上颈椎损伤的手术方式选择及其疗效分析  

The selection of surgery in upper cervical injuries

作　　者：马迅[1] 薛晨晖[2] 关晓明[1] 陈晨[1] 冯皓宇[1] 孙麟[1] 

机构地区：[1]山西医学科学院山西大医院骨科,太原030032 [2]山西医科大学

出　　处：《中华骨科杂志》2015年第5期556-564,共9页Chinese Journal of Orthopaedics

摘　　要：目的 探讨不同类型上颈椎损伤手术方式的选择及其临床疗效.方法 回顾性分析2011年11月至2014年6月手术治疗的25例各类型上颈椎损伤患者资料,男20例,女5例;年龄14～55岁,平均37.1岁.依患者临床表现、损伤类型结合影像学资料进行综合评估,制定个体化手术方案.术前颅环牵引后,7例行前路手术,18例行后路手术.采用美国脊髓损伤协会（American Spinal Injury Association,ASIA）脊髓损伤分级标准及功能独立性评价（Functional Independence Measurement,FIM）评分标准评价术后功能恢复情况;对比术前及术后随访的影像学资料评价骨折复位、骨愈合、植骨融合及内固定情况.采用配对秩和检验对患者术前及末次随访的FIM评分进行统计学分析.结果 所有患者均获得随访,随访时间6～35个月,平均18.2个月.15例术前有高位脊髓损伤表现,按ASIA脊髓损伤分级C级7例、D级8例;术后6个月C级2例、D级4例、E级9例,较术前平均提高1.1级;术后12个月,D级3例、E级11例,较术前平均提高1.2级.术前FIM评分平均76.5分,末次随访时平均87.5分,两者差异有统计学意义.术后X线片及CT示骨折复位良好,术后3～12个月均获得骨性融合.1例患者出现脑脊液漏,予头低脚高体位、补液等保守治疗,8d后引流液减少至30 ml以下,拔除引流管,加压包扎.末次随访未见内固定松动、脱出或断裂现象.结论 上颈椎损伤类型复杂,不同患者具有不同骨折、脱位与神经损伤特点,应根据具体情况综合评估制定个体化手术方案.熟练掌握上颈椎解剖学基础、生物力学特点,术中严格精确的进钉点、方向,选择合适直径的螺钉,掌握进钉深度,是上颈椎手术成功的关键.Objective To investigate the selection of surgery and clinical outcomes of upper cervical injuries.Methods 25 upper cervical injury patients were involved in this retrospective study from November 2011 to June 2014.Including 20 males and 5 females with mean age of 37.1 years old （range,14-55 years old）.Individual operation methods were based on the comprehensive evaluation of specific situations including the clinical manifestation,the type of the injuries and the imaging data.HaloVest distraction was applicated before operation.The surgery by anterior approach were performed for 7 patients and posterior approach were performed for 18 patients.Preoperative and postoperative American Spinal Injury Association （ASIA） grade and Functional Independence Measurement （FIM） score were studied to evaluate the nerve functional restoration.Imaging data before and after the operation were contrasted to evaluate the reduction of the fracture,the bone union,the fusion of the bone graft and the condition of the internal fixation.Wilcoxon Singed Rank Test was applied to compare the FIM score between pre-operation and last follow-up.Results 15 patients presented neurological function deficit because of cervical spinal cord compromise.All cases were followed up for 6-35 months （mean 18.2 months）,showing good clinical and radiological effects.Solid fusion was obtained in all patients among 3-12 months.The ASIA grade improved by an average of 1.1 （6 months after operation） and 1.2 （12 months after operation）.There was significant difference in FIM score between pre-operation and last follow-up.One patient got cerebrospinal fluid leakage.Conservative treatment was implemented with the Trendelenburg position,rehydration fluids and so on.Removal of drainage tube 8 days later when the drainage was less than 30 ml/24 h.No incision infection,cerebrospinal fluid leakage,migration or breakage of internal fixation was observed at the last follow-up.Conclusion The type of upper cervical injuries are complicated,the cha

关 键 词：颈寰椎 枢椎 脊柱骨折 寰枢关节 脱位 脊柱融合术 

分 类 号：R687.3[医药卫生—骨科学]