾性分析自2013-08—2021-10收治的35例前弓分离移位Gehweiler Ⅲa型寰椎骨折,其中24例采用Halo支具固定治疗(Halo支具组),11例行寰椎或寰枢椎后路螺钉内固定治疗(手术治疗组),比较两组患者骨折愈合情况,分析骨折移位程度对骨折愈合的影响。随访观察Halo支具治疗组支具拆除后骨折愈合和骨折不愈合患者的疼痛VAS评分、颈椎功能障碍指数(Neck disability index,NDI)及寰枢椎相对旋转度(Rotating angle of atlas on dentate,RAAD)。结果 所有患者均获得随访,随访时间24～40周,平均33.3周。所有患者后弓均获得骨性愈合,但总体前弓骨折愈合率为71.4%,其中手术治疗组9例(81.8%)获得前弓骨性愈合,Halo支具组16例(66.7%)获得前弓骨性愈合,手术治疗组前弓骨折愈合率高于Halo支具组。Halo支具组根据支具拆除后是否获得骨性愈合分为愈合组(n=16)和不愈合组(n=8),不愈合组寰椎侧块分离移位明显大于...     

Spinal fractures in patients with ankylosing spondylitis

Thirty-one consecutive patients with ankylosing spondylitis and spinal fractures were reviewed. There were 6 women and 25 men with a mean age of 60±11 years; 19 had cervical and 12 had thoracolumbar injuries. Of the patients with cervical fracture, two had an additional cervical fracture and one had an additional thoracic fracture. Three trauma mechanisms were identified: high-energy trauma in 13 patients, low-energy trauma in 13 and insufficiency fracture in 5. One-third of the patients suffered immediate neurological impairment, a further one-third developed neurological impairment before coming for treatment and only one-third remained intact. Two patients with thoracolumbar fractures had deteriorated neurologically due to displacements during surgery at other hospitals. All patients were treated operatively except the two patients with two-level cervical fractures, who were managed in halo vests. In the cervical spine both anterior and posterior approaches were employed. In the thoracolumbar spine the majority of the patients were initially treated using a posterior approach only. Complications were common. Of the 27 patients with neurological compromise, 10 had remained unchanged; 12 had improved one Frankel grade; 4 had improved by two Frankel grades; 1 had improved by four Frankel grades. We conclude that even minor trauma can cause fracture in an ankylosed spine. A high proportion of patients with spinal fractures and ankylosing spondylitis have neurological damage. The risk of late neurological deterioration is substantial. As the condition is very rare and the treatment is demanding and associated with a very high risk of complications, the treatment of these patients should be centralised in special spinal trauma units. A combined approach that stabilises the spine from both sides is probably beneficial.     

Fractures of the atlas

Thirty-four patients who had fractures of the atlas (the first cervical vertebra) were reviewed at an average follow-up of 4.5 years. Seventeen patients had bilateral fracture of the posterior arch of the first cervical vertebra. Eight were treated with immobilization in a cervical orthosis, with no long-term problems secondary to the injury. Nine of these patients had additional fractures in the first and second cervical vertebral complex, complicating the management of the fractures of the posterior arch. Two of the nine patients died, and the treatment of the other seven was dependent on the additional fractures. A second group of six patients had a fracture in the area of the lateral mass, with one fracture just anterior to or within the anterior portion of the lateral mass of the first cervical vertebra and a second fracture posterior to the lateral mass of the first cervical vertebra on the same side; resultant asymmetrical displacement of the lateral masses was seen on the open-mouth roentgenogram that was made for each patient. A third group of eleven patients sustained a Jefferson, or burst, fracture of the first cervical vertebra. These patients had either four fractures (two in the anterior arch and two in the posterior arch) or three fractures (one in the anterior arch and two in the posterior arch). Spreading of the lateral masses was relatively symmetrical on the open-mouth roentgenogram. Patients who had fractures with displacement of two to seven millimeters were treated with immobilization in a halo vest. Patients who had fractures with severe spreading of the lateral masses (more than seven millimeters) were treated with reduction of the lateral masses by axial traction until healing of the arch had occurred. No atlanto-axial instability was evident in any patient at follow-up.     

A review of fractures of the atlas vertebra

From 48 consecutive cases of atlas fractures presenting over a 12.5-year period, two groups are apparent that differ in age, presentation, mechanism of injury, and treatment given. Jefferson fractures were, on average, 42 years of age. Displaced Jefferson fractures were treated by traction. At final review, those that had been reduced and those that were initially undisplaced did better than the displaced group. Inadequate reduction was often obtained due to insufficient traction. Patients sustaining a posterior arch fracture were generally more elderly and were, on average, 17 years older than those with a Jefferson fracture. Patients with a posterior arch fracture had marked degenerative changes in the mid- to distal cervical spine and almost invariably had another cervical spine fracture. Treatment was usually directed to the other cervical spine injury. Injury in the elderly usually followed low velocity trauma.     

上颈椎损伤合并不连续下颈椎损伤的一期手术治疗

目的 探讨上颈椎损伤合并不连续的下颈椎损伤的临床特点及手术治疗策略.方法 2004年5月至2007年8月,对上颈椎损伤合并不连续的下颈椎损伤9例患者进行一期手术治疗.术前神经功能按Frankel评级:A级2例,C级3例,E级4例.其中上颈椎损伤均采用后路手术,经椎弓根寰枢固定融合8例,枕颈固定1例;下颈椎损伤采用后路手术6例,其中以不连续经椎弓根短节段钉棒固定融合4例,2例采用联合上颈椎经椎弓根连续固定;余3例同期行前路减压钛板固定.结果 所有患者获得6～48个月(平均13.7个月)随访.术中无一例椎动脉损伤.术后无气管切开或拔管延迟情况,无严重肺部感染、呼吸衰竭、应激性溃疡等并发症发生.患者复位及融合满意,1例2枚下颈椎椎弓根断钉.神经功能:除2例Frankel A级的患并无恢复外,余均为E级.结论 上颈椎损伤合并不连续下颈椎损伤导致颈椎极度不稳定,伴有的神经损伤常源于下颈段.一期手术治疗,包括上颈椎后路经椎弓根固定及下颈椎后路经椎弓根或前路减压固定,相对安全且可获得满意疗效.     

Atlas fractures

Fractures of the atlas account for 1-2% of all vertebral fractures. We divide atlas fractures into 5 groups: isolated fractures of the anterior arch of the atlas, isolated fractures of the posterior arch, combined fractures of the anterior and posterior arch (so-called Jefferson fractures), isolated fractures of the lateral mass and fractures of the transverse process. Isolated fractures of the anterior or posterior arch are benign and are treated conservatively with a soft collar until the neck pain has disappeared. Jefferson fractures are divided into stable and unstable fracture depending on the integrity of the transverse ligament. Stable Jefferson fractures are treated conservatively with good outcome while unstable Jefferson fractures are probably best treated operatively with a posterior atlanto-axial or occipito-axial stabilization and fusion. The authors preferred treatment modality is the immediate open reduction of the dislocated lateral masses combined with a stabilization in the reduced position using a transarticular screw fixation C1/C2 according to Magerl. This has the advantage of saving the atlanto-occipital joints and offering an immediate stability which makes immobilization in an halo or Minerva cast superfluous. In late instabilities C1/2 with incongruency of the lateral masses occurring after primary conservative treatment, an occipito-cervical fusion is indicated. Isolated fractures of the lateral masses are very rare and may, if the lateral mass is totally destroyed, be a reason for an occipito-cervical fusion. Fractures of the transverse processes may be the cause for a thrombosis of the vertebral artery. No treatment is necessary for the fracture itself.     

Posterior fixation and fusion with atlas pedicle screw system for upper cervical diseases

Objective： To evaluate the feasibility, safety and efficacy of atlas pedicle screws system fixation and fusion for the treatment of upper cervical diseases.
Methods： Twenty-three consecutive patients with upper cervical disorders requiring stabilization, including 19 cases of atlantoaxial dislocation （4 congenital odontoid disconnections, 6 old odontoid fractures, 4 fresh odontoid fractures of Aderson Ⅱ C, 3 ruptures of the C1 transverse ligament, and 2 fractures of C1）, 2 cases of C2 tumor （instability after the resection of the tumors）, and 2 giant neurilemomas of C2-C3（instability after resection of the tumors）, were treated by posterior fixation and fusion with the atlas pedicle screw system, in which the screws were inserted through the posterior arch of C1. The operative time, bleeding volume and complications were reported. All patients were immobilized without external fixation or with rigid cervical collars for 1-3 months. All patients were followed up and evaluated with radiographs and CT.
Results： In the 23 patients, 46 C1 pedicle screws, 42 C2 pedicle screws and 6 lower cervical lateral mass screws and 2 lower cervical pedicle screws were placed. The mean operative time and bleeding volume was 2.7 hours and 490 ml respectively. No intraoperative complications were directly related to surgical technique. No neurological, vascular or infective complications were encountered. All patients were followed up for 3-36 months （average 15 months）. Firm bony fusion was documented in all patients after 3-6 months. One patient with atlas fracture showed anterior occipitocervical fusion. There was no implant failure. Conclusions： Posterior fixation and fusion of the atlas pedicle screw system is feasible and safe for the treatment of upper cervical diseases, and may be applicable to a larger number of patients.     

一期后路寰枢椎固定治疗不稳定寰椎爆裂性骨折

 目的探讨一期后路寰枢椎固定融合治疗不稳定寰椎爆裂性骨折的临床疗效。方法回顾性分析2010年5月至2013年12月收治32例不稳定寰椎爆裂性骨折患者的病历资料,男21例,女11例;年龄22~59岁,平均41.8岁。术前均行颈椎张口位及侧位X线片、CT及MR检查。不稳定性寰椎骨折17例,不稳定性寰椎骨折合并枢椎骨折15例, 其中6例有不同程度的脊髓损害表现,ASIA分级为D级5例、C级1例。32例患者接受一期后路寰枢椎固定融合术。术后观察脊髓功能恢复情况,均行过屈、过伸位X线片和三维CT检查观察寰枢椎复位、融合及内固定情况,采用寰齿前间距（atlanto-dens interval,ADI)、寰椎侧块移位程度（lateral mass distance,LMD）及疼痛视觉模拟评分（visual analogue score,VAS）评价疗效并记录并发症。结果所有患者均获得随访,随访时间10~24个月,平均15.6个月。骨折与寰枢椎骨性融合时间为5~10个月,平均6.9个月。术前颈枕区VAS评分平均为（5.0土1.4）分,末次随访时（1.0土0.7）分,差异有统计学意义。脊髓功能均得到不同程度地改善,术前D级5例中4例恢复至E级、1例无明显改善,术前C级1例恢复至D级。术后X线片和CT均示复位满意,术前ADI平均为（4.6±1.2） mm,末次随访时为（2.4±1.0） mm;术前LMD平均为（5.6±2.2） mm,末次随访时为（1.2±1.0） mm,差异均有统计学意义。结论一期后路寰枢椎椎弓根固定融合术治疗不稳定寰椎爆裂性骨折临床可行,能避免枕颈融合,但寰椎椎弓根螺钉置钉技术具有挑战性。     

A case report of a congenital cleft of the anterior atlas arch: a rare variant of the atlas mimicking fracture

Congenital anterior midline clefts of the atlas are rare developmental anomalies with only a few reported cases in the literature. This normal variant of the atlas results when the anterior arch fails to fuse during the ossification process. Series of cadaveric dissections have demonstrated anterior midline atlas clefts in 0.1-0.2% of the general population. Histological examinations have revealed that the bony defect, which ranges from 1-5 millimetres in width, is bridged by fibrocartilagenous tissue, resulting in what is generally believed to be a stable atlas.Radiographically, congenital anterior clefts mimic many types of atlantal fractures, including Jefferson burst fractures, and vertical fractures of the anterior arches. The distinct radiographic appearances of congenital clefts and acute fractures of the atlas help to distinguish them from each other.In the majority of cases, anterior clefts of the atlas remain undetected and have no clinical ramifications. Detection usually occurs during emergency post-traumatic radiographic imaging of the upper cervical spine. Under these circumstances, the presence of this congenital anomaly can make it difficult to differentiate between an acute fracture and a congenital variant. Where there is suspicion of fracture, computed tomography (CT) must be considered, as it is the most useful means of differentiating between these two clinical entities.Chiropractors considering spinal manipulative therapy should be concerned with stability of an atlas with an anterior cleft, particularly in patients with a recent history of injury to the cervical spine. Appropriate clinical and radiographic examinations must be used to rule out cervical spine instability, before treatment is commenced. A reasonable course of treatment may include the judicious use of spinal manipulation.