寰椎Jefferson's骨折伴横韧带损伤的诊治策略

寰椎是枕-寰-枢复合体的重要一环。其损伤后致枕颈部的不稳对患者的影响很大。寰椎Jefferson’s骨折伴有横韧带损伤临床上罕有,对其临床诊断和外科治疗策略的研讨已成为上颈椎损伤研究和临床实践中的新热点。本文结合近年来相关文献从寰椎Jefferson’s骨折伴横韧带损伤的应用解剖、致伤原理、临床表现和诊断、治疗策略四个方面对其进行了文献总结和讨论     

寰椎横韧带损伤

国内外文献中有关寰椎横韧带损伤的报道至今仍相当少见。寰椎横韧带是维持寰枢椎稳定性的最重要结构,是防止寰枢椎前方半脱位的最主要因素。其临床表现主要取决于韧带损伤后寰椎前脱位的程度以及是否造成脊髓压迫,诊断主要依靠影像学表现,以寰齿间距最为常用。对于寰椎横韧带断裂即I型损伤,一旦诊断明确即应在早期行手术治疗,而对于Ⅱ型损伤,可先行非手术治疗,如发生骨折不愈合并出现迟发性寰枢椎不稳仍需手术治疗。     

外伤性寰椎横韧带断裂的治疗策略

目的探讨外伤性寰椎横韧带断裂治疗策略。方法回顾性分析一组24例寰椎横韧带断裂病例,其中单纯横韧带断裂15例,合并有寰椎骨折7例,合并齿状突骨折2例。急性损伤20例,陈旧性损伤4例。手术行寰枢椎融合术14例,枕颈融合6例,非手术治疗3例,入院后当天死亡1例。结果23例获得随访,平均随访时间为46个月。20例手术治疗患者中15例完全恢复正常,3例仍有局部症状,2例颈脊髓神经损害改善,无术后神经损害加重病例。3例接受非手术治疗患者中有2例出现寰枢椎不稳及迟发性脊髓损害。结论寰椎横韧带是维持寰枢椎正常解剖关系不可或缺的重要结构,横韧带断裂必然导致寰枢椎不稳定。无论是急性或陈旧性损伤,一旦诊断明确即应在早期行寰枢椎或枕颈融合术。     

Cervifix内固定系统治疗Jefferson骨折伴横韧带损伤

目的 探讨Cervifix内固定系统治疗Jefferson骨折伴横韧带损伤的疗效.方法 应用Cervifix内固定术治疗15例Jefferson骨折伴横韧带损伤患者.观察术后近期疗效、植骨融合情况及并发症.结果 术中和术后无神经、椎动脉损伤表现.平均随访21.2个月.7例术后临床症状明显缓解,无神经系统症状加重者.15例植骨全部融合,无内固定并发症.手术前后ASIA分级差异有统计学意义(P<0.05).结论 Cervfix内固定系统坚固可靠,提高了骨融合率,可预防上颈椎潜在不稳导致的脊髓损伤.     

寰椎横韧带损伤

寰椎横韧带是寰枢椎稳定成分中最基本、最重要的韧带。它限制齿突活动范围，阻止寰椎向前半脱位。寰椎横韧带断裂是一种十分严重的创伤，伤后极易发生寰椎向前脱位，从而导致上颈髓的损伤以至死亡，危险性极大。上颈椎外伤后软组织损伤，包括韧带损伤的发生率比人们想象的要普遍。     

应该重视寰椎横韧带损伤

寰枕部韧带损伤（tears of the transverse ligament of the atlas）概念范围比较广范,包括寰枕关节脱位、寰枢椎关节脱位、单纯性寰椎横韧带或翼状韧带撕裂。在许多单纯韧带损伤而无临床症状、无寰椎移位时,早期诊断比较困难,潜在危险性较大,临床发生相对少见,在遇到多发性损伤时容易被漏诊。     

创伤性寰椎横韧带断裂

目的：探讨创伤性寰椎横韧带断裂的诊断和治疗。方法：回顾性分析２３例创伤性寰椎横韧带断裂,其中急性损伤９例,陈旧性损伤１４例。所有患者均有颈部症状。１７例有神经损害。Ｘ线检查显示寰齿间距（ＡＤＩ）为６￣１４ｍｍ。本组有５例行非手术治疗,其余１８例行枕颈融合术或寰枢椎融合术。结果：随访１￣１７年（平均７年）,５例接受保守治疗患者中有４例出现寰枢椎不稳及迟发性脊髓损害,１８例手术治疗患者中４例完全恢复正     

急性外伤性寰椎横韧带损伤程度的评价与治疗探讨

目的对急性外伤性寰椎横韧带损伤程度进行评价,并探讨其治疗。方法回顾性分析2002年6月～2004年12月12例急性外伤性寰椎横韧带损伤病例。5例为单纯性损伤,7例为合并有寰椎和/或齿状突骨折的横韧带损伤。8例行寰枢椎或枕颈融合术,4例保守治疗。结果12例患者均获平均20个月随访。8例手术治疗患者效果均满意。4例保守治疗患者中3例获得满意结果,1例欠佳。结论寰椎横韧带是维持寰枢椎正常解剖关系不可或缺的重要结构,横韧带损伤常导致寰枢椎不稳定,但对一些损伤较轻者仍可采取保守治疗并获得满意效果。因此,正确评价外伤性横韧带损伤程度对治疗策略的选择和疗效至关重要。     

寰椎横韧带损伤的治疗策略

[目的]探讨寰椎横韧带在各种损伤状态下的治疗策略。[方法]本组共收治寰椎横韧带损伤患者26例，分析X线、CT及MRI资料，根据是否合并寰椎（或）齿状突骨折、损伤节段的稳定性及脊髓的损伤情况，4例行枕颈融合术，17例行寰枢椎融合术，5例行保守治疗。[结果]26例患者获6～36个月（平均18个月）随访，21例手术治疗患者疗效满意，5例保守治疗，其中4例效果满意，1例远期效果不佳行手术治疗。[结论]对于寰枢椎脱位、横韧带严重损伤，采用枕颈融合或寰枢椎融合术；对于横韧带部分损伤、寰枢椎稳定的患者采用保守治疗，但必须密切随访，出现不稳症状尽早手术治疗。     

Bilateral atlas laminar hook combined with transarticular screw fixation for an unstable bursting atlantal fracture

Introduction  The unstable atlas burst fracture (“Jefferson fracture”) is a fracture of the anterior and posterior atlantal arch with rupture of the transverse atlantal ligament and an incongruence of the atlanto-occipital and the atlanto-axial joint facets. The posterior atlantoaxial fusion is frequently used to reconstruct the stability of atlantoaxial joint. Conventional posterior atlantoaxial fixations are associated with high rates of pseudoarthrosis and chronic atlantoaxial instability. As a modified three-point fixation the bilateral C1-2 transarticular screws combined with C1 laminar hook and bone grafts can provide best biomechanical stability, but no standard protocol has been reported for the use of this fusion technique. A retrospective review of clinical series should be conducted to evaluate the clinical outcome of bilateral atlas laminar hook combined with transarticular screw fixation for unstable bursting atlantal fracture. Materials and methods  From March 2002 to March 2006, there were total 12 cases of unstable atlantal bursting fractures, 10 males and 2 females, age ranging 18–54, with mean of 36 years old. All patients were operated on posterior atlantoaxial fusion using bilateral atlas laminar hook combined with transarticular screw fixation after atlantoaxial joint were reduced and followed up for 12–24 months. The medical records and radiographs of the 12 patients were reviewed. Each patient underwent a complete cervical radiograph series including lateral flexion-extension view and a computed topographic scan. The Frankel grades and ASIA scores were applied to assess the neurologic status. Results  In all patients, a good bony fusion of the atlanto-axial segment was achieved. All patients showed significant improvement of the neurologic defect and no instability on their follow-up plain radiographs and computerized tomography in follow-up interval. Conclusions  For the patients who suffer from the unstable bursting atlantal fracture, the nonoperative methods could carry some clinical complications including infection, nerve injury, etc. and is frequently failure, Posterior atlantoaxial fusion using bilateral atlas laminar hook combined with transarticular screw fixation is an effective treatment. Xiang Guo and Bin Ni contributed equally to the article.     

老年人外伤性脊柱骨折的临床特点

目的:分析老年人外伤性脊柱骨折的临床特点,提高老年人外伤性脊柱骨折的预防及救治水平。方法:2002年1月～2011年12月我院收治老年人外伤性脊柱骨折患者271例,其中男129例,女142例,年龄60～89岁,平均68.8岁,分析其年龄与性别分布情况、骨折原因、骨折节段、创伤严重度评分(injury severity scores,ISS)、脊髓损伤程度ASIA分级、多发性脊柱骨折及合并伤发生率。结果 :年龄分布主要集中在60～69岁,占60.1%(163/271)。摔伤是主要致伤原因,占44.6%(121/271)。男性高处坠落伤及重物砸伤比例较女性患者高,女性患者摔伤比例较男性高,差异有统计学意义(P<0.05)。426个损伤节段中胸椎及腰椎占80.8%(344/426),其中胸腰段(T11～L2)占53.3%(227/426)。男性患者较女性患者有较高的颈椎骨折比例、脊髓损伤发生率、合并症发生率和创伤严重度评分(ISS),差异有统计学意义(P<0.05)。女性患者较男性患者有较高的胸椎及胸腰段椎体骨折比例,差异有统计学意义(P<0.05)。男性患者多发性脊柱骨折最常见原因为高处坠落伤,女性患者为摔伤。脊髓损伤按ASIA分级,A级、B级、C级、D级分别占7.0%(19/271)、1.8%(5/271)、4.8%(13/271)和18.1%(49/271)。男性患者脊髓损伤分级A级占13.2%(17/129),女性患者为0.8%(2/237),两者差异有统计学意义(P<0.05)。结论:老年人外伤性脊柱骨折的致伤原因、多发性脊柱骨折原因、骨折节段、脊髓损伤分级等方面存在明显的性别差异,应根据其性别差异特点对老年人外伤性脊柱骨折进行防治。     

Epidemiology of traumatic spine fractures

Objectives

To illustrate the correlations and effects of age, gender and cause of accident on the type of vertebral fracture and fracture distribution, as well as on the likelihood to sustain an associated injury or neurological deficit.

Design

Retrospective analysis of 562 patients with a traumatic fracture of the spine. Each patient was analysed by reviewing the medical records, the initial radiographs and CT-scans.

Setting

Level 1 trauma centre from 01/1996 to 12/2000.

Results

The most common cause of accident was a high-energy fall (39%), followed by traffic accidents (26.5%). While fall related fractures were evenly distributed over the whole spine, traffic accidents induced significantly more fractures of the cervical and thoracic spine. Sixty-five percent of all cervical spine fractures and 80% of the multisegmental injuries were accompanied by an associated injury. The highest incidence of associated injuries was observed in patients with multilevel fractures (96.5%). Patients with a concomitant injury were more likely to sustain a spinal cord lesion. Sixty-three (11.2%) patients exhibited a complete motor and sensory deficit, 76 (13.5%) an incomplete and 423 (75.3%) no neurological deficit. The highest number of complete motor and sensory neurological deficits was found in cervical spine fractures (19.7%). The majority of patients, 308 (54.8%), sustained a compression fracture, 95 (16.9%) a distraction fracture, and 104 (18.5%) patients experienced a rotational fracture.

Conclusions

This study demonstrates correlations between the cause of accident, the type of spinal fracture and the fracture distribution. Using the AO classification, the likelihood to sustain either associated and/or spinal cord injuries, is predictable.     

胫骨平台骨折合并周围韧带损伤治疗探讨

目的 分析胫骨平台骨折术后随访病例膝关节稳定性的变化，探讨胫骨平台骨折合并周围韧带损伤的发生率及早期诊断和处理措施。方法 对2000年1月～2003年6月期间在我院治疗的不同类型胫骨平台骨折进行回顾，对有随访的57例良好复位的平台骨折病例膝关节稳定度进行分析。结果 随访6个月～2.5年，平均15个月，未见明显膝关节不稳现象，总结出本组病例膝关节稳定性良好的原因：①胫骨平台骨折合并周围韧带损伤发生率低；②胫骨平台骨折合并韧带损伤程度轻；③解剖复位及坚强内固定；④术后良好制动及正确的康复训练指导。结论 胫骨平台骨折合并周围韧带完全断裂的发生率较低，韧带不全损伤非手术治疗可获得良好疗效。     

A biomechanical rationale for C1-ring osteosynthesis as treatment for displaced Jefferson burst fractures with incompetency of the transverse atlantal ligament

Nonsurgical treatment of Jefferson burst fractures (JBF) confers increased rates of C1–2 malunion with potential for cranial settling and neurologic sequels. Hence, fusion C1–2 was recognized as the superior treatment for displaced JBF, but sacrifies C1–2 motion. Ruf et al. introduced the C1-ring osteosynthesis (C1–RO). First results were favorable, but C1–RO was not without criticism due to the lack of clinical and biomechanical data serving evidence that C1–RO is safe in displaced JBF with proven rupture of the transverse atlantal ligament (TAL). Therefore, our objectives were to perform a biomechanical analysis of C1–RO for the treatment of displaced Jefferson burst fractures (JBF) with incompetency of the TAL. Five specimens C0–2 were subjected to loading with posteroanterior force transmission in an electromechanical testing machine (ETM). With the TAL left intact, loads were applied posteriorly via the C1–RO ramping from 10 to 100 N. Atlantoaxial subluxation was measured radiographically in terms of the anterior antlantodental interval (AADI) with an image intensifier placed surrounding the ETM. Load–displacement data were also recorded by the ETM. After testing the TAL-intact state, the atlas was osteotomized yielding for a JBF, the TAL and left lateral joint capsule were cut and the C1–RO was accomplished. The C1–RO was subjected to cyclic loading, ramping from 20 to 100 N to simulate post-surgery in vivo loading. Afterwards incremental loading (10–100 N) was repeated with subsequent increase in loads until failure occurred. Small differences (1–1.5 mm) existed between the radiographic AADI under incremental loading (10–100 N) with the TAL-intact as compared to the TAL-disrupted state. Significant differences existed for the beginning of loading (10 N, P = 0.02). Under physiological loads, the increase in the AADI within the incremental steps (10–100 N) was not significantly different between TAL-disrupted and TAL-intact state. Analysis of failure load (FL) testing showed no significant differences among the radiologically assessed displacement data (AADI) and that of the ETM (P = 0.5). FL was Ø297.5 ± 108.5 N (range 158.8–449.0 N). The related displacement assessed by the ETM was Ø5.8 ± 2.8 mm (range 2.3–7.9). All specimens succeeded a FL >150 N, four of them >250 N and three of them >300 N. In the TAL-disrupted state loads up to 100 N were transferred to C1, but the radiographic AADI did not exceed 5 mm in any specimen. In conclusion, reconstruction after displaced JBF with TAL and one capsule disrupted using a C1–RO involves imparting an axial tensile force to lift C0 into proper alignment to the C1–2 complex. Simultaneous compressive forces on the C1-lateral masses and occipital condyles allow for the recreation of the functional C0–2 ligamentous tension band and height. We demonstrated that under physiological loads, the C1–RO restores sufficient stability at C1–2 preventing significant translation. C1–RO might be a valid alternative for the treatment of displaced JBF in comparison to fusion of C1–2.     

胸腰椎爆裂性骨折合并后纵韧带损伤的研究进展

胸腰椎爆裂性骨折在脊柱骨折中比较常见,约占椎体前中柱骨折的60%,合并后纵韧带断裂时易出现神经损伤^［1-2］。不同类型胸腰椎爆裂性骨折的治疗方法不尽相同,目前临床上常用的有前路、后路、前后联合入路3种术式,然而最佳的治疗方式目前尚无定论。本文对胸腰椎爆裂性骨折合并后纵韧带损伤的研究现状及手术方式进行综述。     

寰椎骨折治疗进展

长期以来,寰椎骨折的治疗存在多种争议.该文在对单纯寰椎骨折机制、分型和稳定性进行文献复习的基础上,重点介绍寰椎骨折的治疗进展:对于稳定型寰椎骨折,通常采用保守治疗;对于不伴有横韧带断裂的不稳定型寰椎骨折,可依病情采取保守治疗、寰椎单节段复位固定术及寰枢、枕颈融合术;对于伴有横韧带断裂的不稳定型寰椎骨折,寰枢椎融合术或枕颈融合术是经典术式,寰椎单节段固定术的内固定效果亦受到关注,但是否可用于伴横韧带断裂的不稳定型寰椎骨折,目前仍未有令人信服的临床报道.