后路多种内固定技术联合应用治疗寰枢椎不稳

 目的探讨后路多种内固定技术联合应用、个体化治疗寰枢椎不稳的适应证、安全性及有效性。方法回顾性分析2010年6月至2013年6月联合应用多种后路内固定技术治疗寰枢椎不稳19例患者的病历资料, 男7例,女12例;年龄15~57岁,平均（40±13）岁。19例患者均有不同程度的枕颈部疼痛及颈椎活动受限,5例（26%）颈痛是唯一症状;另14例（74%）伴有脊髓压迫症状和体征,表现为不同程度的肢体感觉、运动障碍和反射亢进。19例中8例（42%）寰齿间距>3 mm,为3~10 mm,平均（6.4±3.0） mm。11例（58%）寰椎爆裂骨折侧块分离距离7~9mm,平均（7.7±0.9）mm。采用颈椎CT评估双侧枢椎椎动脉上方侧弓的高度,其中4例（21%）单侧< 4 mm。采用寰椎侧块螺钉、寰椎椎板钩、枢椎椎弓根螺钉、椎板螺钉或寰枢椎经关节螺钉等多种后路内固定技术联合应用行寰枢椎融合术。术前、术后3个月及末次随访时19例患者颈部疼痛采用视觉模拟评分（visual analogue scale, VAS）评估,14例有颈脊髓损伤症状患者采用日本骨科学会（Japanese orthopedic association,JOA）评分并计算改善率评价患者术后改善情况。通过X线及CT评价内固定位置及植骨融合情况。结果19例均获得随访,随访时间12~24个月,平均（15.3±4.2）个月。术后所有患者枕颈部疼痛均明显改善,VAS评分术前平均为（4.5±1.54）分,术后3个月为（1.2±0.97）分,末次随访为（0.63±0.76）分,差异有统计学意义。JOA评分术前平均为（12.2±1.9）分,术后3个月为（14.5±1.8）分,末次随访为（16.1±1.2）分,JOA改善率平均为87.3%,差异有统计学意义。所有患者术后6个月CT检查均显示植骨融合良好。随访期间未发现内固定松动、断裂及新发寰枢椎不稳。结论术前对寰枢椎的解剖情况及损伤类型进行全面、准确地评估,根据各种内固定技术的应用指征及术者技术特点,选择个体化的多种后路内固定技术联合应用治疗寰枢椎不稳安全且有效。

The treatment of atlantoaxial instability with posterior hybrid fixation techniques

ObjectiveTo evaluate the indications, safety and clinical outcomes of hybrid internal fixation techniques in the treatment of atlantoaxial instability. MethodsFrom June 2010 to June 2013, a retrospective study was done on 19 patients (7 males and 12 females, with age range of 15 to 57 years, mean 40±13 years) with atlantoaxial instability who had undergone the treatments of atlantoaxial fusion operations with hybrid fixation techniques. All of 19 patients suffered from neck pain or limitations of cervical motion. Among them, 5 cases presented only the neck pain while 14 cases combined with spinal cord compression systems, including different degrees of sensory and motor disorders and increased reflex. The atlantoodontoid interval was larger than 3 mm in 8/19 cases with an average of 6.4±3.0 mm (3-10 mm). The distance from lateral mass of atlas burst fracture was 7-9 mm (mean, 7.7±0.9). CT scan was used to evaluate the height of the lateral arch above bilateral axial vertebral arteries, with 4 cases < 4 mm unilaterally. The atlantoaxial fusion was achieved using hybrid fixation techniques, including transarticular screw, C₁ lateral mass screw, C₂ pedicle screw, C₂ translaminar screw and C₁ laminar hook. The neck pain that all patients suffered was measured by Visual analogue scale (VAS), and the degree of cervical spinal cord injury of 14 patients who had neural symptoms and dysfunction was evaluated by Japanese Orthopedic Association score（JOA）and the rate of the improved JOA score (RIS). Cervical X-ray and CT scan after operation were used to observe the internal fixations and bone fusion during the follow-up. ResultsAll the 19 patients got 12 to 24 months’ follow-up, 15.3±4.2 months at average. In 3 months follow-up time, all patients got relief from the neck pain, the VAS of neck pain decreased to 1.2±0.97 after 3 months and to 0.63±0.76 at last follow-up postoperatively, comparing to 4.5±1.54 preoperatively. The JOA score increased to 14.5±1.8 after 3 months and to 16.1±1.2 postoperatively, comparing to 12.2±1.9 preoperatively. In 12 to 24 months （15.3±4.2 on average） follow-up there was no failure of internal fixations, pseudarthrosis or instability. No spinal cord injury or vascular complications occurred. ConclusionThe evaluation about the anatomical structure of atlantoaxial region by radiographic examinations is essential to the appropriate options of internal fixations. The individual surgical procedures using hybrid fixation techniques are safe and effective.