不可复性寰枢椎脱位的临床分型及术式选择

 目的 探讨不可复性寰枢椎脱位（寰枢椎脱位且其间存在骨性融合）的临床分型及其术式选择策略。方法 2002年11月至2013年12月,收治不可复性寰枢椎脱位患者 20例,男8例,女12例;年龄22~57岁,平均39岁;6例无手术史,14例有手术史（前路手术史1例、后路手术史11例、前后路联合手术史2例）,其中13例残留内固定物（1例残留寰枢椎前路钢板、12例残留寰枢椎后路钉棒）。根据骨性融合范围、位置分为广泛融合型和点状融合型。在气管插管全麻下施行手术,点状融合型采取软组织松解、骨性融合点解除、复位、固定和融合手术;广泛融合型采用直接减压而不进行复位和固定。术后1周、3、6、12个月及之后每年随访时均行X线、CT和MR检查,以观察寰枢椎间复位、内固定、植骨融合和脊髓减压情况。临床评价采用日本骨科协会（ Japanese Orthopaedic Association Scores,JOA）评分。结果20例患者中广泛融合型5例,点状融合型15例;自发性融合6例,医原性融合14例（3例为广泛融合型、11例为点状融合型）。5例广泛融合型患者经口前路切除寰椎前弓和齿突减压,术后MRI示脊髓压迫完全消除;15例点状融合型患者术后均获得复位。术中均未出现脊髓及椎动脉损伤。1例患者术后出现脑脊液漏,经清创、取出前路内固定,改行后路内固定后治愈。5例广泛融合型和14例点状融合型获得随访,随访时间6~72个月,平均38个月。JOA评分由术前平均11分恢复至末次随访时平均14分。5例广泛融合型患者虽未附加内固定,随访期间均未出现寰枢椎间失稳;14例点状融合型患者术后6个月寰枢椎侧块间植骨均融合。结论 点状融合型患者经彻底松解和解除骨性融合后可获得复位,广泛融合型患者通过减压仍可获得较好的疗效。

The clinical classification and surgical treatment choice of irreducible atlantoaxial dislocation

ObjectiveTo investigate the clinical classification and surgical options for bone-fused irreducible atlantoaxial dislocation. Methods From November 2002 to December 2013, 20 cases of irreducible atlantoaxial dislocation were treated, including 8 males and 12 females, aged 22 to 57 years (mean 39 years). There were 6 cases without operation history and 14 cases with operation history, including 1 cases of anterior operation, 11 cases of posterior operation, and anterior and 2 cases of posterior combined approach. In 14 patients with surgery history, 13 cases had internal fixation residual, including 1 case of anterior plate and 12 cases of posterior screw rods. Under general anesthesia, the extensive fusion type was decompressed directly without restoration and immobilization, while the point fusion type was performed using soft tissue release, bone-fused point release, restoration, immobilization and fusion. 1 week, 3, 6, 12 months postoperatively and the annual review of the X-ray, CT and MR were checked, in order to evaluate the reduction, internal fixation, bone graft fusion and decompression of the spinal cord. The JOA scores of preoperative, postoperative and outpatient follow-up review were recorded. ResultsIn all 20 patients, the extensive fusion type accounted for 5 cases, point fusion type 15 cases, while spontaneous fusion 6 cases, iatrogenic fusion 14 cases, including 3 cases of extensive fusion type and 11 cases of point fusion. In 5 cases of extensive fusion treated with anterior resection of anterior arch of atlas and the odontoid process decompression, postoperative MR showed that the spinal cord compression were completely eliminated, and reduction were achieved. The spinal cord and vertebral artery injury were not found. 1 case with cerebrospinal fluid leakage was cured after anterior internal fixation removal and posterior internal fixation. 5 cases of extensive fusion type and 14 cases of punctate fusion were followed up, ranged from 6 to 72 months (mean, 38 months). The JOA score was restored from preoperative average of 11 points to the last follow-up of 14 points. Even though no additional internal fixation was added, all 5 patients with extensive fusion showed no atlantoaxial intervertebral instability in follow-up period, and solid bony fusion of lateral atlantoaxial joint was obtained in 14 point fusion patients 6 months later. Conlusion The point fusion irreducible atlantoaxial dislocation can still get reduction after release and thoroughly removal of bony fusion point, while the extensive fusion irreducible atlantoaxial dislocation may still achieve good outcome by decompression.