寰枢椎脱位手术后翻修的原因及策略
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摘要
目的 :分析寰枢椎脱位手术后翻修的原因,探讨其策略。方法 :回顾性分析15例寰枢椎脱位手术后翻修患者,男11例,女4例,翻修时年龄15~68岁(46.60±14.95岁);两次手术相隔2~120个月(28.73±38.59个月)。根据影像资料及手术探查情况分析翻修原因。翻修手术中均行8~10kg颅骨牵引及后方松解;后方结构完整患者行后路固定,根据松解后复位情况决定是否选择前路松解术;1例后路减压患者行前路松解复位固定术。导航模板辅助置入寰枢椎螺钉;自体髂骨松质骨颗粒植骨。随访观察寰枢椎复位、螺钉位置、植骨融合及手术疗效。结果:翻修原因,减压或复位不足10例,内固定失败3例,植骨未融合3例(含植骨未融合致内固定失败1例)。15例翻修手术中,14例为后路固定手术,1例为前路固定手术。通过术中颅骨牵引及充分松解,13例获得解剖复位;2例因广泛骨性融合,无法牵引复位,切除齿状突后彻底减压。导航模板辅助下共置入寰枢椎螺钉42枚,均一次性置入;置钉准确率97.6%。随访3~36个月(16.0±4.2个月),所有病例骨性融合,融合时间为3~6个月(3.7±0.5个月);末次随访JOA评分为13.8±3.1分(11~16分),较术前评分8.1±2.3分(6~11分)明显提高,改善率为(64.0±21.2)%(45.4%~88.8%)。结论:寰枢椎脱位手术后翻修的原因为减压或复位不足、内固定失败以及植骨未融合。充分的术中松解、8~10kg的颅骨牵引、恰当的骨质切除减压有利于翻修术中寰枢椎的复位,导航模板辅助有利于提高置钉准确性。
Objectives: To analyze the causes of postoperative revision surgery of atlantoaxial dislocation, and to discuss the therapeutic strategies. Methods: 15 patients with atlantoaxial dislocation revision surgeries(11male, 4 female; 15-68 years, mean 46.60±14.95 years) were analyzed in this retrospective study. The intervals of two operations ranged from 2 to 120 months(28.73 ±38.59 months). The reasons were analyzed for revision surgery according to the image data and intraoperative findings. All patients received 8-10 kg high dose skull traction and posterior release during revision surgery. For patients with integral posterior structure, the option of anterior release depended on the degree of reduction. After decompression and reduction, all patients re-ceived posterior internal fixation. One patient who received posterior decompression in the primary operation was performed with anterior decompression and fixation. Assisted atlantoaxial screw placement under 3D navi-gation template was performed; autogenous iliac cancellous bone was placed. The atlantoaxial reduction, screw position, bone graft fusion and surgical efficacy were evaluated at follow-up. Results: Reasons for revision were as following: 10 cases of insufficient decompression/reduction, 3 cases of failed internal fixation, 3 cases of unfused bone graft(including 1 case of internal fixation failure caused by unfused bone graft). Among all the 15 revision surgeries, 14 cases received posterior fixation surgery, 1 case received anterior fixation surgery. By intraoperative skull traction and full release, 13 cases achieved anatomical reduction, the other 2cases did not reach anatomical reduction due to extensive bony fusion and were fully decompressed after odontoidectomy. 42 atlantoaxial screws were implanted with 3D template-assisted navigation, the accuracy of screw implantation was 97.6%. The follow-up time ranged from 3 to 36 months(16.0±4.2 months). All patients got bone fusion, the fusion time ranged from 3-6 months(3.7 ±0.5 months). The final JOA score ranged from11 to 16( mean, 13.8±3.1), which improved compared with the preoperative(range form 6 to 11, mean 8.1 ±2.3), the improvement rate was(64.0±21.2)%(45.4%-88.8%). Conclusions: Inadequate decompression/reduction,failed internal fixation, and unfused bone graft are the common reasons of C1-2 dislocation needing revision surgery. Intraoperative full release, 8-10 kg skull traction, and proper bony structure resection are leading to the reduction of atlantoaxial dislocation, 3D navigation template is beneficial to the accuracy of screw placement.
Objectives: To analyze the causes of postoperative revision surgery of atlantoaxial dislocation, and to discuss the therapeutic strategies. Methods: 15 patients with atlantoaxial dislocation revision surgeries(11male, 4 female; 15-68 years, mean 46.60±14.95 years) were analyzed in this retrospective study. The intervals of two operations ranged from 2 to 120 months(28.73 ±38.59 months). The reasons were analyzed for revision surgery according to the image data and intraoperative findings. All patients received 8-10 kg high dose skull traction and posterior release during revision surgery. For patients with integral posterior structure, the option of anterior release depended on the degree of reduction. After decompression and reduction, all patients re-ceived posterior internal fixation. One patient who received posterior decompression in the primary operation was performed with anterior decompression and fixation. Assisted atlantoaxial screw placement under 3D navi-gation template was performed; autogenous iliac cancellous bone was placed. The atlantoaxial reduction, screw position, bone graft fusion and surgical efficacy were evaluated at follow-up. Results: Reasons for revision were as following: 10 cases of insufficient decompression/reduction, 3 cases of failed internal fixation, 3 cases of unfused bone graft(including 1 case of internal fixation failure caused by unfused bone graft). Among all the 15 revision surgeries, 14 cases received posterior fixation surgery, 1 case received anterior fixation surgery. By intraoperative skull traction and full release, 13 cases achieved anatomical reduction, the other 2cases did not reach anatomical reduction due to extensive bony fusion and were fully decompressed after odontoidectomy. 42 atlantoaxial screws were implanted with 3D template-assisted navigation, the accuracy of screw implantation was 97.6%. The follow-up time ranged from 3 to 36 months(16.0±4.2 months). All patients got bone fusion, the fusion time ranged from 3-6 months(3.7 ±0.5 months). The final JOA score ranged from11 to 16( mean, 13.8±3.1), which improved compared with the preoperative(range form 6 to 11, mean 8.1 ±2.3), the improvement rate was(64.0±21.2)%(45.4%-88.8%). Conclusions: Inadequate decompression/reduction,failed internal fixation, and unfused bone graft are the common reasons of C1-2 dislocation needing revision surgery. Intraoperative full release, 8-10 kg skull traction, and proper bony structure resection are leading to the reduction of atlantoaxial dislocation, 3D navigation template is beneficial to the accuracy of screw placement.
引文
1.Ma C,Wu JB,Zhao M,et al.Treatment of upper cervica spine instability with posterior fusion plus atlantoaxial pedicle screw[J].Cell Biochem Biophys,2014,69(3):693-697.
2.Meng Y,Chen H,Lou JG,et al.Posterior distraction reduc tion and occipitocervical fixation for the treatment of basila invagination and atlantoaxial dislocation[J].Clin Neurol Neurosurg,2016,140:60-67.
3.张强华,陈其昕,李方财,等.后路寰枢椎内固定治疗上颈椎不稳的疗效分析[J].中国骨伤,2013,26(6):493-496.
4.邓淼,权正学,罗小辑,等.寰枢椎椎弓根螺钉治疗寰枢椎不稳及脱位的临床效果[J].创伤外科杂志,2016,18(1):28-31.
5.Lall R,Patel NJ,Resnick DK,et al.A review of complica tions associated with craniocervical fusion surgery[J].Neurosurgery,2010,67(5):1396-1403.
6.Gautschi OP,Payer M,Corniola MV,et al.Clinically relevan complications related to posterior atlanto-axial fixation in at lanto-axial instability and their management[J].Clin Neuro Neurosurg,2014,123(3):131-135.
7.郝定均,贺宝荣,雷伟,等.颈枕区融合术后并发症的防治[J]中华骨科杂志,2005,25(7):420-425.
8.谭明生,移平,杨峰,等.寰枢椎脱位翻修手术的临床疗效观察[J].中国脊柱脊髓杂志,2012,22(2):106-112.
9.尹磊,倪斌,陶春生.上颈椎手术翻修原因分析及对策[J].中国矫形外科杂志,2006,14(13):998-1000.
10.谭明生,张光铂,王文军,等.寰枢椎脱位的外科分型及其处理对策[J].中国脊柱脊髓杂志,2007,17(2):111-115.
11.Yin QS,Wang JH.Current trends in management of atlantoaxial dislocation[J].Orthop Surg,2015,7(3):189-199.
12.Tubbs RS,Demerdash A,Rizk E,et al.Complications o transoral and transnasal odontoidectomy:a comprehensive review[J].Childs Nerv Syst,2016,32(1):55-59.
13.Chang PY,Yen YS,Wu JC,et al.The importance of at lantoaxial fixation after odontoidectomy[J].J Neurosurg Spine2016,24(2):300-308.
14.安薛,张国庆,相宏飞,等.脊柱手术内固定失败的原因及对策[J].青岛大学医学院学报,2013,49(3):272-276.
15.罗旭,李丹,梁英杰.生物骨材料混合自体髂骨修复寰枢椎可复性脱位:后路固定植骨融合[J].中国组织工程研究2016,20(43):6389-6395.
16.Xia H,Yin QS,Ai FZ,et al.Treatment of basilar invagination with atlantoaxial dislocation:atlantoaxial joint distraction and fixation with transoral atlantoaxial reduction plate(TARPwithout odontoidectomy[J].Eur Spine J,2014,23(8):1648-1655.
17.Laheri V,Chaudhary K,Rathod A,et al.Anterior transora atlantoaxial release and posterior instrumented fusion fo irreducible congenital basilar invagination[J].Eur Spine J2015,24(12):2977-2985.
18.林勇,历强,赵永生,等.后路寰枢椎术中侧壁定位椎弓根螺钉内固定治疗寰枢椎脱位[J].中国骨与关节损伤杂志2011,26(5):423-424.
19.许世宏,杨永良,周东生.三维导航与普通透视下置入寰椎侧块和枢椎椎弓根螺钉治疗寰枢椎不稳的比较[J].中华创伤骨科杂志,2012,14(12):1059-1064.
20.曲哲,钱平,邱勇,等.O型臂3D导航与徒手置钉在上颈椎椎弓根螺钉置入中的精确性比较[J].中国脊柱脊髓杂志2015,25(12):1063-1068.
2.Meng Y,Chen H,Lou JG,et al.Posterior distraction reduc tion and occipitocervical fixation for the treatment of basila invagination and atlantoaxial dislocation[J].Clin Neurol Neurosurg,2016,140:60-67.
3.张强华,陈其昕,李方财,等.后路寰枢椎内固定治疗上颈椎不稳的疗效分析[J].中国骨伤,2013,26(6):493-496.
4.邓淼,权正学,罗小辑,等.寰枢椎椎弓根螺钉治疗寰枢椎不稳及脱位的临床效果[J].创伤外科杂志,2016,18(1):28-31.
5.Lall R,Patel NJ,Resnick DK,et al.A review of complica tions associated with craniocervical fusion surgery[J].Neurosurgery,2010,67(5):1396-1403.
6.Gautschi OP,Payer M,Corniola MV,et al.Clinically relevan complications related to posterior atlanto-axial fixation in at lanto-axial instability and their management[J].Clin Neuro Neurosurg,2014,123(3):131-135.
7.郝定均,贺宝荣,雷伟,等.颈枕区融合术后并发症的防治[J]中华骨科杂志,2005,25(7):420-425.
8.谭明生,移平,杨峰,等.寰枢椎脱位翻修手术的临床疗效观察[J].中国脊柱脊髓杂志,2012,22(2):106-112.
9.尹磊,倪斌,陶春生.上颈椎手术翻修原因分析及对策[J].中国矫形外科杂志,2006,14(13):998-1000.
10.谭明生,张光铂,王文军,等.寰枢椎脱位的外科分型及其处理对策[J].中国脊柱脊髓杂志,2007,17(2):111-115.
11.Yin QS,Wang JH.Current trends in management of atlantoaxial dislocation[J].Orthop Surg,2015,7(3):189-199.
12.Tubbs RS,Demerdash A,Rizk E,et al.Complications o transoral and transnasal odontoidectomy:a comprehensive review[J].Childs Nerv Syst,2016,32(1):55-59.
13.Chang PY,Yen YS,Wu JC,et al.The importance of at lantoaxial fixation after odontoidectomy[J].J Neurosurg Spine2016,24(2):300-308.
14.安薛,张国庆,相宏飞,等.脊柱手术内固定失败的原因及对策[J].青岛大学医学院学报,2013,49(3):272-276.
15.罗旭,李丹,梁英杰.生物骨材料混合自体髂骨修复寰枢椎可复性脱位:后路固定植骨融合[J].中国组织工程研究2016,20(43):6389-6395.
16.Xia H,Yin QS,Ai FZ,et al.Treatment of basilar invagination with atlantoaxial dislocation:atlantoaxial joint distraction and fixation with transoral atlantoaxial reduction plate(TARPwithout odontoidectomy[J].Eur Spine J,2014,23(8):1648-1655.
17.Laheri V,Chaudhary K,Rathod A,et al.Anterior transora atlantoaxial release and posterior instrumented fusion fo irreducible congenital basilar invagination[J].Eur Spine J2015,24(12):2977-2985.
18.林勇,历强,赵永生,等.后路寰枢椎术中侧壁定位椎弓根螺钉内固定治疗寰枢椎脱位[J].中国骨与关节损伤杂志2011,26(5):423-424.
19.许世宏,杨永良,周东生.三维导航与普通透视下置入寰椎侧块和枢椎椎弓根螺钉治疗寰枢椎不稳的比较[J].中华创伤骨科杂志,2012,14(12):1059-1064.
20.曲哲,钱平,邱勇,等.O型臂3D导航与徒手置钉在上颈椎椎弓根螺钉置入中的精确性比较[J].中国脊柱脊髓杂志2015,25(12):1063-1068.