Restoration of fracture and dislocation of lower cervical spine: bone graft fusion and cervical stability

doi:10.3969/j.issn.2095-4344.2015.04.006

Abstract

Abstract:

BACKGROUND: The treatment of lower cervical spine fracture and dislocation is aimed to improve neurological functions of patients, the selection of surgical approach is conductive to the reduction and spinal decompression, also maintain strong fixation and bone graft fusion.

OBJECTIVE: To explore the restoration approach of lower cervical spine fracture and dislocation, and investigate the effect on bone graft fusion and cervical stability.

METHODS: A total of 126 patients with lower cervical spine fracture and dislocation were treated surgically from January 2009 to September 2013 in the First Affiliated Hospital of Xinjiang Medical University. Based on Frankel system, 7 cases were grade A, 48 were grade B, 54 were grade C, and 17 were grade D before surgery. Based on SLIC system, 15 cases were 4 points, 23 were 5 points, 25 were 6 points, 22 were 7 points, 18 were 8 points, 16 were 9 points, and 6 were 10 points. Surgical approaches were determined based on the SLIC system, with a combination of sub-axial injury classification system, the type of fracture, spinal cord compression, and cervical spine injury degree. Anterior surgery (single gap or cervical corpectomy and fusion, bone graft internal fixation) was performed on 91 cases; Posterior treatment (posterior decompression, reduction and internal fixation) was performed on 6 cases; Combined posterior and anterior approach was performed in 29 cases. The neurological function improvement was evaluated at follow-ups; fracture healing, bone graft fusion and cervical stability were determined with imaging findings.

RESULTS AND CONCLUSION: All the 126 patients underwent surgery safely without severe complications such as tracheal or esophageal injury. Four patients appeared spinal cord injury and cerebrospinal fluid leakage, which were healed after corresponsive intervention. All patients were immobilized in a hard collar for 3 months postoperatively and were followed up for 6-18 moths. At postoperative 6 months, 5 cases of grade A were not recovered, one case of grade B was not recovered, 1-2 degree of neurological function recovery was achieved in the remaining cases by Frankel system. X-ray finding showed the good recovery of cervical vertebrae sequence after operation. Fusion was achieved in all cases within 12 months (mean 8.5 months) except non-fusion in one case and delayed fusion in two cases. There was no pseudarthrosis or nonunion occurred. The interbody height, physiological curvature and cervical stability maintained well. The SLIC system, with a combination of sub-axial injury classification system, the type of fracture, spinal cord compression, and cervical spine injury degree should be considered before surgery. Reasonable selection of surgical approach can reconstruct spinal stability and achieve anatomical reduction and complete decompression, which is conducive to the recovery of neurological function.

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

全文链接：

Key words: Cervical Vertebrae, Fracture, Dislocation, Internal Fixators, Follow-Up Studies

CLC Number:

R318

Wang Jian-yuan, Deng Qiang, Sheng Wei-bin, Lu Yong-jiang. Restoration of fracture and dislocation of lower cervical spine: bone graft fusion and cervical stability[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(4): 522-530.

Figures/Tables 4

2.2 基线资料比较各组性别比、年龄等基线资料比较差异无显著性意义(P > 0.05)，具有可比性。 2.3 随访结果 126例患者全部手术治疗。伤后最早7 h实施手术，最晚15 d；手术时间75-145 min，术中出血150-600 mL，术后25例患者诉吞咽困难，1例出现声音嘶哑，4例术中发现硬脊髓破损，术后发生脑脊液漏，术后经过抗炎换药换药治疗半月后，切口愈合。后路手术有1例出现眼部疼痛、流泪、视物不清，给予局部应用氯霉素及玻璃酸钠滴眼液3 d后，症状缓解。术后12个月内全部得到随访。18个月后20例失访。颈椎椎间高度及侧方移位纠正情况见表1。3组组内术前和术后比较差异均有显著性意义(P < 0.05)，组间比较前路组和后路组差异无显著性意义，前后联合组与前路、前后联合组与后路比较差异均有显著性意义(P < 0.05)，术后损伤节段椎间高度和水平移位判断骨折脱位均得到满意复位，但是联合入路的术后组改善程度更高，内固定稳定性更好。术后随访6-18个月，复查X射线片及CT，1例术后半年内出现了内固定的松动，植骨块的移位，二次行前后联合手术。2例1年后植骨未完全融合，术后2年植骨块界面模糊。其余患者内固定牢靠，无松动及内固定断裂，椎体间或关节突间融合或部分融合。术后大部分患者神经功能不同程度恢复，按照Frankel分级标准，除5例A级，1例B级无恢复外，其余患者均恢复1至2级，平均恢复1.2级，各组神经功能分级上升情况见表2-4，组间比较差异无显著性意义。手术时间及术中出血量观察见表5。前路平均手术时间及出血量均低于后路及联合入路组，其次是后路，前后联合入路手术时间及出血量最大，说明前路手术具有时间短，出血少，损伤小的特点。前后联合手术创伤大，出血多，时间长，手术及麻醉风险较大。 2.4 不良事件 126例患者中，并发切口感染2例，经换药治疗1周后愈合；5例出现肺部感染，经抗炎化痰治疗2周后康复。 2.5 典型病例典型病例1：患者男性，35岁，车祸伤后颈部疼痛伴四肢麻木、无力6 h来院，入院后常规行影像学检查，并对损伤进行评估。Frankel评分A级(四肢瘫)，SLIC评分6分。选择前路复位植骨融合治疗，术后复查X射线片提示颈椎序列恢复良好，内固定牢靠(图2)。典型病例2：患者男性，55岁，车祸外伤后颈部疼痛伴四肢麻木、无力4 d来院。入院后查三维CT提示骨折脱位，骨折累及三柱，核磁共振提示椎间损伤。Frankel评分C级(四肢不全瘫)，SLIC评分9分。C6椎体明显脱位，C5-6椎间盘损伤。选择前后联合入路，术后1个月拍片复查，颈椎序列恢复正常，内固定牢靠，植骨有融合迹象。术后半年复查，植骨融合。术后1年复查，植骨骨性融合，CT见骨小梁通过(图3)。典型病例3：患者男性，36岁，摔伤致颈部疼痛伴四肢麻木、无力1 d来院。Frankel评分C级，SLIC评分6分。C5-6骨折脱位，伴有多节段颈椎管狭窄，脊髓压迫主要来自后方。行后路减压植骨内固定治疗(图4)。"

References

[1] Gomes S, Rudkin S, Tsai F, et al. Bilateral cervical spinefacet fracture-dislocation. West J Emerg Med. 2009;10(1):19.
[2] Ebraheim NA,Patil V,Liu J,et al. Mor-phometric analyses of the cervicals Uperior facets and implications forfacet dislocation. Int Orthop. 2008;32(1):97-101.
[3] Mirza SK,Krengel WF,Chapman JR, et al.Early versus delayed surgery foracute cervical spinalCord injury. Clin Orthop Relat Res. 1999;(359):104-114.
[4] 王岩松,姚猛,刘庆鹏,等.颈椎颈髓损伤后外科治疗时间对预后的影响[J].中国脊柱脊髓杂志,2004,14 (11):659-662.
[5] Eismont FJ, Arena MJ, Green BA. Extrusion of an interver-tebral disc associated with traumatic subluxation or disloca-tion of cervical facets. J Bone Joint Surg Am. 1991; 73(10):1555-1560.
[6] 何仿,田纪伟,林昊,等.下颈椎骨折脱位手术方式的初步探讨[J]. 中国矫形外科杂志,2009,17(20):1524-1526.
[7] Allen BL Jr, Ferguson RL, Lehmann T. Amechanistic classification of closed,indirect fractures and dislocations of the lower cervical spine. Spine. 1982;7:1-27.
[8] Samandouras G,Shafafy M,Hamlyn PJ.A new anterior cervical instrumentation system combining an intradiscal cage with an integrated plate: an early technical report. Spine. 2001; 26(10):1188-1192.
[9] Park HK, Jho HD. The management of vertebral artery injury in anterior cervical spine operation: a systematic review of published cases. Eur Spine. 2012;21(12):2475-2485.
[10] 赵筑川,曹永飞,彭智,等.颈椎前路钛网钢板内固定及自体髂骨植骨在不同颈椎节段中的生物力学研究[J].中国修复重建外科杂志,2006,20(11):1076-1079.
[11] Eismont FJ,Arena MJ.Green BA.Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets.J Bone Joint Surg Am. 1991;73(10): 1555-1560.
[12] Payer M. Surgical management of cervical fractur esinanky losing spon-dy litisusing a combined posterior -anterior approach. J Clin Neurosc. 2006;1:73-77.
[13] Kwon BK, Beiner J, Grauer JN, et al. Anterior / posterior operativer educ -tion of cervical spined islocation : techniques and literatur ereview. Curr Opin Orthop. 2003;14:193-199.
[14] ElMasry MA, Badawy WS , Chan D. Combined anterior and posterior stabilisation fortreating an unstable cervical spine fra cture in apatient with long standing anky losing spondylitis. Injury. 2004 ;10:1064-1067.
[15] 王新伟,袁文,陈德玉,等.复杂性下颈椎损伤的手术方案选择[J].中国骨与关节损伤杂志, 2005, 20(9):577-579.
[16] 赵浩宁,陈军,王自立,等.前后联合入路手术治疗下颈椎骨折脱位[J].中华创伤骨科杂志, 2007, 9(3): 290.
[17] Song KJ, Lee KB. Posterior reduction / fusion foll owed by anteriord ecom-pression / fusion of unreduced bilateral facet fracture-dislocation in the lower cervical trauma . Neurosurg Quart. 2008; 2:109-114.
[18] Mirza SK,Krengel WF,Chapman JR,et al.Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop. 1999; 359:104.
[19] Black P.Cerebrospinal fluid leaks following surgery.Use of fat grafts for prevention and repair.Technical note .J Nurasurg. 2002;96:250-252.
[20] Johnson MG,Fisher CG,Boyd M ,et al.The rad iograph ic failure of single segm ent anterior cervical plate fixation in trauma tic cervical flexion distraction in juries.Spine. 2004; 29(1):2815-2820.
[21] Lifeso RM,Colucci MA.Anterior fusion for rotationally unstable cervical spine fracture. Spine. 2000;25(2):2028-2034.
[22] Holdsworth F. Fractures, dislocations, and fracture- dislocations of the spine.J Bone Joint Surg Am. 1970;52: 1534-1551.
[23] Denis F. The three column spine and its signification in the classification of thoracolumbar injuries. 1983;8(8) :817-831.
[24] Harris JH, Edeiken-Monroe B, Kopansiky DR. A practical classification of acute cervical spine injuries. Orthop Clin North Am. 1986;1:15-30.
[25] 戴力扬,李海.下颈椎损伤的诊断与治疗[J].中华外科杂志,2007, 45(6):396-400.
[26] 于圣会,盛伟斌,陈浩贤,等. SLIC评分系统在下颈椎损伤治疗中的应用[J].中华创伤骨科杂志,2010,12(5):425-428.
[27] 于圣会,池雷霆,任永安,等.下颈椎损伤分型评分系统的可信度及可重复性研究[J].中华创伤骨科杂志,2012, 14(3): 193-197.
[28] 易龙,孙天胜,张志成,等. SLIC评分系统在无骨折脱位型颈脊髓损伤治疗中的应用[J]中国矫形外科杂志，2014,22(4):304-307
[29] Felsberg GJ, Tien RD, Osumi AK, et al. Utility of MR imaging in pediatric spinal cord injury. Pediatr Radiol. 1995;25(2): 131-135.
[30] Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children.Neurosurgery. 1994;35(3):406-414.
[31] Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylpredniso lone for 24 or 48 hours or tirilaza dmesy late for 48 hours in the treatment of acute spinal cord injury . JAMA. 1997;277(20):1597-1604.
[32] 钟招明,江建明,王吉兴,等.成人无骨折脱位型颈脊髓损伤的手术治疗[J].创伤外科杂志,2012,14(1):19-23.
[33] 孙天胜,张志成,任永安,等.下颈椎损伤分型评分系统的评估及临床应用[J].中华创伤杂志,2009,25(5):403-407.
[34] Ito S, Ivancic PC, Pearson AM, et al. Cervical intervertebral disc injury during simulated frontal impact．Eur Spine J. 2005;14(4):356-365.