显微镜辅助下寰枢关节后路钉棒固定融合术——改良Goel 术式的临床应用

目的 探讨显微镜辅助下实施寰枢关节后路钉棒固定融合术(改良Goel术式)的可行性及技术操作要点。方法 回顾性分析2014年12月—2017年6月陆军军医大学第三附属医院脊柱外科行上颈椎手术治疗23例患者的临床资料,其中男16例、女7例,年龄18～71(35.1±16.9)岁;陈旧性齿突骨折不愈合所致的寰枢关节不稳定13例,新鲜齿突骨折合并寰枢关节后脱位、不完全脊髓损伤4例,新鲜齿突骨折合并寰椎枕骨化的寰枢关节可复性脱位6例。患者均接受双人双目手术显微镜辅助下寰枢关节后路钉棒固定融合术。术中在2～20倍显微镜下精细解剖寰枢关节后方的神经血管丛,显露并直视寰椎侧块、枢椎峡部全长、寰枢侧块关节后方,并以其为解剖标志直视下确定进钉点、建立钉道,然后植入寰椎侧块螺钉与枢椎峡部螺钉。观察手术时间、手术出血量、并发症以及螺钉位置和术后6个月骨性融合情况,比较术前、术后3个月的寰枢前间隙(AADI)、日本骨科协会(JOA)评分。结果 23例手术顺利实施,无严重并发症发生,手术时间(2.8±0.8)h,出血量(80.4±17.8)mL。术后第2天复查CT示枢椎峡部螺钉均位于骨内,位置满意。术后3个月AADI(屈曲位)以及JOA评分分别为(2.5±0.8) mm和(11.8±1.8)分,较术前的(8.8±2.6) mm和(9.2±1.5)分均有明显改善,差异均有统计学意义(t=12.352、12.058, P值均＜0.01)。随访6个月CT示植骨融合良好。未见螺钉松动、内固定失效。结论 术中使用显微镜辅助放大与照明,实施改良Goel术式比裸眼下施术具有更好的可行性;通过对后方神经血管丛的精细解剖,使相关解剖标志可被直视,从而提高了该手术安全性与规范性。

The clinical application of microscope-assisted atlantoaxial arthrodesis with screw-rod system via posterior approach: modified Goel's procedure

Objective To explore the feasibility and operation points of microscope-assisted Atlantoaxial arthrodesis with screw-rod system via posterior approach (modified Goel's procedure). Methods Clinical data of twenty-three patients who underwent atlanto-axial fusion at the Department of Spine Surgery of the Third Affiliated Hospital of Army Medical University from December 2014 to June 2017 were analyzed retrospectively. There were 16 males and 7 females, aged from 18 to 71 (35.1±16.9) years old. In all the cases, there were 13 patients of atlantoaxial joint instability due to non-fusion of old odontoid fracture, 4 patients of fresh odontoid fracture combined with posterior dislocation of atlantoaxial joint, 4 patients of incomplete spinal cord injury, and 6 patients of fresh reversible odontoid fracture combined with occipitalization. All patients underwent binocular surgical microscope-assisted posterior axillary-articular screw fixation and fusion. During the operation, the neurovascular plexus covering posterior aspect of atlantoaxial joint was cautiously dissected under the microscope (2-20 times). Lateral masses of the atlas, the isthmus of the atlas, and the posterior aspect of the atlantoaxial joints were exposed and visualized directly. The insertion points of C₁ lateral mass screw and whole upper aspect of C₂ isthmus were visualized directly, which provided reliable anatomical landmarks for insertion. The patient's operative time, surgical bleeding, operative complications, position of screw and osseous fusion at 6 months after operation were observed. To compared the anterior atlantodental interval(AADI) and Japanese Orthopaedic Association(JOA) score between the preoperation and 3 months after operation. Results The surgery was performed successfully and had no complications. The operation duration was (2.8±0.8)h and the bleeding volume was (80.4±17.8)mL. CT reexamination showed that the position of screws was satisfactory at the second days after operation. Three months after the operation, the AADI and JOA scores were(2.5±0.8)mm, (11.8±1.8) scores. Compared with preoperative(8.8±2.6)mm and (9.2±1.5) scores, both were significantly improved(t=12.352, 12.058, all P values＜0.05). All patients had bone graft fusion in 6 months. There were no loose screws or failed internal fixation. Conclusions With the illumination and magnification of microscope in operation, the implementation of Goel’s procedure is more feasible than that with naked eyes. By meticulous dissection of the neurovascular tissue which covering the posterior aspect of atlantoaxial joint, the relevant anatomic landmarks can be visualized directly. This processing improves the safety and standardization of the operation.