经口咽前、后路一期手术治疗难复性寰枢椎脱位伴脊髓压迫症

目的：总结经口咽前路同时后路减压枕颈内固定治疗难复性寰枢椎脱位的临床效果。方法：C地10例难复性寰枢椎脱位,根据术前临床分型安排前后路手术顺序。同时期进行经口咽前路减压松解复位和后路减压,枕颈CD或Cervifix枕颈内固定。按JOA17分法颈脊髓损害功能评定标准进行手术前后颈髓功能评定,并测量比较脊髓矢径的变化。结果：平均随访8个月。仍髓功能改善率达58．3％,颈髓减压改善率平均达69％。结论：经口咽前路减压同时行后路减压枕颈内固定手术的临床疗效佳,适用于难复性寰枢椎脱位或不可复性寰枢椎脱位伴颈髓压迫症。     

经口咽入路松解Ⅱ期后路器械融合治疗寰枢椎脱位

目的：评价经口咽入路松解、Ⅱ期后路器械融合治疗陈旧性寰枢椎脱位。方法：经口咽入路寰枢椎前方松解颅骨牵引复位、Ⅱ期后路寰枢椎融合内固定治疗6例陈旧性寰枢椎脱位患者,术后对脊髓功能和颈椎影像学进行评定。结果：术后2年脊髓功能改善2级3例,改善1级2例,无变化1例。术后X线显示寰枢椎复位理想和后方融合满意,MRI显示脊髓压迫解除。结论：经口咽入路行寰枢椎前方松解后颅骨牵引复位、Ⅱ期后路器械融合术治疗陈旧性寰枢椎脱位,临床和影像学评估满意。     

经口咽前路寰枢椎钢板内固定

对颅颈交界区畸形及其他病变引起的寰枢椎脱位伴脊髓压迫症需减压内固定，可根据不同情况选择不同的内固定方法，包括寰枢前路内固定、寰枢后路内固定或枕颈内固定，经口咽前路囊枢椎钢板内固定是新近发展起来的一种寰枢椎前路固定方法，用于治疗先天性疾患、外伤或类风湿性关节炎等所致的难复性寰枢椎脱位，但临床应用不多。     

经口咽齿突切除结合H—V环复位治疗重度陈旧性寰枢椎脱位

目的：探讨经口咽齿突切除结合H－V环复位治疗重度陈旧性寰枢椎脱位的方法及重度寰枢椎脱位的病理机制。方法：对2例重度陈旧性寰枢椎脱位患者采用经口咽齿突切除前方松解、减压,结合H－V环缓慢复位,二期行后路减压枕颈融合方法治疗。结果：1例术前Frankel C级恢复至正常,1例术前Frankel C级恢复至D级。结论：重度陈旧性寰枢椎脱位,在寰椎前弓与枢椎体间形成纤维组织增生,这种纤维连接使寰枢椎相对趋向稳定是障碍复位的主要因素。结合H－V环缓慢牵引,复位制动,经口咽入路行齿突切除前方松解减压,二期行后路减压枕颈融合,确能从前后方解除致压因素,结合H－V环制动、复位能够保障复位和手术过程中头颈部的运动在H－V环控制下,对手术和复位提供了极大的安全保证。     

TARP钢板系统在难复型寰枢椎脱位手术中的临床应用

目的探讨经口咽前路寰枢椎复位钢板系统（TARP）在难复型寰枢椎脱位的临床应用。方法自2003年4月-2004年9月，对13例陈旧性的难复型寰枢椎脱位患者行经口咽前路松解减压，应用TARP系统复位和固定，两侧寰枢关节间植入自体髂骨融合。结果除1例因跌倒引起螺钉松动再次脱位外，均固定牢固，融合理想，脊髓减压满意。结论经口咽前路寰枢椎复位钢板系统一次完成寰枢椎脱位的复位和固定是治疗陈旧性难复型寰枢椎脱位较为理想的手术方法。     

难复型寰枢椎脱位经口咽入路手术治疗进展

对颅颈交界区畸形及其它病变引起的寰枢椎脱位伴脊髓压迫症需减压内固定,可根据不同的情况选择不同的内固定方法,包括寰枢前路内固定、寰枢后路内固定或枕颈内固定。经口咽前路寰枢椎钢板内固定是新近发展起来的一种寰枢椎前路固定方法,用于先天性疾患、外伤或类风湿性关节炎等所致的难复型寰枢椎脱位,但临床应用不多。虽然应用经口咽入路处理颅颈交界区腹侧病变已有近100年的历史,但由于此入路术野显露困难,手术风险较大,术后并发症严重等,至今未能广泛开展,本文就此入路手术治疗寰枢椎脱位近年的进展情况做一综述。     

经颈前路松解后路融合一期手术治疗难复性寰枢椎半脱位

目的：探讨经颈前路松解后路融合一期手术治疗难复性寰枢椎脱位的方法及其可行性。方法：本组7例，男6例，女1例；年龄14～49岁，平均35岁。陈旧性齿突骨折例，横韧带断裂9例，同时合并有枕颈或颈椎先天性畸形6例。先天性寰枢椎半脱位8例，斜坡颅底型状突陷入症13例。根据术前临床分型安排前后路手术的顺序。经口咽前路松解：仰卧位维持头颅牵引，口腔常规清洁处理后，碘伏消毒面部、口腔及咽部。用Codmart口咽显露器撑开口腔及咽皱襞及软腭，充分显露咽后壁，纵行切开咽后壁诸层结构，分离显露寰椎前弓，用磨钻磨除环椎前弓、齿状突，予以脊髓前方的彻底减压：颈后路减压及内固定术：更换体位，置患者于俯卧位，维持头颅牵引，行枕颈后正中纵切口，分离显露枕骨背部、寰椎后结节和C2一C4棘突和椎板，若脊髓后方有压迫，则切除寰椎后结节减压，取髂骨块移植于枕颈部，遂行枕颈后方内固定。结果：42例获得6．24个月随访，平均随访19个月，观察手术前后的临床症状、体征。按JOA 17分法评定标准进行手术前后的颈髓功能评定，术后改善率=（术后总分－术前总分）÷（17－术前总分）×100％。结果显示，术后改善率为14．4％－100％，平均58．9％。术后40例枕颈骨性融合，所有病例均无内固定物折断、松动现象，1例患者3枚螺钉退出，1例患者2枚螺钉方法不佳。术后颈椎活动功能近期受到一定影响，通过功能练习和下位颈椎的活动功能代偿基本能满足生活需要。结论：经口咽前、后路一期手术治疗寰枢椎脱位伴脊髓压迫症效果良好。     

颈前路松解后路融合一期手术治疗难复性寰枢椎半脱位

目的：探讨经颈前路松解后路融合一期手术治疗难复性寰枢椎脱位的方法及其町行性。方法：本组7例，男6例，女1例；年龄14～49岁，平均35岁。陈旧性齿突骨折例，横韧带断裂9例，同时合并有枕颁或颈椎先天性畸形6例。先天性寰枢椎半脱位8例，斜坡颅底型状突陷入症13例。根据术前临床分型安排前后路于术的顺序。经口咽前路松解：仰卧位维持头颅牵引，口腔常规清洁处理后，碘伏消毒面部、口腔及咽部。用Codman口咽显露器撑开口腔及咽皱襞及软腭，充分显露咽后壁，纵行切开咽后壁诸层结构，分离显露寰椎前弓，用磨钻磨除环椎前弓、齿状突，予以脊髓前方的彻底减压：颈后路减压及内固定术：更换体位，置患者于俯卧位，维持头颅牵引，行枕颈后正中纵切口，分离显露枕骨背部、寰椎后结节和C2～C4棘突和椎板，若脊髓后方有压迫，则切除寰椎后结节减压，取髂骨块移植于枕颈部，遂行枕颈后方内固定。结果：42例获得6～24个月随访，平均随访19个月，观察手术前后的临床症状、体征。按JOA17分法评定标准进行手术前后的颈髓功能评定，术后改善率=（术后总分-术前总分）÷（17-术前总分）×100％。结果显示，术后改善率为14．4％～100％，平均58．9％。术后40例枕颈骨性融合，所有病例均无内固定物折断、松动现象，1例患者3枚螺钉退出，1例患者2枚螺钉方法不佳。术后颈椎活动功能近期受到一定影响，通过功能练习和下位颈椎的活动功能代偿基本能满足生活需要。结论：经口咽前、后路一期手术治疗寰枢椎脱化伴脊髓压迫症效果良好。     

内窥镜辅助下经口咽前路寰枢椎减压术

目的：探讨内窥镜辅助下经口咽前路寰枢椎减压术的临床效果。方法：1998年8月～2004年8月对38例陈旧性寰枢椎脱位患者采用内窥镜辅助下经口咽前入路减压术，其中18例行一期经口咽入路减压和后路枕颈内固定术：15例行经口咽前路寰枢椎复位钢板内固定术；5例不可复型仅行经口咽前入路减压术。结果：平均随访38个月（6～96个月）。术后患者临床症状均明显改善，上颈段脊髓减压改善率达89.3％。发生颅内感染1例，前路钢板松脱1例。结论：与常规减压方法相比，内窥镜辅助下经口咽前路寰枢椎减压手术创伤小，操作精细、准确，术中与助手可协同操作。     

经口咽下颌骨劈开入路处理上颈椎或上、下颈椎腹侧病变

目的：探讨经口咽下颌骨劈开入路处理上颈椎或上、下颈椎腹侧病变的临床效果。方法：采用经口咽唇面下颌骨劈开入路处理伴有下颌关节僵直的陈旧性寰枢椎脱位1例，行TARP钢板内固定术；处理枢椎体肿瘤1例，行C2椎体肿瘤切除，异形钛网笼置入重建椎体，同期行后路C1～C3椎弓根钉棒植骨内固定术。采用经口、舌、唇面下颌骨劈开入路处理C1～C5肿瘤1例，行肿瘤切除，异形钛网笼置入重建C2～C4椎体，同期后路C1～C5附件肿瘤切除．枕颈植骨融合内固定术。随访观察治疗效果。结果：病变部位显露满意，顺利完成手术操作。随访12～24个月。2例肿瘤患者的肿瘤切除彻底，前路椎体重建满意，后路内固定稳妥，临床症状消失，行走正常；1例寰枢椎陈旧性脱位患者的寰枢椎达解剖复位，颈髓减压充分，C1～C2前路内固定稳妥，临床症状消失。结论：经口咽下颌骨劈开扩大入路适合于处理同时累及上下颈椎的腹侧病变或患者张口困难的上颈椎腹侧病变。     

Transoral approach for the treatment of atlanto-axial dislocation with the Os odontoideum and obstruction of the bilateral vertebral arteries (author's transl)]

The two approaches are well-known in the surgical treatment of atlanto-axial dislocation, the one is the anterior and the other is the posterior approach. The indication of these methods is still controversial. This report concerns with one case of atlanto-axial dislocation with the separate odontoid and bilateral obstruction of both vertebral arteries, which was successfully treated by transoral decompression and fusion between the bodies of the atlas and axis. The reasons why we chose this method were: (1) the spinal cord decompression was necessary because of the presence of compression of the cord by the separate odontoid process, (2) the spinal fusion had to be performed to stabilize the atlanto-axial articulation, (3) it was necessary to avoid the damage of collateral circulations to the brainstem through the deep cervical arteries demonstrated by bilat vertebral angiography. The posterior approach is highly susceptible to injure these collateral circulations.     

Posttraumatic atlanto-axial subluxation and myelopathy. Efficacy of anterior decompression

Compression of the neuraxis may occur after displaced fractures of the dens. Nonunion or malunion increases the risk of developing neurologic complications because of the resulting atlanto-axial instability. Posterior decompression has generally been the surgical solution to myelopathy at this level. Two patients with cervical myelopathy due to displaced ununited dens fractures were treated with posterior fossa decompression and high cervical laminectomy. Both patients deteriorated after the surgery. Most of their neurologic deficits finally resolved after microsurgical transoral decompression (by resection of the dens). In those patients in whom atlanto-axial instability causes primarily anterior compression of the neuraxis, especially by a bony lesion, decompression posteriorly may not achieve the desired effect, and, instead, may cause a deterioration in the patient's condition. Anterior atlanto-axial subluxation effectively lengthens the bony spinal canal, which results in stretching of the relatively inelastic spinal cord over the bony deformity. If indirect methods of reduction fail to relieve the condition, then anterior transoral decompression is recommended.     

下颈椎粉碎性骨折伴脊髓损伤的手术治疗

目的：探讨前路椎体次全切除和钢板系统固定在治疗下颈椎粉碎性骨折中的应用；方法：对16例下颈椎粉碎性骨折伴脊髓损伤的病人，先行颈椎牵引、药物治疗，于伤后1周行颈前路椎体次全切除植骨融合和钢板内固定术；结果：随访6—42个月，16例植骨均骨性愈合，ALIA脊髓损伤的分级恢复1—3级，无术后加重和因手术所致并发症；结论：颈前路椎体次全切除植骨融合和钢板内固定具有如下优点：颈前路椎体次全切除具有减压充分、可探查脊髓前方压迫情况；钢板内固定可获得即刻稳定，便于护理和功能锻炼；取髂骨作植骨融合的融合率高和获得长期稳定；是治疗下颈椎粉碎性骨折安全有效的治疗方法。     

Chiari I malformation associated with atlanto-axial dislocation: focussing on the anterior cervico-medullary compression

Summary Background. Chiari I malformation with atlantoaxial dislocation may cause both posterior and anterior cervicomedullary compression. We studied the clinicoradiological features and surgical outcome in patients having Chiari I malformation with atlantoaxial dislocation. Method. Thirty-nine patients with Chiari I malformation with atlanto-axial dislocation underwent preoperative and follow-up neurological status assessment. In Chiari I malformation with reducible atlanto-axial dislocation (n = 11), a direct posterior stabilization was done. In Chiari I malformation with irreducible atlanto-axial dislocation (n = 28), a single stage transoral decompression with posterior stabilization and/or posterior decompression and duraplasty were done in 18 patients. In 10 patients, only posterior decompression and/or posterior stabilization was performed. Seven among the latter patients subsequently deteriorated and required transoral decompression. Comparison of mean neurological status scores of patients with Chiari I malformation with irreducible atlanto-axial dislocation who underwent single stage transoral decompression with posterior stabilization versus the posterior procedure alone was done using T-test and proportional significance also calculated. Findings. Patients with Chiari I malformation with atlanto-axial dislocation have a high incidence of long tract signs and sphincteric disturbances with a decrease in the mean foramen magnum diameter. The mean neurological status scores of patients with Chiari I malformation with irreducible atlanto-axial dislocation who underwent single stage transoral decompression with posterior stabilization were significantly better than those patients who underwent the posterior procedure alone. The latter patients also showed significant clinical improvement following transoral decompression. In the presence of Chiari I malformation with reducible atlanto-axial dislocation, reduction and stabilization of atlanto-axial dislocation resulted in neurological improvement. The follow up neurological status scores of these patients improved after surgical intervention even in the presence of poor preoperative grades. Conclusions. Patients with Chiari I malformation should be investigated for the presence of atlanto-axial dislocation. In case atlantoaxial dislocation coexists, priority must be given to relieving anterior cervicomedullary compression.     

Pure endoscopic endonasal odontoidectomy: anatomical study

Different disorders may produce irreducible atlanto-axial dislocation with compression of the ventral spinal cord. Among the surgical approaches available for a such condition, the transoral resection of the odontoid process is the most often used. The aim of this anatomical study is to demonstrate the possibility of an anterior cervico-medullary decompression through an endoscopic endonasal approach. Three fresh cadaver heads were used. A modified endonasal endoscopic approach was made in all cases. Endoscopic dissections were performed using a rigid endoscope, 4 mm in diameter, 18 cm in length, with 0 degree lenses. Access to the cranio-vertebral junction was possible using a lower trajectory, when compared to that necessary for the sellar region. The choana is entered and the mucosa of the rhinopharynx is dissected and transposed in the oral cavity in order to expose the cranio-vertebral junction and to obtain a mucosal flap useful for the closure. The anterior arch of the atlas and the odontoid process of C2 are removed, thus exposing the dura mater. The endoscopic endonasal approach could be a valid alternative to the transoral approach for anterior odontoidectomy.     

Transoral operations for craniospinal malformations

The transoral approach to the lower third of the clivus and to the ventral aspect of the upper cervical spine is used in craniospinal malformations with or without dislocation as well as in basilar aneurysms, ventrally situated cranio-spinal tumours, fractures of the odontoid process, and in rheumatoid arthritis compressing the spinal cord. In consideration of the literature and ten personal cases the indications and techniques of the transoral approach in craniospinal malformations are discussed. According to our own experiences and those of other authors it is possible to expose the lower clivus and the cervical spine down to C2 by a midline incision of the pharyngeal wall using a mouth retractor and oral intubation. Splitting of the soft palate or resection of the hard palate are not necessary, a tracheotomy should be performed only in exceptional cases. In congenital craniospinal malformations without dislocation or instability causing a ventral compression of the spinal cord, for instance by the odontoid process, the transoral decompression is preferable to dorsal decompressing operations. In cases of pure instability without any space-occupying lesion the transoral and posterior approach are possible in order to perform a fusion. The last one seems more advantageous in these cases. In craniospinal malformations with dislocation causing a ventral and dorsal narrowing of the spinal canal, apart from the decompression a stabilization has to be achieved. In these usually complex malformations individual treatment is necessary. According to the rare cases in the literature and to our own experience a primary anterior decompression, followed by a most careful posterior stabilization seems to produce the most favourable results.     

椎体次全切除植骨融合治疗颈椎后纵韧带骨化症

目的：分析椎体次全切除植骨融合术治疗颈椎后纵韧带骨化症。方法：75例患者，男45例，女30例；年龄42～64岁，平均51.6岁。病变累及1个椎节者29例，2个椎节者39例；3个椎节者7例。椎体次全切除提供向侧方低达椎弓根前内缘的减压骨槽，其底宽一般为18～20mm，使椎管前壁近乎完全敞开。直视下切除骨化的后纵韧带。强调牵引下植骨。按JOA评分和X线片，判定改善率和植骨区骨性融合。结果：75例中有68例获3个月～6年2个月（平均2年7个月）的随访。X线片示：切除1或2个椎节者，术后3～4个月植骨区骨性融合；而切除3个椎节者，5～6个月获骨性融合。优良率85.3%，改善率3.4%～91.3%，平均70.8%。3例并发短期C5或C6神经根麻痹，2例并发硬脊膜损伤，无脊髓和椎动脉等损伤并发症。结论：椎体次全切除术使椎管前壁近乎完全敞开，给切除骨化的后纵韧带提供足够大的视野条件，使减压更趋完善。     

上段颈髓减压效果MR评估标准的探讨

目的探讨寰枢关节脱位伴上段颈髓受压和减压的形态学及MR矢径变化特点,建立上段颈髓减压效果的MR评估标准。方法通过观察和测量20例正常及25例寰枢关节脱位的上段颈髓受压及减压的MR矢径变化规律,设计出上段颈髓受压指数公式和上段颈髓减压改善率公式。结果上段颈髓受压指数=(拟正常颈髓矢径-最窄段颈髓矢径)/拟正常颈髓矢径；颈髓减压改善率=(治疗后最窄段矢径-治疗前最窄段矢径)/(拟正常颈髓矢径-治疗前最窄段矢径)×100%。结论上述MR评估标准能客观评估上段颈髓受压程度和减压改善效果。