术中即时三维导航辅助寰枢椎经关节螺钉固定治疗寰枢椎不稳定  

Intraoperative three-dimensional fluoroscopy based navigation assisted C1,2 transarticular screw placement for the treatment of atlantoaxia instability

作　　者：王华栋[1] 何达[1] 刘波[1] 孙宇庆[1] 田伟[1] Wang Huadong;He Da;Liu Bo;Sun Yuqing;Tian Wei(Department of Spine Surgery,Beijing Jishuitan Hospital,Beijing 100035,China)

机构地区：[1]北京积水潭医院脊柱外科,100035

出　　处：《中华骨科杂志》2019年第21期1311-1319,共9页Chinese Journal of Orthopaedics

摘　　要：目的探讨术中即时三维导航辅助寰枢椎经关节螺钉固定治疗寰枢椎不稳定的置钉精确性及临床效果。方法回顾性分析2005年11月至2015年10月采用术中即时三维导航辅助下行后路寰枢椎经关节螺钉内固定治疗56例寰枢椎不稳定患者资料。男26例,女30例;年龄9~68岁,平均44.5岁;导致不稳的原因包括先天畸形44例,陈旧性齿突骨折脱位4例,自发性脱位7例,类风湿关节炎1例。所有患者术前行CT检查,并测量C2峡部宽度和高度。基于既往研究及评分系统,提出一个改良的评分系统来评价使用术中即时三维导航辅助置钉时置入寰枢椎经关节螺钉的难度。将寰枢椎经关节螺钉置钉难度分为三组:容易组(总分为0)、中等组(总分为1)和困难组(总分为2,3)。术后行CT检查,评价螺钉位置,分为3类,即Ⅰ类螺钉(理想位置)、Ⅱ类螺钉(合格位置)、Ⅲ类螺钉(不合格位置),判断螺钉置入精确性。采用视觉模拟评分(visual analogue scale,VAS)评价患者颈部疼痛情况,采用Nurick脊髓功能分级和Odom标准评价神经改善情况。结果C2峡部宽度:右侧(5.46±1.86)mm,左侧(5.38±1.36)mm;C2峡部高度:右侧(4.89±1.33)mm,左侧(4.97±1.17)mm。根据评分标准,容易组、中等组和困难组分别有78侧、11侧和23侧C2峡部(56例,共有112侧C2峡部)。56例患者共置入螺钉107枚,其中76枚(71.03%)为Ⅰ类螺钉,31枚(28.97%)为Ⅱ类螺钉,无Ⅲ类螺钉;其中5例患者因一侧C2峡部维度过于狭窄,仅置入单侧螺钉。容易组(55/23)、中等组(6/4)和困难组(15/4),Ⅰ、Ⅱ类螺钉比例比较差异无统计学意义(χ2=0.46,0.54,1.18;P=0.50,0.46,0.28)。术后56例患者均获得随访,随访时间6~120个月,平均44.7个月。末次随访时,Nurick脊髓功能分级,0级30例,1级25例,2级1例;根据Odom标准,37例(66.1%)为很好,15例(26.8%)为较好,4例(7.1%)为一般。患者颈部疼痛均有明显改善,VAS评分由术前(6.7±0.8)分改善至(1.2±0.4)分。Objective To evaluate the accuracy of transarticular screw fixation using intraoperative three-dimensional fluoroscopy-based navigation(ITFN)and to evaluate the clinical outcomes of this treatment method.Methodse Data of 56 patients(26 males and 30 females)with atlantoaxial instability who were treated by C1,2 transarticular screw fixation using ITFN from November 2005 to October 2015 were retrospectively analyzed.The mean age of the patients was 44.5 years(range,9-68 years).There were 44 cases with congenital malformation,4 with old odontoid fracture,7 with spontaneous dislocation,and 1 with rheumatoid arthritis.C2 isthmus width and height were measured on preoperatively obtained CT scans,and screw positioning was evaluated on postoperatively obtained CT scans,and classified into three types:ideal position(type I),acceptable position(type II)and unacceptable position(type III).A novel grading system is proposed based on previous study and grading system,and the difficulty of placing C1,2 transarticular screw using ITFN was classified into three types:easy(total score 0),median(total score 1)and hard(total score 2,3).Pain scores were assessed using the visual analogue scale.Myelopathy was assessed using the Nurick scale and Odom’s criteria.Results The isthmus width was 5.46±1.86 mm on the right side and 5.38±1.36 mm on the left side.The isthmus height was 4.89±1.33 mm on the right side and 4.97±1.17 mm on the left side.According to the grading system,78,11,and 23 of the sides were classified into easy,median and hard groups respectively.One hundred and seven transarticular screws were placed in 56 patients,and 71.03%of which were ideal screws,and 28.97%were acceptable screws.Five patients had unilateral screws placed.There was no significant difference in screw positioning among the three groups(χ2=0.46,0.54,1.18;P=0.50,0.46,0.28).The mean follow-up period was 44.7 months(range,6-120 months).At the latest follow-up,according to Nurick score,there are 30 patients scoring 0,25 patients scoring 1,and 1 patien

关 键 词：颈寰椎 枢椎 关节不稳定性 外科手术 计算机辅助 

分 类 号：R68[医药卫生—骨科学]