经后路寰枢椎侧块螺钉固定联合枕下减压治疗Arnold-Chiari畸形合并寰枢关节脱位
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摘要
目的探讨经后路寰枢椎侧块螺钉固定联合枕下减压治疗Arnold-Chiari畸形合并寰枢关节脱位的疗效。方法 2012年9月-2015年11月,收治17例Arnold-Chiari畸形合并寰枢关节脱位患者,均行经寰枢椎侧块螺钉固定+枕下减压扩大硬脑膜修补+植骨融合术治疗。男10例,女7例;年龄35~65岁,平均51.4岁。病程14个月~15年,平均7.4年。Arnold-Chiari畸形分型:Ⅰ型13例,Ⅱ型3例,Ⅲ~Ⅳ型1例。存在中上颈神经根刺激和压迫症状12例,枕大孔综合征11例,小脑受压症状6例,脊髓空洞症10例。结果 1例术后第3天拔除引流管后出现脑脊液切口漏,腰大池引流7 d后切口愈合良好,脑脊液漏消失。其余患者切口均Ⅰ期愈合,无手术早期并发症发生。患者均获随访,随访时间6个月~2年,平均18.4个月。患者神经功能障碍均有不同程度改善,术后6个月日本骨科协会(JOA)评分为(16.12±1.11)分,较术前的(11.76±2.01)分明显提高,比较差异有统计学意义(t=13.596,P=0.000);脊髓及延髓受压改善。X线片复查示,术后6个月内植骨均达融合。10例合并脊髓空洞者6个月复查MRI显示3例空洞消失,6例空洞变小,1例无明显变化。结论寰枢椎侧块螺钉固定联合枕下减压扩大硬脑膜修补术治疗Arnold-Chiari畸形合并寰枢关节脱位可获得良好疗效。
Objective To evaluate the effectiveness of the posterior atlantoaxial lateral mass screw fixation and suboccipital decompression in the treatment of Arnold-Chiari malformation associated with atlantoaxial joint dislocation. Methods Between September 2012 and November 2015, 17 cases of Arnold-Chiari malformation associated with atlantoaxial dislocation were treated by the posterior atlantoaxial lateral mass screw fixation and suboccipital decompression and expansion to repair the dura mater and bone graft fusion. There were 10 males and 7 females, aged 35- 65 years(mean, 51. 4 years). The disease duration was 14 months to 15 years with an average of 7. 4 years. According to Arnold-Chiari malformation classification, 13 cases were rated as type I, 3 cases as type II, and 1 case as type III-IV. Cervical nerve root stimulation and compression symptoms were observed in 12 cases, occipital foramen syndrome in 11 cases, cerebellar compression symptoms in 6 cases, and syringomyelia in 10 cases. Results Primary healing of incision was obtained in the other patients except 1 patient who had postoperative cerebrospinal fluid leakage after removal of drainage tube at 3 days after operation, which was cured after 7 days. All patients were followed up 6 months to 2 years, with an average of 18. 4 months. The neurological dysfunction was improved in different degrees after operation. The Japanese Orthopedic Association(JOA) score was significantly increased to 16. 12 ± 1. 11 at 6 months from preoperative 11. 76 ± 2. 01(t= 13. 596, P= 0. 000); compression of spinal cord and medulla was improved. X-ray examination showed bone graft fusion at 6 months after operation. In 10 patients with spinal cord cavity, MRI showed empty disappearance in 3 cases, empty cavity lessening in 6 cases, and no obvious change in 1 case at 6 months. Conclusion Atlantoaxial lateral mass screw fixation and suboccipital decompression and expansion to repair the dura mater can obtain good effectiveness in the treatment of Arnold Chiari malformation associated with atlantoaxial transarticular dislocation.
Objective To evaluate the effectiveness of the posterior atlantoaxial lateral mass screw fixation and suboccipital decompression in the treatment of Arnold-Chiari malformation associated with atlantoaxial joint dislocation. Methods Between September 2012 and November 2015, 17 cases of Arnold-Chiari malformation associated with atlantoaxial dislocation were treated by the posterior atlantoaxial lateral mass screw fixation and suboccipital decompression and expansion to repair the dura mater and bone graft fusion. There were 10 males and 7 females, aged 35- 65 years(mean, 51. 4 years). The disease duration was 14 months to 15 years with an average of 7. 4 years. According to Arnold-Chiari malformation classification, 13 cases were rated as type I, 3 cases as type II, and 1 case as type III-IV. Cervical nerve root stimulation and compression symptoms were observed in 12 cases, occipital foramen syndrome in 11 cases, cerebellar compression symptoms in 6 cases, and syringomyelia in 10 cases. Results Primary healing of incision was obtained in the other patients except 1 patient who had postoperative cerebrospinal fluid leakage after removal of drainage tube at 3 days after operation, which was cured after 7 days. All patients were followed up 6 months to 2 years, with an average of 18. 4 months. The neurological dysfunction was improved in different degrees after operation. The Japanese Orthopedic Association(JOA) score was significantly increased to 16. 12 ± 1. 11 at 6 months from preoperative 11. 76 ± 2. 01(t= 13. 596, P= 0. 000); compression of spinal cord and medulla was improved. X-ray examination showed bone graft fusion at 6 months after operation. In 10 patients with spinal cord cavity, MRI showed empty disappearance in 3 cases, empty cavity lessening in 6 cases, and no obvious change in 1 case at 6 months. Conclusion Atlantoaxial lateral mass screw fixation and suboccipital decompression and expansion to repair the dura mater can obtain good effectiveness in the treatment of Arnold Chiari malformation associated with atlantoaxial transarticular dislocation.
引文
1 Du JY,Aichmair A,Kueper J,et al.Biomechanical analysis of screw constructs for atlantoaxial fixation in cadavers:a systematic review and meta-analysis.J Neurosurg Spine,2015,22(2):151-161.
2 Goel A,Jankharia B,Shah A,et al.Three-dimensional models:an emerging investigational revolution for craniovertebral junction surgery.J Neurosurg Spine,2016.[Epub ahead of print]
3 Ai FZ,Yin QS,Xu DC,et al.Transoral atlantoaxial reduction plate intemal fixation with transoral transpedicular or articular mass screw of C2 for the treatment of irreducible atlantoaxial dislocation:two case reports.Spine(Phila Pa 1976),2011,36(8):E556-562.
4 Yin YH,Qiao GY,Yu XG,et al.Posterior realignment of irreducible atlantoaxial dislocation with C1-C2 screw and rod system:a technique of direct reduction and fixation.Spine J,2013,13(12):1864-1871.
5 Srivastava SK,Aggarwal RA,Nemade PS,et al.Single-stage anterior release and posterior instrumented fusion for irreducible atlantoaxial dislocation with basilar invagination.Spine J,2016,16(1):1-9.
6 Xu ZW,Liu TJ,He BR,et al.Transoral anterior release,odontoid partial resection,and reduction with posterior fusion for the treatment of irreducible atlantoaxial dislocation caused by odontoidfracture malunion.Eur Spine J,2015,24(4):694-701.
7贾贵军,吉宏明,张刚利,等.合并寰枢椎脱位的复杂颅颈交界区畸形后路减压复位内固定术疗效初步观察.中国现代神经疾病杂志,2012,12(4):424-429.
8 Menzes AH,Van Gilder JC,Clark CR,et al.Odontoid upward migration in rheumatoid arthritis.An alysis of 45 patients with“cranial settling”.J Neurosurg,1985,63(4):500-509.
9崔建军,李东,夏国庆,等.后颅窝减压硬脑膜扩大修补术治疗Arnold-Chiari畸形24例分析.中国误诊学杂志,2010,10(22):5484.
10赵红宇,马良,李帅,等.Arnold-Chiari畸形143例显微手术治疗经验体会.中国医科大学学报,2011,40(12):1134-1136.
11 Fearon JA,Dimas V,Ditthakasem K.Lambdoid craniosynostosis:the relationship with chiari deformations and an analysis of surgical outcomes.Plast Reconstr Surg,2016,137(3):946-951.
12 Chotai S,Kshettry VR,Lamki T,et al.Surgical outcomes using wide suboccipital decompression for adult Chiari I malformation with and without syringomyelia.Clin Neurol Neurosurg,2014,120:129-135.
13 Quon JL,Grant RA,Di Luna ML.Multimodal evaluation of CSF dynamics following extradural decompression for Chiari malformation Type I.J Neurosurg Spine,2015,22(6):622-630.
14尹一恒,余新光,乔广宇,等.采用C1-2钉棒复位技术治疗难复性寰枢椎脱位及颅底陷入.中华医学杂志,2014,94(41):3248-3251.
15 Yin YH,Tong HY,Qiao GY,et al.Posterior reduction of fixed atlantoaxial dislocation and basilar invagination by atlantoaxial facet joint release and fixation:A modified technique with 174 cases.Neurosurgery,2016,78(3):391-400.
16刘瑞端,贾长青.合并复杂颅颈交界畸形可复性寰枢椎脱位的个性化治疗策略.中国骨与关节损伤杂志,2015,30(1):4-6.
17 Anderson PA,Oza AL,Puschak TJ,et al.Biomeehanics of occipitocervieal fixation.Spine(Phila Pa 1976),2006,31(7):755-761.
18 Abumi K,Takada T,Shono Y,et al.Posterior occipitocervical reconstruction using cervical pedicle screws and plate-rod systems.Spine(Phila Pa 1976),1999,24(14):1425-1434.
19 Wang S,Wang C,Leng H,et al.Cable-strengthened C2 pedicle screw fixation in the treatment of congenital C2-3 fusion,atlas oecipitalization,and atlantoaxial dislocation.Neurosurgery,2012,71(5):976-984.
2 Goel A,Jankharia B,Shah A,et al.Three-dimensional models:an emerging investigational revolution for craniovertebral junction surgery.J Neurosurg Spine,2016.[Epub ahead of print]
3 Ai FZ,Yin QS,Xu DC,et al.Transoral atlantoaxial reduction plate intemal fixation with transoral transpedicular or articular mass screw of C2 for the treatment of irreducible atlantoaxial dislocation:two case reports.Spine(Phila Pa 1976),2011,36(8):E556-562.
4 Yin YH,Qiao GY,Yu XG,et al.Posterior realignment of irreducible atlantoaxial dislocation with C1-C2 screw and rod system:a technique of direct reduction and fixation.Spine J,2013,13(12):1864-1871.
5 Srivastava SK,Aggarwal RA,Nemade PS,et al.Single-stage anterior release and posterior instrumented fusion for irreducible atlantoaxial dislocation with basilar invagination.Spine J,2016,16(1):1-9.
6 Xu ZW,Liu TJ,He BR,et al.Transoral anterior release,odontoid partial resection,and reduction with posterior fusion for the treatment of irreducible atlantoaxial dislocation caused by odontoidfracture malunion.Eur Spine J,2015,24(4):694-701.
7贾贵军,吉宏明,张刚利,等.合并寰枢椎脱位的复杂颅颈交界区畸形后路减压复位内固定术疗效初步观察.中国现代神经疾病杂志,2012,12(4):424-429.
8 Menzes AH,Van Gilder JC,Clark CR,et al.Odontoid upward migration in rheumatoid arthritis.An alysis of 45 patients with“cranial settling”.J Neurosurg,1985,63(4):500-509.
9崔建军,李东,夏国庆,等.后颅窝减压硬脑膜扩大修补术治疗Arnold-Chiari畸形24例分析.中国误诊学杂志,2010,10(22):5484.
10赵红宇,马良,李帅,等.Arnold-Chiari畸形143例显微手术治疗经验体会.中国医科大学学报,2011,40(12):1134-1136.
11 Fearon JA,Dimas V,Ditthakasem K.Lambdoid craniosynostosis:the relationship with chiari deformations and an analysis of surgical outcomes.Plast Reconstr Surg,2016,137(3):946-951.
12 Chotai S,Kshettry VR,Lamki T,et al.Surgical outcomes using wide suboccipital decompression for adult Chiari I malformation with and without syringomyelia.Clin Neurol Neurosurg,2014,120:129-135.
13 Quon JL,Grant RA,Di Luna ML.Multimodal evaluation of CSF dynamics following extradural decompression for Chiari malformation Type I.J Neurosurg Spine,2015,22(6):622-630.
14尹一恒,余新光,乔广宇,等.采用C1-2钉棒复位技术治疗难复性寰枢椎脱位及颅底陷入.中华医学杂志,2014,94(41):3248-3251.
15 Yin YH,Tong HY,Qiao GY,et al.Posterior reduction of fixed atlantoaxial dislocation and basilar invagination by atlantoaxial facet joint release and fixation:A modified technique with 174 cases.Neurosurgery,2016,78(3):391-400.
16刘瑞端,贾长青.合并复杂颅颈交界畸形可复性寰枢椎脱位的个性化治疗策略.中国骨与关节损伤杂志,2015,30(1):4-6.
17 Anderson PA,Oza AL,Puschak TJ,et al.Biomeehanics of occipitocervieal fixation.Spine(Phila Pa 1976),2006,31(7):755-761.
18 Abumi K,Takada T,Shono Y,et al.Posterior occipitocervical reconstruction using cervical pedicle screws and plate-rod systems.Spine(Phila Pa 1976),1999,24(14):1425-1434.
19 Wang S,Wang C,Leng H,et al.Cable-strengthened C2 pedicle screw fixation in the treatment of congenital C2-3 fusion,atlas oecipitalization,and atlantoaxial dislocation.Neurosurgery,2012,71(5):976-984.