寰椎椎弓根三维螺旋CT测量及临床应用
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摘要
目的寰椎结构特殊,由前弓、后弓以及两侧块和横突构成骨环,没有椎体和棘突,经典解剖学没有椎弓根的结构,大量解剖观察发现寰椎后弓与侧块的连接部分在结构和力学上类似于其他脊椎的椎弓根,解剖与影像测量显示寰椎侧块螺钉可以经后弓经过椎弓根进行固定,称之为寰椎椎弓根螺钉。测量数据显示解剖与影像测量数据一致,可以应用影像学测量指导手术中椎弓根螺钉的置入。寰椎椎弓根螺钉成功置入的关键之一在于进钉点和进钉角度的把握,本研究旨在利用寰椎横断面CT测量建立寰椎椎弓根螺钉安全置钉区域及相应的进钉角度并指导临床手术操作。
方法随机选取38例就诊患者的寰椎螺旋CT薄层扫描和三维重建。置钉空间定义为寰椎横断面上进钉通道与横突孔内缘的切线、与椎管外缘的切线这两条平行线间的距离。要安全通过直径3.5mm螺丝钉,寰椎椎弓根螺钉的置钉空间至少5mm。以寰椎椎管外缘与横突孔内缘的最小距离为椎弓根宽度,以此线段的垂直平分线与寰椎后弓的交点为安全置钉区域的外侧界,若此交点在过横突孔内缘的寰椎中线的平行线和后弓交点以外,则以后者为外界。以置钉空间为5mm时螺钉通道中轴线与寰椎后弓交点为内侧界,若此交点落在过寰椎椎管外缘的寰椎中线的平行线和后弓的交点的内侧则以后者为内侧界。测量寰椎后结节与安全置钉区域内、外界点的距离,安全置钉区域内、外侧界点间的距离和相应的进钉角度、进钉通道长度以及椎弓根的宽度。以术前螺旋CT测量确定安全置钉区域的方法,应用管道疏通法对7例患者行寰椎椎弓根螺钉内固定。
结果CT测量：椎弓根宽度为(9.15±2.57)mm,可以安全容纳3.5mm螺钉,安全置钉区域：在寰椎后弓距后结节距离(18.35±2.86)mm～(25.26±1.76)mm,进钉角度范围为外倾(9.09±7.45)°～内倾(18.72±17.42)°,钉道长度在(26.20±2.69)mm～(27.04±2.51)mm。安全置钉区域宽度达(6.914±7.66)mm,横断面倾斜角度范围达到(27.81±10.32)。。但存在个体差异。7例患者手术时间90～120min,术中出血60～300ml,无椎动脉、神经根及脊髓损伤。术后行颈椎正侧位X线片及颈椎螺旋CT检查显示14枚椎弓根螺钉位置理想,均位于术前测量安全置钉区域内,无穿破椎弓根骨皮质现象。术后随访6～12月无内固定松动及断裂现象。7例患者植骨均获骨性融合。
结论寰椎椎弓根螺钉存在安全置钉区域,在安全置钉区域内可根据进钉点不同相应的内倾或外倾置钉。详尽的术前影像测量,确定安全置钉区域,个体化置钉是手术成功的关键。
Objective:The atlas is special with no vertebral body and no spinous process, which is constituted by anterior arch, posterior arch, two lateral masses and transverse process. No structure of pedicle of vertebral arch can be found in classic anatomy, but massive anatomical observations reveal that the connecting part between the posterior arch of atlas and lateral mass resemble pedicle of vertebral arch of other spines in structure and mechanics. Anatomical and imaging measurements demonstrate that atlas lateral mass screw can be fixed through posterior arch and pedicle of vertebral arch, which is called atlas pedicle screw. Measurement data present that the data in the anatomy and image are consistent, therefore, imaging measurement can guide the placement of pedicle screw in surgery. One of the key points in successful placement of pedicle screw lies in taking control of the entry point and the angle of pedicle screw. Through axial CT measurement of atlas, the study is to confirm the safe placement area and corresponding entry angle of atlas pedicle screw, and to guide the clinical operations.
Methods:With random selection of spiral CT thin-layer scanning and three-dimensional reconstruction of atlas of38patients, the space available for the screw (SAS) is defined as the distance between two paralleled lines, one of which is the tangent line of the inner edge of transverse foramen, the other of which is the tangent line of outer edge of vertebral canal. The SAS should be at least5mm with successful placement of the atlas pedicle screw, the diameter of which is3.5mm. The minimum distance between the outer edge of vertebral canal and the inner edge of transverse foramen is the width of pedicle of vertebral arch, and the intersection of the perpendicular bisector of the width and posterior arch of atlas is the lateral boundary of safe placement area. If the intersection is beyond that intersection of tangent line and the posterior arch, the latter intersection was the lateral boundary. The tangent line, in parallel with atlas midline, is of the inner edge of transverse foramen. The intersection of central axis line of screw channel and posterior arch of atlas is the inner boundary when the space available for the screw is5mm. If the intersection is in the inside of that intersection of tangent line and the posterior arch, the latter intersection is the inner boundary. The tangent line, in parallel with atlas midline, is of the outer edge of vertebral canal. Measure the distance between the posterior tubercle of atlas and the inner and the lateral boundary of the safe placement area of screw, corresponding entry angle and depth of pedicle screw, and the width of pedicle of vertebral arch. Guided by preoperative spiral CT measurement,7patients were performed pedicle screw internal fixation in atlas with the application of dredging pipeline method.
Results:CT measurement:the width of pedicle of vertebral arch was (9.15±2.57) mm, which was safe to fix the3.5mm screw. The safe placement area of screw:the entry point was (18.35±2.86) mm～(25.26±1.76) mm away from posterior tubercle of atlas, the entry angle of screw ranges from leaning outwards (9.09±7.45)°to leaning inwards (18.72±17.42)°. The length of screw channel was (26.20±2.69) mm～(27.04±2.51) mm. The width of the safe placement area of screw was6.91±7.66) mm. The transverse angle was (27.81±10.32)°. But there were individual differences. The duration of operation of the7patients was90～120min, and intraoperative hemorrhage was60～300ml, with no vertebral artery injury, no nerve root injury. or no spinal cord injury. After surgery the7patients were examined by X-film and spiral CT of cervical spine, which revealed that the14pedicle screw positions were ideal within the safe placement area of screw measured before surgery, with no break-through of bone cortex of pedicle of vertebral arch. The7patients were followed up from6to12months, which showed no loosening and breakage of internal fixation and bone fusion were observed in all7patients.
Conclusion:There exists safe placement area in fixing pedicle screw. The fixation of pedicle screw in the safe placement area can lean inwards or lean outwards according to the entry point of screw. It is critical for successful surgery to have exhaustive preoperative imaging measurement, to confirm safe placement area of screw, and to fix pedicle screw individually.
方法随机选取38例就诊患者的寰椎螺旋CT薄层扫描和三维重建。置钉空间定义为寰椎横断面上进钉通道与横突孔内缘的切线、与椎管外缘的切线这两条平行线间的距离。要安全通过直径3.5mm螺丝钉,寰椎椎弓根螺钉的置钉空间至少5mm。以寰椎椎管外缘与横突孔内缘的最小距离为椎弓根宽度,以此线段的垂直平分线与寰椎后弓的交点为安全置钉区域的外侧界,若此交点在过横突孔内缘的寰椎中线的平行线和后弓交点以外,则以后者为外界。以置钉空间为5mm时螺钉通道中轴线与寰椎后弓交点为内侧界,若此交点落在过寰椎椎管外缘的寰椎中线的平行线和后弓的交点的内侧则以后者为内侧界。测量寰椎后结节与安全置钉区域内、外界点的距离,安全置钉区域内、外侧界点间的距离和相应的进钉角度、进钉通道长度以及椎弓根的宽度。以术前螺旋CT测量确定安全置钉区域的方法,应用管道疏通法对7例患者行寰椎椎弓根螺钉内固定。
结果CT测量：椎弓根宽度为(9.15±2.57)mm,可以安全容纳3.5mm螺钉,安全置钉区域：在寰椎后弓距后结节距离(18.35±2.86)mm～(25.26±1.76)mm,进钉角度范围为外倾(9.09±7.45)°～内倾(18.72±17.42)°,钉道长度在(26.20±2.69)mm～(27.04±2.51)mm。安全置钉区域宽度达(6.914±7.66)mm,横断面倾斜角度范围达到(27.81±10.32)。。但存在个体差异。7例患者手术时间90～120min,术中出血60～300ml,无椎动脉、神经根及脊髓损伤。术后行颈椎正侧位X线片及颈椎螺旋CT检查显示14枚椎弓根螺钉位置理想,均位于术前测量安全置钉区域内,无穿破椎弓根骨皮质现象。术后随访6～12月无内固定松动及断裂现象。7例患者植骨均获骨性融合。
结论寰椎椎弓根螺钉存在安全置钉区域,在安全置钉区域内可根据进钉点不同相应的内倾或外倾置钉。详尽的术前影像测量,确定安全置钉区域,个体化置钉是手术成功的关键。
Objective:The atlas is special with no vertebral body and no spinous process, which is constituted by anterior arch, posterior arch, two lateral masses and transverse process. No structure of pedicle of vertebral arch can be found in classic anatomy, but massive anatomical observations reveal that the connecting part between the posterior arch of atlas and lateral mass resemble pedicle of vertebral arch of other spines in structure and mechanics. Anatomical and imaging measurements demonstrate that atlas lateral mass screw can be fixed through posterior arch and pedicle of vertebral arch, which is called atlas pedicle screw. Measurement data present that the data in the anatomy and image are consistent, therefore, imaging measurement can guide the placement of pedicle screw in surgery. One of the key points in successful placement of pedicle screw lies in taking control of the entry point and the angle of pedicle screw. Through axial CT measurement of atlas, the study is to confirm the safe placement area and corresponding entry angle of atlas pedicle screw, and to guide the clinical operations.
Methods:With random selection of spiral CT thin-layer scanning and three-dimensional reconstruction of atlas of38patients, the space available for the screw (SAS) is defined as the distance between two paralleled lines, one of which is the tangent line of the inner edge of transverse foramen, the other of which is the tangent line of outer edge of vertebral canal. The SAS should be at least5mm with successful placement of the atlas pedicle screw, the diameter of which is3.5mm. The minimum distance between the outer edge of vertebral canal and the inner edge of transverse foramen is the width of pedicle of vertebral arch, and the intersection of the perpendicular bisector of the width and posterior arch of atlas is the lateral boundary of safe placement area. If the intersection is beyond that intersection of tangent line and the posterior arch, the latter intersection was the lateral boundary. The tangent line, in parallel with atlas midline, is of the inner edge of transverse foramen. The intersection of central axis line of screw channel and posterior arch of atlas is the inner boundary when the space available for the screw is5mm. If the intersection is in the inside of that intersection of tangent line and the posterior arch, the latter intersection is the inner boundary. The tangent line, in parallel with atlas midline, is of the outer edge of vertebral canal. Measure the distance between the posterior tubercle of atlas and the inner and the lateral boundary of the safe placement area of screw, corresponding entry angle and depth of pedicle screw, and the width of pedicle of vertebral arch. Guided by preoperative spiral CT measurement,7patients were performed pedicle screw internal fixation in atlas with the application of dredging pipeline method.
Results:CT measurement:the width of pedicle of vertebral arch was (9.15±2.57) mm, which was safe to fix the3.5mm screw. The safe placement area of screw:the entry point was (18.35±2.86) mm～(25.26±1.76) mm away from posterior tubercle of atlas, the entry angle of screw ranges from leaning outwards (9.09±7.45)°to leaning inwards (18.72±17.42)°. The length of screw channel was (26.20±2.69) mm～(27.04±2.51) mm. The width of the safe placement area of screw was6.91±7.66) mm. The transverse angle was (27.81±10.32)°. But there were individual differences. The duration of operation of the7patients was90～120min, and intraoperative hemorrhage was60～300ml, with no vertebral artery injury, no nerve root injury. or no spinal cord injury. After surgery the7patients were examined by X-film and spiral CT of cervical spine, which revealed that the14pedicle screw positions were ideal within the safe placement area of screw measured before surgery, with no break-through of bone cortex of pedicle of vertebral arch. The7patients were followed up from6to12months, which showed no loosening and breakage of internal fixation and bone fusion were observed in all7patients.
Conclusion:There exists safe placement area in fixing pedicle screw. The fixation of pedicle screw in the safe placement area can lean inwards or lean outwards according to the entry point of screw. It is critical for successful surgery to have exhaustive preoperative imaging measurement, to confirm safe placement area of screw, and to fix pedicle screw individually.
引文
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[45]邵将,贾连顺,陈雄生,等.难复性寰枢椎脱位的外科治疗.中华骨科杂志,2010,30(2)：192-197.
[46]移平,谭明生,塔娜,等.寰椎椎弓根螺钉置钉技巧探讨.中国矫形外科杂志,2010,18(10)：862-864.
[47]郝定均,许正伟,贺宝荣,等.寰枢椎椎弓根螺钉技术治疗陈旧性齿状突骨折并寰枢椎失稳.中华创伤杂志,2011,27(2)：121-124.
[48]覃炜,权正学,欧云生,等.颈后路椎弓根螺钉内固定术治疗寰枢椎不稳及脱位.中国修复重建外科杂志.2010,24(2)：202-205.
[49]王麓山,王文军,王程,等.寰枢椎后路三点式固定的适应证与初步临床应用.中国脊柱脊髓杂志,2011,21(6)：459-462.
[50]谭明生,张光铂,移平,等.管道疏通法行颈椎弓根螺钉置入的研究.中国脊柱脊髓杂志,2002,12(7)：405-410.
[51]陆斌,李广琪.李建武.等.人工寰齿关节置换与Magerl经关节螺钉固定的生物力学比较.中国矫形外科杂志.2010,18(7)：568-572
[1]Goel A, Laheri V. Plate and screw fixation for atlanto-axial subluxation. Acta Neurochirurgica,1994,129(1-2):47-53.
[2]Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation[J].Spine,2001,26 (22):2467-2471.
[3]Resnick DK, Lapsiwala S, Trost GR.Anatomic suitability of the C1-C2 complex for pedicle screw fixation [J].Spine,2002,27 (14):1494-1498.
[4]Tan M, Wang H, Wang Y, et al.Morphometric evaluation of screw fixation in atlas via posterior arch and lateral mass [J]. Spine,2003,28(9):888-895.
[5]马向阳,钟世镇,刘景发,等.寰枢椎后路椎弓根螺钉固定的解剖可行性研究.中国临床解剖学杂志,2003,21(6)：554—555.
[6]马向阳,钟世镇,刘景发,等.寰椎后弓侧块螺钉固定的解剖学测量.中国脊柱脊髓杂志。2004,14(1)：23—25.
[7]何帆,尹庆水,赵廷宝,等.寰椎椎弓根螺钉固定技术的改进研究.中华创伤骨科杂志,2008,10(3)：257-259.
[8]谭明生,张光铂,李子荣,等.寰椎测量及其经后弓侧块螺钉固定通道的研究.中国脊柱脊髓杂志.2002,12(1)：5-8.
[9]Ebraheim NA, Xu R, Ahmad M, et al. The quantitative anatomy of the vertebral artery groove of the atlasandits relation to the posterior atlantonxial approach. Spine, 1998,23(3):320-323.
[10]Bilge O. An anatomic al and morphoetric study of C2 nerve root ganglion and its corresponding foramen. Spine,2004,29(5):4.
[11]夏虹,钟世镇,刘景发,等.寰椎侧块后路螺钉固定的应用解剖学.中国临床解剖学杂志,2002,20(2)：83-85.
[12]马向阳,赵卫东,尹庆水,等.寰椎后路单或双层皮质骨螺钉固定强度的生物力学评价[J].中国脊柱脊髓杂志.2005,15(1)：34-37.
[13]Goel A, Desai KI, Muzumdar DP. Atltoaxial fLxelion using plate and screw method:a report of 160 treated patients. Neurosurgery,2002,51(6):1351-1356.
[14]Resnick DK, Benzel Ec. C1-C2 pedicle screw fixation with rigid cantilever beam construct:case report and technical note. Neuro-surgery,2002,50 (2):426-428.
[15]马向阳,尹庆水,吴增晖,等.寰椎椎弓根与枢椎侧块关系的解剖与临床研究.中华骨科杂志2004,24(5)：295-298.
[16]谭明生,唐向盛,移平,等.寰椎椎弓根显露置钉法的临床应用.脊柱外科杂志,2011,9(3)：148-152.
[17]贾卫斗,白桂有,杨博贵,等.徒手经寰枢椎椎弓根植钉固定的X线片和CT片个性化设计.中国修复重建外科杂志,2008,22(4)：416-420.
[18]覃炜,权正学,刘洋,等.寰枢椎椎弓根螺钉个体化导向模板的研制与实验研究[J].中国修复重建外科杂志,2010,24(10)：1168-1173.
[19]王圣林,王超,闫明,等.寰枢侧块钉板固定术第1颈椎侧块螺钉置入准确性的分析.中华外科杂志,2008,46(2)：115-117.
[2]Resnick DK, Benzel Ec. C1-C2 pedicle screw fixation with rigid cantilever beam construct:case report and technical note. Neuro-surgery,2002,50 (2):426-428.
[3]马向阳,钟世镇,刘景发,等.寰枢椎后路椎弓根螺钉固定的解剖可行性研究.中国临床解剖学杂志,2003,21(6)：554—555.
[4]谭明生,张光铂,李子荣,等.寰椎测量及其经后弓侧块螺钉固定通道的研究.中国脊柱脊髓杂志.2002,12(1)：5-8.
[5]马向阳,尹庆水,钟世镇,等.寰枢关节后部神经血管丛与寰椎椎弓根螺钉固定的解剖关系.中国临床解剖学杂志,2005,23(5)：454-457
[6]Wang C, Yan M, Zhou H, et al. Atlantoaxial transarticular screw fixation with morselized autograft and without additional internal fixation:technical description and report of 57 cases[J].Spine,2007,32 (6):643-646.
[7]Goel A, Laheri V. Plate and screw fixation for atlanto-axial subluxation. Acta Neurochirurgica,1994,129(1-2):47-53.
[8]Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation[J].Spine,2001,26 (22):2467-2471.
[9]Resnick DK, Lapsiwala S, Trost GR.Anatomic suitability of the Cl-C2 complex for pedicle screw fixation [J].Spine,2002,27(14):1494-1498.
[10]Tan M, Wang H, Wang Y, et al.Morphometric evaluation of screw fixation in atlas via posterior arch and lateral mass [J]. Spine,2003,28(9):888-895.
[11]夏虹,钟世镇,刘景发,等.寰椎侧块后路螺钉固定的应用解剖学.中国临床解剖学杂志,2002,20(2)：83-85.
[12]尹东,原林,夏虹,等.寰椎侧块的测量及其临床意义.中国临床解剖学杂志,2003,21(3)：241-242.
[13]闫明,王超,党耕町,等.经寰椎侧块和枢椎峡部内固定的解剖学基础.中国脊柱脊髓杂志,2003,13(1)：25-27.
[14]马向阳,钟世镇,刘景发,等.寰椎后弓侧块螺钉固定的解剖学测量.中 国脊柱脊髓杂志。2004,14(1)：23-25.
[15]李桂成,覃冰兰,冯照善,等.寰椎的测量及临床应用意义.四川解剖学杂志,2010,18(2)：18-21.
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[17]陈前芬,金大地,肖增明,等.寰枢椎椎弓根螺钉技术的应用解剖研究.广西医科大学学报,2009,26(3)：365-368.
[18]夏虹,钟世镇,刘景发,等.寰椎侧块后路螺钉固定的可行性研究.中国矫形外科杂志,2002,10(9)：888-891.
[19]马向阳,赵卫东,尹庆水,等.寰椎后路单或双层皮质骨螺钉固定强度的生物力学评价[J].中国脊柱脊髓杂志.2005,15(1)：34-37.
[20]张昊,白净,谭明生,等.寰椎后路椎弓根螺钉及侧块螺钉的生物力学分析.清华大学学报(自然科学版),2008,48(3)：419-422.
[21]林锋,池永龙,许崇永,等.国人寰枢椎影像解剖测量及其临床意义.温州医学院学报,2004,34(4)：304-305
[22]谭明生,王惠敏,张光铂,等.寰椎后弓侧块螺钉固定通道的CT测量.中国脊柱脊髓杂志,2003,13(1)：28-31.
[23]贾卫斗,郑铁钢,杨博贵,等.寰枢椎椎弓根影像学测量及临床应用.中国矫形外科杂志,2008,16(16)：1221-1223.
[24]陈前芬,肖增明,张忠民,等.寰椎椎弓根螺钉技术的剖面解剖和三维CT应用研究.中国临床解剖学杂志,2009,27(2)：166-169.
[25]王圣林,王超,闫明,等.寰枢侧块钉板固定术第1颈椎侧块螺钉置入准确性的分析.中华外科杂志,2008,46(2)：115-117.
[26]贾卫斗,白桂有,杨博贵,等.徒手经寰枢椎椎弓根植钉固定的X线片和CT片个性化设计.中国修复重建外科杂志,2008,22(4)：416-420.
[27]何帆,尹庆水,赵廷宝,等.寰椎椎弓根螺钉固定技术的改进研究.中华创伤骨科杂志,2008,10(3)：257-259.
[28]蔡小军,何斌,韩建华,等.寰椎椎动脉沟后结节的观测及其临床意义.中华外科杂志,2010,48(9)：709-710.
[29]覃炜,权正学,刘洋,等.寰枢椎椎弓根螺钉个体化导向模板的研制与实验研究[J].中国修复重建外科杂志,2010,24(10)：1168-1173.
[30]谭健,王文军,李严兵.寰椎椎弓根进钉通道的数字解剖学研究.中国脊柱脊髓杂志,2010 20(11)：885-888.
[31]Ma XY, Yin QS, Wu ZH, et al.Anatomic considerations for the pedicle screw placement in the rst lervical vertebra[J].Spine,2005,30 (13):1519-1523.
[32]刘晓岚,周若舟,刘社庭,等.枢椎椎弓峡部引导下寰椎椎弓根置钉的CT测量及其应用.中国脊柱脊髓杂志,2010,20(11)：930-934.
[33]谭明生,唐向盛,移平,等.寰椎椎弓根显露置钉法的临床应用.脊柱外科杂志,2011,9(3)：148-152.
[34]王程,王文军,刘海兵,等.寰枢椎后路“三点式”经椎弓根固定的生物力学评价.中国脊柱脊髓杂志,2010,20(10)：860-863.
[35]谭明生,移平,王文军,等.经寰椎“椎弓根”内固定技术的临床应用.中国脊柱脊髓杂志,2006,16(5)：336-340.
[36]马向阳,尹庆水,吴增晖,等.寰椎椎弓根与枢椎侧块关系的解剖与临床研究.中华骨科杂志2004,24(5)：295-298.
[37]王清,康建平,谭美云,等.椎弓根螺钉技术治疗寰枢椎骨折脱位的临床观察.中华创伤杂志,2007,23(1)：16-20.
[38]钱普健,林刚,张华山,等.经寰椎侧块枢椎椎弓根钉棒系统治疗寰枢椎不稳.中华骨科杂志,2007,27(3)：228-230.
[39]郝定均,贺宝荣,周劲松,等.后路寰椎侧块螺钉结合枢椎椎弓根螺钉固定治疗寰枢椎不稳.中华骨科杂志,2005,25(9)：537-540.
[40]陈其听,杨迪,李方才,等.寰椎后弓侧块螺钉进钉角度的影像学研究及临床研究.中华骨科杂志,2006,26(7)：442-446.
[41]卢旭华,陈德玉,王新伟,等.后路椎弓根螺钉治疗齿状突骨折伴可复性寰枢椎脱位.中华创伤杂志,2008,24(8)：598-601.
[42]王群波,邵高海,李波,等.经寰枢椎椎弓根侧块螺钉技术治疗寰枢椎失稳.中华创伤杂志,2008,24(11)：871-874.
[43]李雷,王欢,崔少千,等.寰枢椎椎弓根钉棒系统内固定融合术治疗上颈椎 损伤.中华创伤杂志,2009,25(9)：813-817.
[44]左春光,王新虎,王建顺,等.寰枢椎椎弓根螺钉固定治疗寰枢椎失稳.中国脊柱脊髓杂志,2009,19(11)：877-878.
[45]邵将,贾连顺,陈雄生,等.难复性寰枢椎脱位的外科治疗.中华骨科杂志,2010,30(2)：192-197.
[46]移平,谭明生,塔娜,等.寰椎椎弓根螺钉置钉技巧探讨.中国矫形外科杂志,2010,18(10)：862-864.
[47]郝定均,许正伟,贺宝荣,等.寰枢椎椎弓根螺钉技术治疗陈旧性齿状突骨折并寰枢椎失稳.中华创伤杂志,2011,27(2)：121-124.
[48]覃炜,权正学,欧云生,等.颈后路椎弓根螺钉内固定术治疗寰枢椎不稳及脱位.中国修复重建外科杂志.2010,24(2)：202-205.
[49]王麓山,王文军,王程,等.寰枢椎后路三点式固定的适应证与初步临床应用.中国脊柱脊髓杂志,2011,21(6)：459-462.
[50]谭明生,张光铂,移平,等.管道疏通法行颈椎弓根螺钉置入的研究.中国脊柱脊髓杂志,2002,12(7)：405-410.
[51]陆斌,李广琪.李建武.等.人工寰齿关节置换与Magerl经关节螺钉固定的生物力学比较.中国矫形外科杂志.2010,18(7)：568-572
[1]Goel A, Laheri V. Plate and screw fixation for atlanto-axial subluxation. Acta Neurochirurgica,1994,129(1-2):47-53.
[2]Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation[J].Spine,2001,26 (22):2467-2471.
[3]Resnick DK, Lapsiwala S, Trost GR.Anatomic suitability of the C1-C2 complex for pedicle screw fixation [J].Spine,2002,27 (14):1494-1498.
[4]Tan M, Wang H, Wang Y, et al.Morphometric evaluation of screw fixation in atlas via posterior arch and lateral mass [J]. Spine,2003,28(9):888-895.
[5]马向阳,钟世镇,刘景发,等.寰枢椎后路椎弓根螺钉固定的解剖可行性研究.中国临床解剖学杂志,2003,21(6)：554—555.
[6]马向阳,钟世镇,刘景发,等.寰椎后弓侧块螺钉固定的解剖学测量.中国脊柱脊髓杂志。2004,14(1)：23—25.
[7]何帆,尹庆水,赵廷宝,等.寰椎椎弓根螺钉固定技术的改进研究.中华创伤骨科杂志,2008,10(3)：257-259.
[8]谭明生,张光铂,李子荣,等.寰椎测量及其经后弓侧块螺钉固定通道的研究.中国脊柱脊髓杂志.2002,12(1)：5-8.
[9]Ebraheim NA, Xu R, Ahmad M, et al. The quantitative anatomy of the vertebral artery groove of the atlasandits relation to the posterior atlantonxial approach. Spine, 1998,23(3):320-323.
[10]Bilge O. An anatomic al and morphoetric study of C2 nerve root ganglion and its corresponding foramen. Spine,2004,29(5):4.
[11]夏虹,钟世镇,刘景发,等.寰椎侧块后路螺钉固定的应用解剖学.中国临床解剖学杂志,2002,20(2)：83-85.
[12]马向阳,赵卫东,尹庆水,等.寰椎后路单或双层皮质骨螺钉固定强度的生物力学评价[J].中国脊柱脊髓杂志.2005,15(1)：34-37.
[13]Goel A, Desai KI, Muzumdar DP. Atltoaxial fLxelion using plate and screw method:a report of 160 treated patients. Neurosurgery,2002,51(6):1351-1356.
[14]Resnick DK, Benzel Ec. C1-C2 pedicle screw fixation with rigid cantilever beam construct:case report and technical note. Neuro-surgery,2002,50 (2):426-428.
[15]马向阳,尹庆水,吴增晖,等.寰椎椎弓根与枢椎侧块关系的解剖与临床研究.中华骨科杂志2004,24(5)：295-298.
[16]谭明生,唐向盛,移平,等.寰椎椎弓根显露置钉法的临床应用.脊柱外科杂志,2011,9(3)：148-152.
[17]贾卫斗,白桂有,杨博贵,等.徒手经寰枢椎椎弓根植钉固定的X线片和CT片个性化设计.中国修复重建外科杂志,2008,22(4)：416-420.
[18]覃炜,权正学,刘洋,等.寰枢椎椎弓根螺钉个体化导向模板的研制与实验研究[J].中国修复重建外科杂志,2010,24(10)：1168-1173.
[19]王圣林,王超,闫明,等.寰枢侧块钉板固定术第1颈椎侧块螺钉置入准确性的分析.中华外科杂志,2008,46(2)：115-117.