前路后凸偏心撑开复位技术治疗下颈椎小关节脱位
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摘要
目的:探讨前路后凸偏心撑开复位技术治疗下颈椎小关节脱位的临床疗效与安全性。方法 :收集2014年1月～2017年12月陆军军医大学第二附属医院骨科采用前路后凸偏心撑开复位技术治疗的下颈椎小关节脱位患者63例,其中男55例,女8例,年龄21～73岁(48.8±12.2岁)。脱位节段:C3/4 4例,C4/5 9例,C5/6 26例,C6/7 22例,C7/T1 2例;单侧脱位22例,双侧脱位41例。合并创伤性椎间盘突出18例,椎体骨折20例,关节突骨折14例。伤后ASIA分级:A级17例,B级3例,C级3例,D级23例,E级17例。从受伤至手术的间隔时间为3～64d(9.5±8.5d)。复位成功后,椎间置入装满自体骨的cage并用前路钢板椎体钉固定。术后随访9～24个月(15.7±5.1个月)。分析其复位成功率、手术时间、术中出血量及出院后随访神经功能恢复情况(ASIA分级)、融合率等指标。结果:63例患者均顺利完成手术。经后凸偏心撑开复位技术直接复位成功52例(82.5%),其中包括单侧小关节脱位22例,双侧脱位30例;合并椎体骨折15例,关节突骨折7例;受伤至手术的间隔时间在2周以内46例、2～4周6例;手术时间为76.2±21.9min,术中出血量为66.3±37.0ml。复位失败的11例患者辅以前路小关节突切除术,最终均成功复位。末次随访时,经后凸偏心撑开复位技术复位成功的52例患者中,20例(38.5%)的ASIA分级至少升高1级(3例术前A级患者末次随访时升至B级2例、C级1例,3例由术前C级升至D级,14例由术前D级升至E级),其余32例的ASIA分级保持不变(包括9例A级,2例B级,7例D级及14例E级);融合率为100%,无内固定松动、断裂。结论 :前路后凸偏心撑开复位技术复位下颈椎小关节脱位成功率高、手术操作简单、创伤小、安全有效。
Objectives: To explore the clinical efficacy and safety of anterior kyphotic paramedian distraction technique for reduction of cervical facet dislocation. Methods: From January 2014 to December 2017, there were 63 cases of lower cervical facet dislocation which were treated by anterior kyphotic paramedian distrac-tion technique in our hospital. There were 55 males and 8 females, with an average age of 48.8 ±12.2 years(range, 21 to 73 years). The injury segments were C3/4 in 4 cases, C4/5 in 9 cases, C5/6 in 26 cases, C6/7 in 22 cases, C7/T1 in 2 cases. Dislocation types were unilateral facet dislocation in 22 cases and bilateral facet dislocation in 41 cases. There were 18 cases with traumatic disc herniation, 20 cases with vertebra fracture and 14 cases with articular process fracture. The spinal cord injury grade(American Spinal Injury Association, ASIS) at admission was ASIA grade A in 17 cases, grade B in 3 cases, grade C in 3 cases, grade D in 23 cases, grade E in 17 cases. The preoperative time was from 3 to 64 days(average, 9.5 ±8.5 days),and follow-up ranged from 9 to 24 months(average, 15.7 ±5.1 months) after surgery. After successful reduction, cage with autogenous bone and anterior plate fixation were implanted. And then the success rate of reduction, operation time, intraoperative blood loss, the ASIA grade and fusion rate at the last follow-up were analyzed. Results: All the 63 patients were successfully treated. Fifty-two cases(82.5%) were directly reduced by anterior kyphotic paramedian distraction technique, including 22 cases of unilateral facet dislocation, 30 cases of bilateral facet dislocation, 15 cases with vertebra fracture and 7 cases with articular process fracture.The preoperation time was less than 2 weeks in 46 cases and 2-4 weeks in 6 cases. The mean operation time was 76.2±21.9 minutes and the mean blood loss was 66.3 ±37.0 ml. The other 11 patients with failed reduction needed to be assisted with anterior facetectomy, and all of them were successfully reduced. At the last follow-up, 20(38.5%) of 52 patients with successful reduction by anterior kyphotic paramedian technique increased the ASIA grade by at least one grade(including 3 cases with preoperative grade A to grade B in 2 cases and grade C in 1 case at the last follow-up, 3 cases from grade C to grade D, 14 cases from grade D to grade E), and the other 32 cases remained ASIA grade unchanged(including 9 cases of grade A, 2 cases of grade B, 7 cases of grade C, 14 cases of grade E). All patients achieved satisfactory fusion, and there was no implant failure. Conclusions: Anterior kyphotic paramedian distraction technique for reduction of lower cervical facet dislocation has the advantages of high success rate, simple operation, less trauma, safe and effective clinical result.
Objectives: To explore the clinical efficacy and safety of anterior kyphotic paramedian distraction technique for reduction of cervical facet dislocation. Methods: From January 2014 to December 2017, there were 63 cases of lower cervical facet dislocation which were treated by anterior kyphotic paramedian distrac-tion technique in our hospital. There were 55 males and 8 females, with an average age of 48.8 ±12.2 years(range, 21 to 73 years). The injury segments were C3/4 in 4 cases, C4/5 in 9 cases, C5/6 in 26 cases, C6/7 in 22 cases, C7/T1 in 2 cases. Dislocation types were unilateral facet dislocation in 22 cases and bilateral facet dislocation in 41 cases. There were 18 cases with traumatic disc herniation, 20 cases with vertebra fracture and 14 cases with articular process fracture. The spinal cord injury grade(American Spinal Injury Association, ASIS) at admission was ASIA grade A in 17 cases, grade B in 3 cases, grade C in 3 cases, grade D in 23 cases, grade E in 17 cases. The preoperative time was from 3 to 64 days(average, 9.5 ±8.5 days),and follow-up ranged from 9 to 24 months(average, 15.7 ±5.1 months) after surgery. After successful reduction, cage with autogenous bone and anterior plate fixation were implanted. And then the success rate of reduction, operation time, intraoperative blood loss, the ASIA grade and fusion rate at the last follow-up were analyzed. Results: All the 63 patients were successfully treated. Fifty-two cases(82.5%) were directly reduced by anterior kyphotic paramedian distraction technique, including 22 cases of unilateral facet dislocation, 30 cases of bilateral facet dislocation, 15 cases with vertebra fracture and 7 cases with articular process fracture.The preoperation time was less than 2 weeks in 46 cases and 2-4 weeks in 6 cases. The mean operation time was 76.2±21.9 minutes and the mean blood loss was 66.3 ±37.0 ml. The other 11 patients with failed reduction needed to be assisted with anterior facetectomy, and all of them were successfully reduced. At the last follow-up, 20(38.5%) of 52 patients with successful reduction by anterior kyphotic paramedian technique increased the ASIA grade by at least one grade(including 3 cases with preoperative grade A to grade B in 2 cases and grade C in 1 case at the last follow-up, 3 cases from grade C to grade D, 14 cases from grade D to grade E), and the other 32 cases remained ASIA grade unchanged(including 9 cases of grade A, 2 cases of grade B, 7 cases of grade C, 14 cases of grade E). All patients achieved satisfactory fusion, and there was no implant failure. Conclusions: Anterior kyphotic paramedian distraction technique for reduction of lower cervical facet dislocation has the advantages of high success rate, simple operation, less trauma, safe and effective clinical result.
引文
1.Reindl R,Ouellet J,Harvey EJ,et al.Anterior reduction for cervical spine dislocation[J].Spine(Phila Pa 1976),2006,31(6):648-652.
2.Du W,Wang C,Tan J,et al.Management of subaxial cervical facet dislocation through anterior approach monitored by spinal cord evoked potential[J].Spine(Phila Pa 1976),2014,39(1):48-52.
3.Li H,Huang Y,Cheng C,et al.Comparison of the technique of anterior cervical distraction and screw elevating-pulling reduction and conventional anterior cervical reduction technique for traumatic cervical spine fractures and dislocations[J].Int JSurg,2017,40:45-51.
4.Ditunno JF Jr,Young W,Donovan WH,et al.The international standards booklet for neurological and functional classification of spinal cord injury:American Spinal Injury Association[J].Paraplegia,1994,32(2):70-80.
5.Smith GW,Robinson RA.The treatment of certain cervicalspine disorders by anterior removal of the intervertebral disc and interbody fusion[J].J Bone Joint Surg Am,1958,40(3):607-624.
6.Zhang Z,Liu C,Mu Z,et al.Anterior facetectomy for reduction of cervical facet dislocation[J].Spine(Phila Pa 1976),2016,41(7):E403-409.
7.Glaser JA,Jaworski BA,Cuddy BG,et al.Variation in surgical opinion regarding management of selected cervical spine injuries:a preliminary study[J].Spine(Phila Pa 1976),1998,23(9):975-983.
8.Nassr A,Lee JY,Dvorak MF,et al.Variations in surgical treatment of cervical facet dislocations[J].Spine(Phila Pa1976),2008,33(7):E188-193.
9.Vital JM,Gille O,Sénégas J,et al.Reduction technique for uni-and biarticular dislocations of the lower cervical spine[J].Spine(Phila Pa 1976),1998,23(8):949-955.
10.Grant GA,Mirza SK,Chapman JR,et al.Risk of early closed reduction in cervical spine subluxation injuries[J].JNeurosurg,1999,90(1 Suppl):13-18.
11.Star AM,Jones AA,Cotler JM,et al.Immediate closed reduction of cervical spine dislocations using traction[J].Spine(Phila Pa 1976),1990,15(10):1068-1072.
12.Sabiston CP,Wing PC,Schweigel JF,et al.Closed reduction of dislocations of the lower cervical spine[J].J Trauma,1988,28(6):832-835.
13.Robertson PA,Ryan MD.Neurological deterioration after reduction of cervical subluxation:mechanical compression by disc tissue[J].J Bone Joint Surg Br,1992,74(2):224-227.
14.Olerud C,Jónsson H Jr.Compression of the cervical spine cord after reduction of fracture dislocations:report of 2 cases[J].Acta Orthop Scand,1991,62(6):599-601.
15.Rizzolo SJ,Piazza MR,Cotler JM,et al.Intervertebral disc injury complicating cervical spine trauma[J].Spine(Phila Pa1976),1991,16(6 Suppl):S187-189.
16.Panjabi MM,Simpson AK,Ivancic PC,et al.Cervical facet joint kinematics during bilateral facet dislocation[J].Eur Spine J,2007,16(10):1680-1688.
17.Gallego-Goyanes A,Caeiro-Rey JR,Díez-Ulloa MA,et al.Inveterate subaxial cervical dislocations:a discussion on the best therapeutic strategy[J].Rev Esp Cir Ortop Traumatol,2013,57(6):446-449.
18.Keynan O,Dvorak M,Fisher C.Reduction techniques in cervical facet dislocations[J].Techniques in Orthopaedics,2002,17(3):336-344.
19.Ngo LM,Aizawa T,Hoshikawa T,et al.Fracture and contralateral dislocation of the twin facet joints of the lower cervical spine[J].Eur Spine J,2012,21(2):282-288.
20.Kocis J,Wendsche P,Visna P,et al.Injuries to the lower cervical spine[J].Acta Chir Orthop Traumatol Cech,2004,71(6):366-372.
21.Berrington NR,van Staden JF,Willers JG,et al.Cervical intervertebral disc prolapse associated with traumatic facet dislocations[J].Surg Neurol,1993,40(5):395-399.
22.Doran SE,Papadopoulos SM,Ducker TB,et al.Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation[J].JNeurosurg,1993,79(3):341-345.
23.Eismont FJ,Arena MJ,Green BA.Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets:case report[J].J Bone Joint Surg Am,1991,73(10):1555-1560.
24.Ordonez BJ,Benzel EC,Naderi S,et al.Cervical facet dislocation:techniques for ventral reduction and stabilization[J].J Neurosurg,2000,92(1 Suppl):18-23.
25.Feng G,Hong Y,Li L,et al.Anterior decompression and nonstructural bone grafting and posterior fixation for cervical facet dislocation with traumatic disc herniation[J].Spine(Phila Pa 1976),2012,37(25):2082-2088.
26.Kanna RM,Shetty AP,Rajasekaran S.Modified anterior-only reduction and fixation for traumatic cervical facet dislocation(AO type C injuries)[J].Eur Spine J,2018,27(6):1447-1453.
2.Du W,Wang C,Tan J,et al.Management of subaxial cervical facet dislocation through anterior approach monitored by spinal cord evoked potential[J].Spine(Phila Pa 1976),2014,39(1):48-52.
3.Li H,Huang Y,Cheng C,et al.Comparison of the technique of anterior cervical distraction and screw elevating-pulling reduction and conventional anterior cervical reduction technique for traumatic cervical spine fractures and dislocations[J].Int JSurg,2017,40:45-51.
4.Ditunno JF Jr,Young W,Donovan WH,et al.The international standards booklet for neurological and functional classification of spinal cord injury:American Spinal Injury Association[J].Paraplegia,1994,32(2):70-80.
5.Smith GW,Robinson RA.The treatment of certain cervicalspine disorders by anterior removal of the intervertebral disc and interbody fusion[J].J Bone Joint Surg Am,1958,40(3):607-624.
6.Zhang Z,Liu C,Mu Z,et al.Anterior facetectomy for reduction of cervical facet dislocation[J].Spine(Phila Pa 1976),2016,41(7):E403-409.
7.Glaser JA,Jaworski BA,Cuddy BG,et al.Variation in surgical opinion regarding management of selected cervical spine injuries:a preliminary study[J].Spine(Phila Pa 1976),1998,23(9):975-983.
8.Nassr A,Lee JY,Dvorak MF,et al.Variations in surgical treatment of cervical facet dislocations[J].Spine(Phila Pa1976),2008,33(7):E188-193.
9.Vital JM,Gille O,Sénégas J,et al.Reduction technique for uni-and biarticular dislocations of the lower cervical spine[J].Spine(Phila Pa 1976),1998,23(8):949-955.
10.Grant GA,Mirza SK,Chapman JR,et al.Risk of early closed reduction in cervical spine subluxation injuries[J].JNeurosurg,1999,90(1 Suppl):13-18.
11.Star AM,Jones AA,Cotler JM,et al.Immediate closed reduction of cervical spine dislocations using traction[J].Spine(Phila Pa 1976),1990,15(10):1068-1072.
12.Sabiston CP,Wing PC,Schweigel JF,et al.Closed reduction of dislocations of the lower cervical spine[J].J Trauma,1988,28(6):832-835.
13.Robertson PA,Ryan MD.Neurological deterioration after reduction of cervical subluxation:mechanical compression by disc tissue[J].J Bone Joint Surg Br,1992,74(2):224-227.
14.Olerud C,Jónsson H Jr.Compression of the cervical spine cord after reduction of fracture dislocations:report of 2 cases[J].Acta Orthop Scand,1991,62(6):599-601.
15.Rizzolo SJ,Piazza MR,Cotler JM,et al.Intervertebral disc injury complicating cervical spine trauma[J].Spine(Phila Pa1976),1991,16(6 Suppl):S187-189.
16.Panjabi MM,Simpson AK,Ivancic PC,et al.Cervical facet joint kinematics during bilateral facet dislocation[J].Eur Spine J,2007,16(10):1680-1688.
17.Gallego-Goyanes A,Caeiro-Rey JR,Díez-Ulloa MA,et al.Inveterate subaxial cervical dislocations:a discussion on the best therapeutic strategy[J].Rev Esp Cir Ortop Traumatol,2013,57(6):446-449.
18.Keynan O,Dvorak M,Fisher C.Reduction techniques in cervical facet dislocations[J].Techniques in Orthopaedics,2002,17(3):336-344.
19.Ngo LM,Aizawa T,Hoshikawa T,et al.Fracture and contralateral dislocation of the twin facet joints of the lower cervical spine[J].Eur Spine J,2012,21(2):282-288.
20.Kocis J,Wendsche P,Visna P,et al.Injuries to the lower cervical spine[J].Acta Chir Orthop Traumatol Cech,2004,71(6):366-372.
21.Berrington NR,van Staden JF,Willers JG,et al.Cervical intervertebral disc prolapse associated with traumatic facet dislocations[J].Surg Neurol,1993,40(5):395-399.
22.Doran SE,Papadopoulos SM,Ducker TB,et al.Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation[J].JNeurosurg,1993,79(3):341-345.
23.Eismont FJ,Arena MJ,Green BA.Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets:case report[J].J Bone Joint Surg Am,1991,73(10):1555-1560.
24.Ordonez BJ,Benzel EC,Naderi S,et al.Cervical facet dislocation:techniques for ventral reduction and stabilization[J].J Neurosurg,2000,92(1 Suppl):18-23.
25.Feng G,Hong Y,Li L,et al.Anterior decompression and nonstructural bone grafting and posterior fixation for cervical facet dislocation with traumatic disc herniation[J].Spine(Phila Pa 1976),2012,37(25):2082-2088.
26.Kanna RM,Shetty AP,Rajasekaran S.Modified anterior-only reduction and fixation for traumatic cervical facet dislocation(AO type C injuries)[J].Eur Spine J,2018,27(6):1447-1453.