颈椎侧块钢板螺钉内固定术治疗下颈椎骨折脱位

目的应用颈椎侧块钢板螺钉内固定术治疗下颈椎骨折脱位。方法应用此项技术治疗下颈椎骨折脱拉22例。其中单侧小关节骨折脱位3例,双侧10例;单侧小关节脱位4例,双侧1例;双侧小关节脱位合并椎体压缩骨折2例;双侧小关节骨折脱位合并椎体裂纹骨折1例;椎体爆裂型骨折1例。无神经系统损伤者3例,仅合并神经报损伤者7例,合并脊髓损伤者12例（完全性6例,不完全性6例）。切开复位,将螺钉固定于颈椎侧块上,配以钢板连接和植骨,实现坚强固定。结果本组22例平均随访34个月（10个月～7年2个月）,平均融合时间为3．5个月,术后平均3．3d可在围领保护下从床上坐起。仅合并神经根损伤的患者平均术后7d离床活动,围领保护平均112周,平均3．5个月恢复原工作或劳动。合并脊髓损伤的问例中,6例不完全性损伤者,根性症状明显减轻,脊髓功能稍有改善（Frankel分级提高Ⅰ级）。术中无血管、神经系统损伤。1例术中复位不完全,2例（共4枚）螺钉松动,但均未影响症状的减轻及融合效果。结论本术式具有短节段固定、稳定作用强、术后仅需轻便外固定、可早期活动等优点。     

Injuries to the cervical spine causing vertebral artery trauma: case reports

In four patients with lesions of the vertebral artery resulting from cervical spine injury, two were due to unilateral facet dislocation and two to fractures of the dens. There was one arterial occlusion with minor vertebrobasilar symptoms, and an arterial lesion with thrombosis causing embolic occlusion of the basilar artery with lethal outcome. In one patient a fresh fracture of the dens caused dislocation of C1/2 with reversible occlusion of the left and stenosis of the right vertebral artery, resulting in unconsciousness. In a patient with pseudarthrosis of the dens an aneurysm of the vertebral artery could be detected. Cerebellar or cerebral symptoms associated with cervical spine injury should be investigated by vertebral angiography because vertebral arterial injury may be more common than suspected and may simulate traumatic brain damage.     

颈椎横突孔骨折合并椎动脉损伤

目的：研究颈椎横突孔骨折患者椎动脉损伤的发生率及椎动脉损伤的临床特征。方法：选择2000年8月-2003年6月，CT证实的25例急性颈椎横突孔骨折患者进行颈部动脉磁共振血管造影(MRA)检查。结果：12例患者发生椎动脉损伤(48％)，其中8例为单侧损伤，4例为双侧损伤；椎动脉损伤的发生率在横突孔骨折伴小关节绞锁脱位组与横突孔骨折无小关节绞锁脱位组之间有统计学差异(P=0．03)。2例椎动脉损伤患者出现椎基底动脉缺血症状。结论：急性颈椎横突孔骨折患者椎动脉损伤的发生率较高，尤其伴小关节绞锁脱位者；大多数椎动脉损伤患者无特异性临床表现。     

Operative treatment for cervical fracture and dislocation with blunt unilateral vertebral artery injury

Objective： To investigate risks and clinical effects of operative treatment for cervical vertebral fracture and dislocation associated with unilateral vertebral artery injury. Methods： This group consisted of 76 cases of closed cervical spine trauma combined with unilateral vertebral artery injury （23 cases of bilateral facet dislocation, 28 unilateral facet dislocation and 25 fracture）. All patients underwent prospective examination of cervical spine MRI and vertebral artery two-dimensional time-of-flight （2D TOF） magnetic resonance angiography （MRA）, and anterior cervical decompression. The healthy vertebral artery paths were evaluated before the surgery, and were protected during the surgery according to the anatomical signs. Results： There were no acute or chronic clinical dam- age symptoms in 76 cases after surgery. No neural damage symptoms were observed in patients with normal neural functions. The neural functions of incomplete paralyzed patients were improved in different grades. Conclusions： Reliable anterior operation can produce good results for cervical fracture and dislocation with unilateral vertebral artery injury. Detecting the course of uninjured vertebral artery before operation and locating the anatomical site during operation are effective to avoid damaging vertebral artery of uninjured side.     

颈椎不稳定性损伤的放射学诊断

作者报告87例颈椎不稳定性损伤,并就其放射学诊断问题进行讨论。提出凡存在颈椎中柱损伤者即应视为不稳定性损伤,其主要X线征象包括椎体移位、椎板间或棘突间间隙增宽、椎间隙异常增宽或变窄、关节突关节间隙增宽、椎体后缘连线不连续以及椎管增宽等。作者认为,X线平片检查对于颈椎不稳定性损伤的诊断具有十分重要的价值,多数颈椎不稳者在伤后早期即可被发现。     

不同手术入路治疗无椎体骨折的下颈椎小关节脱位

目的 探讨不同手术入路治疗无椎体骨折的下颈椎小关节脱位的临床效果.方法 回顾性分析34例无椎体骨折的下颈椎小关节脱位伴不同程度颈髓损伤患者,其中单侧小关节脱位7例,双侧小关节脱位27例.采用美国脊髓损伤协会(American Spinal Injury Association,ASIA)分级:A级5例,B级8例,C级1...     

Vertebral artery injury in destabilized midcervical spine trauma; predisposing factors and proposed mechanism

Background

By now it has been well established that vertebral artery injury (VAI) is associated with unstable cervical spine injuries resulting from blunt trauma. A more complete understanding of predisposing factors and the mechanism of injury in VAI should result in improved outcomes and reduced risk for patients with VAI associated with unstable cervical spine injury following blunt trauma. The authors report statistical outcome and hypothesis to more thoroughly examine the predisposing factors for VAI, of which management is controversial, in destabilized midcervical spine trauma.

Methods

Ninety-one of 131 consecutive patients who underwent surgery for a traumatically destabilized subaxial cervical spine were included, and results were analyzed statistically by logistic regression.

Results

Eighteen patients (19.8?% of 91 patients) had a VAI associated with midcervical spine trauma (C2-C6). In univariate statistical analysis, transverse foramen fracture (P?=?0.002), facet dislocation (P?=?0.014), and facet fracture (P?=?0.001) were significant risk factors. However, only facet fracture was determined to be significant risk factor after multivariate analysis (P?=?0.006, odds ratio 20.98). It is hypothesized that a VAI occurs in a midcervical spine injury when a facet fracture allows the bony compartment to impinge on the relatively narrow free space of the intervertebral foramen, which is also occupied by the cervical root.

Conclusion

A facet fracture is the most important risk factor for VAI in patients with a destabilized midcervical spine injury. Patients with a C2–C6 facet fracture may require a definitive evaluation with vertebral artery imaging.     

下颈椎骨折脱位合并脊髓损伤的外科手术入路选择

目的探讨下颈椎骨折脱位合并脊髓损伤的外科手术入路选择。方法回顾性分析54例下颈椎骨折脱位合并脊髓损伤患者行手术治疗的临床资料。其中颈椎压缩型骨折脱位29例,颈椎爆裂性骨折脱位7例,单侧小关节脱位3例,双侧小关节脱位15例。美国脊髓损伤学会(ASIA)评分：A级21例,B级5例,C级22例,D级6例。43例采用前路手术,11例采用后路手术。结果术中均无大血管、气管、食道、脊髓意外损伤。术后随访12～36个月,平均18个月。无一例发生钢板、螺钉松动、断裂等并发症。植骨于术后12周均获得骨性融合,无假关节、骨不连发生。96．3％患者术后获得完全复位,术后颈椎椎间高度、生理曲度无丢失。完全性脊髓损伤患者术后神经功能均无恢复,但上肢疼痛、麻木有不同程度的缓解。不完全性脊髓损伤患者术后神经功能均有一定恢复,平均ASIA评分提高1～2级。结论采用前路或后路手术治疗下颈椎骨折脱位均能达到良好的解剖复位,根据颈椎损伤的类型采取适合的手术入路是手术成功的关键。     

Sagittally oriented fractures of the lateral masses of the cervical vertebrae.

Lateral flexion of the cervical spine may cause a sagittally oriented fracture of the lateral mass with shearing of all or part of the lateral mass away from the vertebral body. We report 22 patients with 24 sagittal fractures of the cervical lateral masses. Cross-table lateral roentgenograms suggested the presence of a sagittal lateral mass fracture in two thirds of the cases based upon malalignment or widening of the facet joints, displaced fracture fragments, subluxation of the spine, or rotation of the spine above the level of abnormality. However, the cross-table lateral roentgenogram was normal in one third of cases. Oblique roentgenograms were available in eight cases; these were positive in five, equivocal in one, and negative in two. Visible fracture lines, often associated with lateral displacement of part or all of the lateral mass, allowed all 24 fractures to be detected on the supine anteroposterior view films. Sagittal lateral mass fractures were unstable in 59% (13/22) of the cases; neurologic deficits, including quadriplegia, hemiplegia, and radiculopathy, were present in 45% (10/22). Computed tomography and complex-motion tomography were useful in confirming the sagittal lateral mass fracture and in detecting other associated fractures.     

Cervical spine injury in patients with ankylosing spondylitis.

Fractures of the cervical spine associated with ankylosing spondylitis are rare. Relatively minor injury can cause a fracture of the vertebral body or through the ossified intervertebral space, because of the loss of normal flexibility, mobility, and elasticity in the rigid spine. Sixty-six per cent of the fracture subluxations of the ankylosed spine are associated with injury to the spinal cord, and the mortality rate is 40%. Because of the complete nature of fracture and instability, there is a high risk of neurologic deterioration. Immobilization of the cervical spine in a Halo cast appears to be the treatment of choice. If skull traction is applied the cervical spine should be immobilized in the neutral position, and overzealous traction exceeding 10 pounds should be avoided. Callus formation and fracture healing following immobilization is rapid. Four new cases are described and 44 previously reported cases in the literature have been reviewed.     

Vertebral artery occlusion after acute cervical spine trauma

STUDY DESIGN: A retrospective study of vertebral artery injury diagnosed during the last 6 years in our institution. OBJECTIVES: To determine the clinical and radiologic features of vertebral artery injury. SUMMARY OF BACKGROUND DATA: Extracranial occlusion of the vertebral artery associated with cervical spine fracture is uncommon and can cause serious and even fatal neurologic deficit due to back lifting and cerebellar infarction. Magnetic resonance imaging and magnetic resonance angiography are extremely helpful in the examination of acute injuries of the cervical spine. METHODS: Magnetic resonance imaging and magnetic resonance angiography were performed at the time of injury. RESULTS: The authors reviewed six patients with cervical spine fractures who were diagnosed with a unilateral occlusion of the vertebral artery by means of magnetic resonance imaging/magnetic resonance angiography. One patient had signs of vertebrobasilar insufficiency and another with complete cord lesion had cerebellar and back lifting infarctions. Surgical anterior spinal fusion was performed in five patients, and one was treated by traction and orthosis. At the time of discharge, five patients had no vertebrobasilar symptoms, and the patient who experienced vertebrobasilar territory infarctions showed no progression of the neurologic damage. CONCLUSIONS: Vertebral artery injury should be suspected in cervical trauma patients with facet joint dislocation or transverse foramen fracture. Magnetic resonance imaging/magnetic resonance angiography is a helpful test to rule out vascular injury. Vertebral artery injury affects the extracranial segment at the same level as the cervical fracture. This is a retrospective review that did not permit drawing conclusions about the effects of early surgical stabilization in the treatment of cervical spine injuries with associated vertebral artery injury; however, surgical stabilization may avoid propagation and embolization of the clot located at the site of the lesion.     

Disc herniation in cervical fracture subluxation

Previous reports of computed tomographic scan with contrast myelography in cervical spinal cord injury have shown a rate of disc herniation of less than 5%. We hypothesized that injuries associated with forces adequate to cause bone or ligamentous injury in the region of the disc space could be associated with higher and more significant rates of disc herniation. Thirty-seven consecutive traumatic midcervical fracture subluxations were reviewed. Fracture subluxation was defined by fracture of the facet joints, pedicles, or vertebral bodies or more than 3.5 mm subluxation from C2-C3 to C7-T1. Reduction was achieved in 97% and was not associated with neurological deterioration. On the basis of plain films, tomograms, and plain computed tomographic scans, the injuries were classified as flexion dislocation, flexion compression, compression burst, or extension injuries. Twenty-five computed tomographic scans with contrast myelograms and one magnetic resonance imaging scan were obtained. All patients with partial neurological deficits were studied. A herniated disc was defined as that which deformed the thecal sac and/or nerve roots. Retrospectively, a neuroradiologist reviewed the studies for the presence of herniated disc. Disc herniation was seen at the level of injury in 9 (35%) patients and not seen in other patients. Forty-seven percent of the patients with partial deficits had herniated discs. Herniated disc was seen most frequently in flexion dislocation and flexion compression injuries. Three patients (20%) with partial deficits underwent discectomy. Patients with partial spinal cord injury and discectomy, on average, improved more than other patients with partial spinal cord injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

颈椎小关节脱位继发椎动脉损伤的发生率及损伤机制的实验研究

目的 研究闭合性颈椎小关节脱位损伤条件下椎动脉损伤的发生率及其损伤机制。方法 实验犬26只随机分为两组,A组12只以手术牵拉方式撑开C5～C6关节突关节,B组14只,以撞击伤方式造成C5～C6颈椎小关节脱位。通过MI认诊断椎动脉是否发生损伤,并进一步通过病理学检查明确椎动脉损伤。结果 A组的动物均未发生椎动脉损伤,B组有8只犬发生了椎动脉损伤。结论 颈椎小关节脱位易继发椎动脉损伤,其损伤机制在于受到瞬间暴力的牵拉造成内膜的撕裂而诱发血栓的形成。     

Cervical spinal cord injury caused by vertebral body fracture in a patient with concomitant OALL and OPLL

We encountered a case of cervical spinal cord injury associated with cervical vertebral dislocation fracture that occurred in a patient with concomitant ossification of the anterior and posterior longitudinal ligaments. The cervical vertebrae were injured by hyperextension in a car accident. On admission, shearing fracture was noted in the OALL region and vertebral body OPLL region over the posterior column at the fourth cervical level, but no dislocation or neurological findings were noted. Restlessness occurred and caused dislocation several hours after admission, leading to complete injury of the cervical spinal cord. The patient died of complications after 3 weeks. Vertebral body fracture complicated by both OALL and OPLL is very rare, and only four cases have been reported. Since vertebral injury causes delayed fracture/dislocation after a symptom-free interval in cases with ligament ossification, accurate clinical evaluation early after injury and early fixation are necessary.     

颈椎关节突退变临床特征与康复治疗对策

目的：探讨颈椎关节突退变的发病机制以及康复治疗对策。方法：抽查颈椎病200例有颈椎斜位X线片的资料，有轻重不同的关节突退变90例，年龄在31～76岁，以中老年居多，占80％，男女无明显差异。结果：发现颈椎关节突退变有3种原因。①关节突生理性退行性病变；②急慢性外伤，尤其挥鞭性损伤；⑧医源性损伤。当椎间关节不稳定时，慢性劳损或急性损伤将不可避免地产生症状，临床表现出神经根型、椎动脉型、乃至二者混合型颈椎病的症状。结论：X线斜位片可见上关节突刺入椎间孔，致该椎间孔缩小，其缩小程度与仰头伸颈成正比。科学的辨证治疗是关键，屈颈位扩孔手法整复有明显的针对性，起到了标本兼治之功，特殊病例应摄过伸、过屈位X线片。     

颈椎骨折类型与脊髓损伤关系之临床观察

通过对９２例颈椎骨折病例的分析，发现屈曲型损伤最多见（５３％），其次为过伸型（２６％），压缩型（２１％）。屈曲型和压缩型多见于年轻人，而屈曲损伤导致的脱位及过伸型则多见于年龄较大者。爆裂骨折引起的神经损害最重，其次为屈曲型、过伸型及压缩（非爆裂）骨折。神经功能改善率以爆裂型骨折最差，死亡率亦最高，以压缩（非爆裂型）骨折最好，其次为过伸型及屈曲型。文内对各型的特点进行了详细讨论。     

Cervical spine fracture patterns predictive of blunt vertebral artery injury

BACKGROUND: Aggressive screening for blunt cerebrovascular injury (BCVI) has uncovered an astonishing incidence of vertebral artery injuries (VAIs) and associated stroke rate. Stroke incidence is reduced with early recognition and prompt anticoagulation. Because of the proximity of the cervical spine and vertebral arteries, we queried whether all patients with cervical spine fractures required arteriography to rule out VAI. METHODS: Four-vessel cerebrovascular angiography remains the standard screening test for patients at risk for BCVI. Patients undergoing angiographic screening for blunt cerebrovascular injuries have been prospectively followed at our regional trauma center since January 1990; however, in January 1996, we began aggressive screening based on injury patterns. RESULTS: Ninety-two patients with vertebral artery injuries were identified during the study period from January 1996 to June 2002. Two patients with vertebral injuries had minor cervical fractures, a C6 body fracture and a C7 spinous process/laminar fracture; both underwent diagnostic angiography for injury mechanism. Of the 21 patients without cervical spine fracture, angiographic screening for BCVI was performed for neurologic symptoms (11 patients), basilar skull fracture (6 patients), or severe facial fractures (4 patients). Cervical spine fracture was the sole indication for VAI in 69 patients. The fracture patterns were subluxations in 38 patients (55%) or extension of the fracture through the foramen transversarium in 18 patients (26%). The remaining injuries (18%) were located in the upper cervical spine: isolated C1 arch in eight patients and C2/3 body fractures in five patients. CONCLUSION: Blunt vertebral artery injury is associated with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Routine screening should incorporate these findings to maximize yield while limiting the use of invasive procedures.     

Cervical spine stabilization. A three-dimensional, biomechanical evaluation of rotational stability, strength, and failure mechanisms

The three-dimensional rotational biomechanical properties of several different types of posterior stabilizing procedures are reported. A severe ligamentous and bony injury was simulated with three vertebral body human cervical spine segments. Good stabilization was noted for all of the repairs in flexion loading. Without polymethylmethacrylate supplementation, none of the repairs was stable in extension. All of the repairs provided reasonable stabilization for lateral bending except for the posterior wiring without methacrylate, and all but the posterior wiring and facet fusion provided reasonable stabilization against axial rotation loading. The supplementation of all of these repairs with polymethylmethacrylate added considerably to the stability of all the constraints. These findings may be useful in clinical decision-making for determining the kind of repairs and postoperative brace protection to use.     

In vitro genesis of subaxial cervical unilateral facet dislocations through sequential soft tissue ablation.

STUDY DESIGN: In vitro anatomic study investigating the degree of soft tissue disruption required to produce a subaxial cervical unilateral facet dislocation. OBJECTIVES: To develop an understanding of the relative contributions to stability of the subaxial cervical soft tissues and to define an anatomic threshold of injury necessary to produce a unilateral cervical facet dislocation. SUMMARY OF BACKGROUND DATA: The literature at this time is unclear regarding the precise pathomechanics of a cervical unilateral facet dislocation and the required threshold of soft tissue injury necessary for its genesis. Published clinical reports do not make any specific reference to these factors or are unclear in their objectivity. METHODS: Two adjacent vertebra at a time in 10 fresh-frozen subaxial cervical spine specimens (C2-C3 to C6-C7) were transfixed in the coronal plane with 3.5-mm Schanz screws. A steady unilateral vertical distraction force resulting in lateral cervical flexion was applied to these screws as the surrounding cervical soft tissue structures were sequentially ablated. Four experimental models were developed, varying the order of soft tissue disruption. RESULTS: The physiologic coupling of subaxial cervical unilateral distraction and rotation, because of the spatial orientation or inclination of the cervical facet joints, allowed the creation of a unilateral facet dislocation without an additional flexion moment. Disruption of the ipsilateral articular capsule, ligamentum flavum, and more than half of the anulus fibrosus was necessary for the genesis of a unilateral facet dislocation. Disruption of the supraspinous and interspinous ligaments was not necessary but appeared to facilitate or lessen the force required to dislocate a unilateral facet. Disruption of the anterior and posterior longitudinal ligaments and intertransverse ligaments was not necessary to create a unilateral facet dislocation. CONCLUSION: This anatomic study further supports the theory that discontinuity of the anterior and posterior longitudinal ligaments is not necessary for a unilateral facet dislocation to occur. The ipsilateral facet capsule, anulus fibrosus, and ligamentum flavum appear to be the physical soft tissue restraints that need to be disrupted to produce a unilateral facet dislocation.     

颈椎小关节脱位与闭合性椎动脉损伤的相关性研究

[目的]探讨颈椎小关节脱位与闭合性椎动脉损伤的相关性。[方法]本组319仍颈椎创伤患者，颈椎骨折261例；小关节脱位46例，其中单侧小关节脱位22例，双侧小关节脱位24例；无放射影像异常的脊髓损伤12例。所有患者接受了颈椎MRI和椎动脉2DTOF MRA的前瞻性检查。动物实验建立犬颈椎小关节脱位的撞击模型，撞击后摄颈椎X线片，24—36h后行椎动脉2DTOF MRA检查。[结果]临床319例颈椎创伤患者，52例继发有椎动脉损伤，单侧51例，双侧1例。发现有椎动脉损伤的患者中，34例（65．4％）原始损伤为颈椎小关节脱位，16例为颈椎骨折，2例为无放射影像异常的颈髓损伤。动物实验14只犬撞击后发生颈椎小关节脱位，12只犬无小关节脱位。14只发生小关节脱位犬中，8只继发有单侧椎动脉损伤，12只无小关节脱位犬均无椎动脉损伤。[结论]闭合性椎动脉损伤最常继发于颈椎小关节脱位，瞬间位移使椎动脉受到过度牵张是主要的致伤因素。