中国组织工程研究 ›› 2023, Vol. 27 ›› Issue (4): 594-599.doi: 10.12307/2022.986

• 骨科植入物 orthopedic implant • 上一篇    下一篇

后路单节段椎弓根钉内固定治疗不稳定寰椎骨折

鲍  凯,宋文慧,刘昌文,梁凯恒,王佳佳   

  1. 山西医科大学第二医院骨科,山西省太原市   030001
  • 收稿日期:2021-12-14 接受日期:2022-01-18 出版日期:2023-02-08 发布日期:2022-06-23
  • 通讯作者: 宋文慧,博士,主任医师,山西医科大学第二医院骨科,山西省太原市 030001
  • 作者简介:鲍凯,男,1994年生,山西医科大学在读硕士,主要从事脊柱外科方面的研究。

Posterior single-segment pedicle screw fixation for unstable atlas fractures

Bao Kai, Song Wenhui, Liu Changwen, Liang Kaiheng, Wang Jiajia   

  1. Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
  • Received:2021-12-14 Accepted:2022-01-18 Online:2023-02-08 Published:2022-06-23
  • Contact: Song Wenhui, MD, Chief physician, Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
  • About author:Bao Kai, Master candidate, Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China

摘要:

文题释义:
单节段寰椎固定:指仅固定寰椎,尽量保留枕-寰-枢关节功能,同时达到固定骨折的目的,可有效避免因融合导致的寰枢关节活动度丧失的临床弊端,能很大程度上减少卧床及非手术治疗时间。
不稳定寰椎骨折:横韧带是否完整是评价寰椎骨折稳定性的主要依据,一般认为伴有横韧带断裂的寰椎骨折被视为不稳定寰椎骨折,但枕寰枢复合体中的骨性结构、关节囊以及横向、纵向韧带也在维持寰枢椎稳定性中发挥了不可或缺的作用。

背景:近几十年来不稳定寰椎骨折的治疗一直存有争议,手术方式的选择也已从C1-C2或C0-C2融合发展到现在尽可能保留运动节段,然而,无论是经口入路还是后路入路,复位效果及术后并发症问题仍待进一步研究。
目的:观察后路单节段椎弓根钉内固定治疗不稳定寰椎骨折的疗效。
方法:回顾性分析2017年7月至2020年9月山西医科大学第二医院收治的14例不稳定寰椎骨折患者的临床资料,男10例,女4例,平均年龄51.8岁,所有患者均采用单节段椎弓根螺钉-棒系统进行后路切开复位内固定治疗。查阅病历和术前、术后X射线片,并通过术前和术后CT扫描,根据Spence标准即张口位X射线片寰椎两侧块移位之和≥6.9 mm判定为不稳定寰椎骨折,同时明确骨折类型,并评估骨折复位情况,末次随访时行颈椎过伸过屈位X射线片来评估寰枢关节是否稳定。
结果与结论:①14例患者均成功完成手术,平均随访(21.0±6.4)个月,术后复查颈椎X射线片及CT均可见内固定位置良好,复位良好;所有患者均未出现神经功能受损、椎动脉损伤、伤口感染等与手术相关的并发症;②目测类比评分由术前的(6.5±1.3)分降至术后的(1.9±0.8)分,差异有显著性意义(P < 0.05);颈部功能障碍指数由术前的74.4±4.5降至末次随访时的12.1±4.3,差异有显著性意义(P < 0.05);③末次随访时颈部屈伸70°-88°(79.7±6.0)°;颈部左右侧屈76°-85°(82.1±2.8)°;左右旋转129°-155°(143.5±8.4),所有患者在末次随访时颈椎活动范围均恢复良好,末次随访时拍摄颈椎过伸过屈位X射线片未见寰枢关节存在任何不稳定的影响学表现;术后4例患者主诉颈部僵硬伴活动受限,在规范康复及指导治疗下均基本恢复正常水平;④提示后路单节段椎弓根钉内固定治疗不稳定寰椎骨折手术时间短、出血量少、并发症少,复位效果也较好,而且更主要的是患者颈部屈伸及旋转功能基本不受限;对于C1骨折,横韧带断裂可能不是切开复位内固定的禁忌证,但C1-C2不稳定的长期影响仍有待进一步研究。

https://orcid.org/0000-0003-3291-6091 (鲍凯)

中国组织工程研究杂志出版内容重点:人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程

关键词: 寰椎骨折, 颈后路, 单节段, 内固定, 椎弓根钉, 骨折复位

Abstract: BACKGROUND: In recent decades, the treatment of unstable atlantogenic fractures has been controversial, and the choice of surgical methods has evolved from C1-C2 or C0-C2 fusion to the present situation of preserving motor segments as much as possible. However, the reduction effect and postoperative complications of both oral and posterior approaches remain to be improved.
OBJECTIVE: To observe the effect of posterior single-segment pedicle screw fixation on unstable atlas fractures. 
METHODS: Clinical data of 14 patients with unstable atlas fractures admitted from July 2017 to September 2020 in Second Hospital of Shanxi Medical University were retrospectively analyzed. There were 10 males and 4 females, with an average age of 51.8 years. All patients underwent posterior open reduction and internal fixation using a single-segment pedicle screw-rod system. Medical records and preoperative and postoperative radiographs were reviewed, and preoperative and postoperative CT scans were used to determine fracture types and assess fracture reduction. According to Spence's standard, the sum of displacement on both sides of the atlas in the mouth-opening X-ray film ≥6.9 mm was judged as unstable atlas fractures. At the last follow-up, cervical hyperextension and hyperflexion X-ray films were used to assess the stability of the atlantoaxial joint.
RESULTS AND CONCLUSION: (1) All 14 patients were successfully operated. The mean follow-up duration was (21.0±6.4) months. Postoperative cervical X-ray and CT examination showed that the internal fixation position was good and the reduction was good. None of the patients had neurological impairment, vertebral artery injury, wound infection or other surgery-related complications. (2) Visual analogue scale score significantly decreased from (6.5±1.3) before operation to (1.9±0.8) after operation (P < 0.05). Neck Disabilitv Index score significantly decreased from (74.4±4.5) before surgery to (12.1±4.3) at the last follow-up (P < 0.05). (3) At the last follow-up, cervical flexion and extension ranged from 70° to 88° (79.7±6.0)°. Left and right cervical flexion ranged from 76° to 85° (82.1±2.8)°. Left-right rotation ranged from 129° to 155° (143.5±8.4). Cervical range of motion was well recovered in all patients at the last follow-up. X-ray films of cervical hyperextension and flexion at the last follow-up did not show any influence of atlantoaxial joint instability. After surgery, four patients complained of neck stiffness with limited movement, which basically returned to a normal level under standardized rehabilitation and guided treatment. (4) It is concluded that posterior single-segment pedicle screw internal fixation for unstable atlas fractures has short operation time, less blood loss, fewer complications, and better reduction effect. More importantly, the patient’s neck flexion, extension and rotation functions are basically not limited. For C1 fractures, transverse ligament rupture may not be a contraindication for open reduction and internal fixation, but the long-term effects of C1-C2 instability remain to be investigated. 

Key words: atlas fraction, cervical posterior, single vertebral segment, internal fixation, pedicle screw, fracture reduction

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