寰枢椎脱位TOI外科分型临床应用的前瞻性多中心研究

 目的 探讨TOI外科分型诊疗流程图对寰枢椎脱位治疗方案、固定方式及融合范围选择的指导价值及其临床适用性。方法 根据病因、症状、体征、动力位X线片、三维CT重建和牵引复位情况,并充分考虑手术松解和创伤因素制订TOI分型诊疗流程图：牵引复位型（traction reduction type,T型）,分为T1、T2亚型;手术复位型（operation reduction type,O型）;不可复位型（irreducible type,Ⅰ型）。T1型采用牵引、支具固定,或临时内固定等寰枢椎非融合治疗;T2型采用牵引复位后寰枢椎或枕颈固定融合;O型采用前路松解,联合后路复位固定融合;Ⅰ型采用后路或前路减压,原位固定融合。固定方式取决于患者上颈椎解剖特点和稳定性。2007年7月至2014年6月,9家医院收治1 218例寰枢椎脱位患者行多中心前瞻性研究,依Symon和Lavender临床功能评定标准、日本骨科协会（ Japanese Orthopaedic Association Scores,JOA）评分和影像学测量寰齿前间隙（atlas-dens interval,ADI）、脊髓有效空间（space available for the cord,SAC）评定疗效。结果1 218例患者中T1型234例（19.2%）、T2型699例（57.4%）、O型239例（19.6%）、I型46例（3.8%）。平均随访（35.5±18.9）个月。术后脊髓功能改善2级572例（47.0％）,改善1级512例（42.0％）,无变化134例(11.0％),有效率89.0%。术前JOA平均（9.80±1.90）分,术后（14.60±2.30）分,改善率为66.7%。术前ADI平均（8.34±1.96） mm,术后（4.18±5.97） mm。术前SAC（10.24±6.80） mm,术后（14.53±4.87）mm。影像学检查示枕颈区植骨已融合,鹅颈畸形已矫正,脊髓前和（或）后方减压良好。结论 寰枢椎脱位TOI外科分型对选择治疗方案、固定方式及融合范围有较高的临床指导价值。

Clinical observation of atlantoaxial dislocation treated using TOI classification

ObjectiveTo investigate the feasibility of TOI classification diagnostic flow chart in treating atlantoaxial dislocation(atlantoaxial dislocation, AAD). Methods According to pathologies, symptoms, signs, flexion-extension radiograph, 3D CT and responses of traction reduction, especially operative release and trauma which were considered, AAD was classified into 3 types and 4 subtypes with a TOI classification diagnostic flow chart. (1) Traction reduction type(type T) with two subtypes as T1 and T2, (2) Operation type(type O), (3)Irreducible type(type I). T1 were treated by traction, orthosis or temporary fixation without fusion in C_1-2 and T2 were fused in C_1-2 after traction reduction. Type O underwent single-stage anterior release and sequential posterior reduction and fusion, and operations were performed with in-stu decompression and fusion in patients with type I. The technique of internal fixation was selected based on biomechanical stability and upper cervical structure of patients. From July 2007 to June 2014, 1218 cases with AAD from 9 hospital were treated prospectively. Symon and Lavender clinical standard, JOA score and SAC imaging index were used to evaluate the therapeutic effect. ResultsAmong 1218 cases, which were followed up from 6 to 75 months with an average of 35.5±18.9 months, type T1 had 234 cases, type T2 had 699 cases, type O had 239 cases and type I had 46 cases; According to Symon and Lavender clinical standard, 572(47.0%) cases improved by two grades, 512(42.0%) cases improved by one grade, 134 cases(11.0%) had no improvement with effective rate as 89.0%. JOA score was 9.8±1.9 preoperatively and 14.6±2.3 postoperatively with effective rate as 66.7%. ADI was 8.34±1.96 mm preoperatively and 4.18±5.97 mm postoperatively, and SAC was 10.24±6.80 mm preoperatively and 14.53±4.87 mm postoperatively; Bony fusions were shown in occipitocervical area, swan-neck malformation were corrected and satisfactory decompressions were achieved in anterior/posterior side of the spinal cord seen in CT and MRI. Conclusion TOI clinical classification of AAD is definitive with clear concept and prove its value in guiding therapies, internal fixations and range of fusion when treating AAD.