"三明治型"寰枢椎脱位的临床特点及其临床疗效  

The clinical characteristics and treatment of"sandwich"atlantoaxial dislocation

作　　者：田英轮 许南方 陈金国 闫明[1] 洪甘霖 侯翔宇 李危石[1] 王圣林[1] Tian Yinglun;Xu Nanfang;Chen Jinguo;Yan Ming;Hong Ganlin;Hou Xiangyu;Li Weishi;Wang Shenglin(Department of Orthopaedics,Peking University Third Hospital,Beijing 100191,China;Department of Minimal Invasive Spine Surgery,the first Hospital of Putian,Putian 351100,China)

机构地区：[1]北京大学第三医院骨科,北京100191 [2]莆田市第一医院微创脊柱外科,莆田351100

出　　处：《中华骨科杂志》2023年第7期422-429,共8页Chinese Journal of Orthopaedics

基　　金：国家自然科学基金面上项目(82172377)。

摘　　要：目的探讨"三明治型"寰枢椎脱位的临床特点、手术方法、手术疗效及预后的特殊性。方法回顾性分析2008年至2018年于北京大学第三医院手术治疗的160例"三明治型"寰枢椎脱位患者的临床及影像学资料,男80例、女80例,年龄(35.5±14.6)岁(范围5~77岁)。重点观察指标包括发病年龄、临床表现、合并畸形、手术入路选择、后路固定节段、术后神经功能恢复情况进行总结,影像学指标包括寰齿间距、齿突超Chamberlain线距离、延髓脊髓角。结果"三明治型"寰枢椎脱位的症状包括四肢无力、麻木和笨拙(67.5%,108/160),步态不稳(30.0%,48/160)和眩晕(20.0%,32/160)。其中130例(81.3%,130/160)合并脊髓病,颈椎日本骨科协会(Japanese Orthopaedic Association,JOA)评分为(13.5±2.5)分(范围4~16分);20例(12.5%)出现颅神经病变。影像学检查显示延脊髓压迫130例(81.3%),脊髓空洞症37例(23.1%),Chiari畸形30例(18.8%)。90例患者接受CTA检查,结果显示55例患者(61.0%)存在椎动脉畸形,5例患者(6.0%)存在颈内动脉内聚迂曲。术式包括后路枕颈融合术(可复位脱位,145例)、前路经口咽松解联合后路融合(不可复位脱位,15例)。160例中57例(35.6%)采用备用术式,即不对称的组合式固定。随访时间为(50.5±22.4)个月(范围24~120个月)。152例患者(95.0%)获得坚强骨性融合;6例患者(3.8%)术后影像学未见明显骨性融合,但动力位X线片未见明显寰枢椎不稳;2例患者(1.2%)出现内固定松动,脱位复发。脊髓病患者末次随访时JOA评分为(15.1±1.8)分(范围5~17分),改善率为42.9%±33.3%。术后9例(5.6%)患者出现并发症:包括4例脱位复发症状加重、2例螺钉松动、2例吞咽困难和1例切口感染。结论"三明治型"寰枢椎脱位是寰枢椎脱位的一个亚型,具有特殊的临床特征,即发病年龄小,合并脊髓病比例高、病情程度重、预后较差;常合并严重的骨畸形和血管畸形,术中常需使用组合Objective To evaluate the specialty of the clinical features,treatment procedure,clinical outcome,and prognosis in the patients with"sandwich"atlantoaxial dislocation(AAD).Methods From 2008 to 2018,160 cases with"sandwich"AAD were retrospectively selected from the case series of AAD in Peking University Third Hospital.The case series had 80 males and 80 females.The mean age at the initial visit was 35.5±14.6 years(range,5-77).The clinical courses,treatment methodology and prognosis were reviewed.And the surgical approach,posterior fixation segment and the recovery of neurological function were mainly summarized.The atlantodental interval(ADI),the distance by which the odontoid exceeded the Chamberlain line and the cervical-medullary angle were analyzed.Results The most common symptoms included weakness or numbness of the limbs(67.5%,108/160),unstable gait(30%,48/160)and vertigo(20%,32/160).Among all,130 cases(81.3%,130/160)had myelopathy,with the Japanese Orthopaedic Association(JOA)scores from 4 to 16(mean JOA scores 13.5±2.5).Cranial neuropathy was involved in 20 cases(12.5%).Radiological findings showed brainstem and/or cervical-medullar in 130 cases(81.3%),syringomyelia in 37 cases(23.1%)and Chiari malformation in 30 cases(18.8%).Computed tomography angiography(CTA)was performed in 90 cases,which showed vertebral artery anomalies in 55 cases(61.0%)and excessive medialized internal carotid artery in 5 cases(5.6%).All cases had no spinal cord or vertebral artery injury.The surgery included posterior occipito-cervical fusion(reducible dislocation,145 cases),and transoral release followed by posterior fusion(irreducible dislocation,15 cases).Fifty-seven cases were treated using alternative fixation technique.The average follow-up time was 50.5±22.4 months(range,24 to 120 months).All of 152 cases(95.0%)achieved solid atlantoaxial fusion;there was no obvious osseous fusion formation on postoperative images in 6 cases(3.8%),but no atlantoaxial instability was found on dynamic radiographs;screw loosening happened

关 键 词：颈寰椎 枢椎 颈椎 脱位 脊柱融合术 治疗结果 

分 类 号：R687.3[医药卫生—骨科学]