新型寰枢椎后路动态固定系统的研制与实验研究
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摘要
目的结合国人寰枢椎的解剖学特点,原创性设计新型的寰枢椎后路动态固定系统,评价其生物力学稳定性,为完善设计与临床应用提供基础理论依据。
方法研究由二个部分组成：(一)新型的寰枢椎后路动态内固定系统的设计与制作。取100例正常成人上颈椎CT三维重建图像,测量相关解剖参数,并与文献国人颈椎的解剖学参数比较,设计新型的寰枢椎后路动态内固定系统,并制作样品。(二)新型的寰枢椎后路动态内固定系统的生物力学研究。采集较为新鲜颈椎枕颈CO-C48具,分成完整状态组、失稳状态组、寰枢椎后路动态内固定以及寰枢椎后路椎弓根固定组四个组。用生物力学三维运动测试仪分别进行位移、刚度等测试,以完整状态的节段运动为对照组,对其在维持局部稳定性、保存运动功能以及对下位椎间活动度的影响等方面进行生物力学评价,结果进行统计学处理。
结果新型的寰枢椎后路动态内固定系统的设计符合国人颈椎解剖特点。生物力学测试显示在屈曲、伸展、左右侧屈、旋转等工况下,新型寰枢椎后路动态固定系统组的寰枢椎的ROM与完整状态相比,呈无明显差异(P>0.05),常规寰枢椎椎弓根螺钉固定组寰枢椎的ROM与完整状态相比呈非常显著性差异(P<0.001),两种固定方法组寰枢椎的ROM相比,呈非常显著性差异(P<0.001)。新型寰枢椎后路动态固定系统组的颈2/3节段ROM与完整状态相比,呈无明显差异(P>0.05),常规寰枢椎椎弓根螺钉固定组颈2/3节段的ROM与完整状态相比呈非常显著性差异(P<0.001)；两种固定方法组颈2/3节段的ROM相比,呈非常显著性差异(P<0.001)。稳定指数和颈椎总体刚度测定也体现了动态固定的优越性。
结论全新寰枢椎后路动态固定系统具有良好的生物力学性能,且符合国人颈椎解剖要求；生物力学实验研究表明它既能恢复寰枢椎的稳定性又能保留其生理运动功能,并可有效减少对邻近节段的影响。
Objective A new type Atlantoaxial dynamic stabilization system were original designed based on the anatomic character of Chinese People. The biomechanics of the new dynamic stabilization system were investigated, to provide theoretical principle for clinic application and optimize design.
Methods This study was divided in two Parts. Part one:The design and manufacture a new type Atlantoaxial dynamic stabilization system based on the anatomic character of100normal Chinese People through three dimension CT of upper cervical. Part two:Biomechanical study of the new type Atlantoaxial dynamic stabilization system.8fresh adult cervical spine (C0-C4) sample were made into four groups successively, include integrity status group,Unstable status group, dynamic stabilization system fixation group, pedicle screw fixation group. ROM of the segment and stiffness were tested by mechanical test machine. Compared with integrity status respectively, analyzed the influence to the ROM of the stabilized segment, motion function and influence of adjacent segment. The consequence were analyzed by statistics.
Results The Atlantoaxial dynamic stabilization system is in accordance with the feature cervical spine of Chinese People. The biomechanical study shows the ROM of Cl/2in integrity status group and dynamic stabilization system fixation group under various models such as flexion, extension, Lateral bending and rotation was no significant difference (P>0.05), integrity status group and pedicle screw fixation group under various models was obvious significant difference (P<0.001),dynamic stabilization system fixation group, and pedicle screw fixation group under various models was obvious significant difference (P<0.001). The ROM of C2/3in integrity status group and dynamic stabilization system fixation group under various models such as flexion, extension, Lateral bending and rotation was no significant difference (P>0.05), integrity status group and pedicle screw fixation group under various models was obvious significant difference (P<0.001),dynamic stabilization system fixation group, and pedicle screw fixation group under various models was obvious significant difference (P<0.001). Consequence of stability and stiffness also illustrated the advantage of dynamic stabilization system.
Conclusion A new type of dynamic stabilization system can provide an sufficient biomechanical stability, and correspond with characteristic of Chinese people anatomy. The new type of dynamic stabilization system not only can recover stability of Cl/2,but retain the motion function of C1/2,and decrease influence to the adjacent segment effectively.
方法研究由二个部分组成：(一)新型的寰枢椎后路动态内固定系统的设计与制作。取100例正常成人上颈椎CT三维重建图像,测量相关解剖参数,并与文献国人颈椎的解剖学参数比较,设计新型的寰枢椎后路动态内固定系统,并制作样品。(二)新型的寰枢椎后路动态内固定系统的生物力学研究。采集较为新鲜颈椎枕颈CO-C48具,分成完整状态组、失稳状态组、寰枢椎后路动态内固定以及寰枢椎后路椎弓根固定组四个组。用生物力学三维运动测试仪分别进行位移、刚度等测试,以完整状态的节段运动为对照组,对其在维持局部稳定性、保存运动功能以及对下位椎间活动度的影响等方面进行生物力学评价,结果进行统计学处理。
结果新型的寰枢椎后路动态内固定系统的设计符合国人颈椎解剖特点。生物力学测试显示在屈曲、伸展、左右侧屈、旋转等工况下,新型寰枢椎后路动态固定系统组的寰枢椎的ROM与完整状态相比,呈无明显差异(P>0.05),常规寰枢椎椎弓根螺钉固定组寰枢椎的ROM与完整状态相比呈非常显著性差异(P<0.001),两种固定方法组寰枢椎的ROM相比,呈非常显著性差异(P<0.001)。新型寰枢椎后路动态固定系统组的颈2/3节段ROM与完整状态相比,呈无明显差异(P>0.05),常规寰枢椎椎弓根螺钉固定组颈2/3节段的ROM与完整状态相比呈非常显著性差异(P<0.001)；两种固定方法组颈2/3节段的ROM相比,呈非常显著性差异(P<0.001)。稳定指数和颈椎总体刚度测定也体现了动态固定的优越性。
结论全新寰枢椎后路动态固定系统具有良好的生物力学性能,且符合国人颈椎解剖要求；生物力学实验研究表明它既能恢复寰枢椎的稳定性又能保留其生理运动功能,并可有效减少对邻近节段的影响。
Objective A new type Atlantoaxial dynamic stabilization system were original designed based on the anatomic character of Chinese People. The biomechanics of the new dynamic stabilization system were investigated, to provide theoretical principle for clinic application and optimize design.
Methods This study was divided in two Parts. Part one:The design and manufacture a new type Atlantoaxial dynamic stabilization system based on the anatomic character of100normal Chinese People through three dimension CT of upper cervical. Part two:Biomechanical study of the new type Atlantoaxial dynamic stabilization system.8fresh adult cervical spine (C0-C4) sample were made into four groups successively, include integrity status group,Unstable status group, dynamic stabilization system fixation group, pedicle screw fixation group. ROM of the segment and stiffness were tested by mechanical test machine. Compared with integrity status respectively, analyzed the influence to the ROM of the stabilized segment, motion function and influence of adjacent segment. The consequence were analyzed by statistics.
Results The Atlantoaxial dynamic stabilization system is in accordance with the feature cervical spine of Chinese People. The biomechanical study shows the ROM of Cl/2in integrity status group and dynamic stabilization system fixation group under various models such as flexion, extension, Lateral bending and rotation was no significant difference (P>0.05), integrity status group and pedicle screw fixation group under various models was obvious significant difference (P<0.001),dynamic stabilization system fixation group, and pedicle screw fixation group under various models was obvious significant difference (P<0.001). The ROM of C2/3in integrity status group and dynamic stabilization system fixation group under various models such as flexion, extension, Lateral bending and rotation was no significant difference (P>0.05), integrity status group and pedicle screw fixation group under various models was obvious significant difference (P<0.001),dynamic stabilization system fixation group, and pedicle screw fixation group under various models was obvious significant difference (P<0.001). Consequence of stability and stiffness also illustrated the advantage of dynamic stabilization system.
Conclusion A new type of dynamic stabilization system can provide an sufficient biomechanical stability, and correspond with characteristic of Chinese people anatomy. The new type of dynamic stabilization system not only can recover stability of Cl/2,but retain the motion function of C1/2,and decrease influence to the adjacent segment effectively.
引文
1.程士德.内经讲义[M].上海：上海科学技术出版社,1984.
2.项良碧祖启明,上颈椎内固定技术及其进展[J].中华骨科杂志,2005,6(25)375-378
3. Stulik J, V vskocil T, Sebesta P, et al. Atlantoaxial fixation using the polyaxial screw-rod system[J]. Eur Spine J,2007,16(4):479-484
4.马维虎,刘观燚,徐荣明,等.寰椎椎弓根螺钉及枢椎椎板螺钉固定植骨融合治疗创伤性上颈椎不稳[J].中国脊柱脊髓杂志,2010.3(20)：214-21 8
5.马维虎,刘观燚,孙韶华,等.经后路寰枢椎椎弓根螺钉内固定治疗C1-2不稳定[J].中国脊柱脊髓杂志,2009,1(19)：47-51
6. M.Stoll,Giues,Dubois,et al.The dynamic neutralization system for the spine:a multi-center study of a novel non-fusion system [J]. Eur Spine J,2002,11(2):170-172
7.曹正霖,钟世镇,刘景发,等.人工寰齿关节置换术的生物力学研究[J].中国矫形外科杂志,2003,11：240-242
8.陈坚,刘浩,杨志明.人工寰枢关节的研制及应用解剖研究[J].中国临床解剖学杂志,1999,17：150-152
9.胡勇,杨述华,谢辉,寰齿关节定量解剖研究及人工寰齿关节的研制[J].中华创伤杂志,2006,11：858-863
10.覃海飚,韦蒙,刘义斌,等.后路寰椎钉板系统内固定治疗不稳定型Jefferson骨折中国脊柱脊髓杂志,2012,22(20)：123-125
11.马维虎,刘观燚,孙韶华,等.经后路寰枢椎椎弓根螺钉内固定治疗C1-2不稳.中国脊柱脊髓杂志,2009,19：47-51
12.徐荣明,胡勇,马维虎,等.寰枢椎后路三种组合固定技术治疗寰枢关节不稳的临床评估.中华创伤杂志,2010,26(6)：516-522.
13.马向阳,钟世镇,刘景发,等.寰枢椎后路椎弓根螺钉固定的生物力学评价.中国脊椎脊髓杂志,2003,13(12)：735-738.
14. Xiao ZM, Zhan XL, Gong DF, et al. C2 pedicle screw and plate combined with C1 titanium cable fixation for the treatment of atlantoaxial instability not suitable for placement of C1 screw. JSpinal Disord Tech,2008,21:514-517.
15. Kandziora F, Schnake K, Hoffmann R. Surgical procedures to stabilize the upper cervical spine. Unfallchirurg,2010,113:845-858.
16. Nassos JT, Ghanayem AJ, Sasso RC, et al. Biomechanical evaluation of segmental occipitoatlantoaxial stabilization techniques. Spine (Phila Pa 1976),2009,34:2740-2744
17. Richter M, Schmidt R,Claes L et a 1.Posterior atlantoaxial fixation:biomechanical in vitro comparison of six different techniques.Spine.2002 Aug15,27(16):1724-1732
18.同德强,谢志军,于有德,等.颈椎弓根螺钉内固定的解剖学研究.中华骨科杂志,2002,22(11)：657-661.
19. Doherty BJ, Heggeness MH, The quantitative anatomy of the atlas. Spine,1994; 19(22): 2497-2500
20.曹正霖,钟世镇,徐达传.寰枢椎的解剖学测量及其临床意义.中国临床解剖学杂志,2000；18(4)：299-301
21.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
22.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
23. Resnick DK, Benzel EC.C1-C2 pedicle screw fixation with rigid cantilever beam construct:case report and technical note. Neurosurg,2002;50(2):426-428.
24.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
25. Borne GM, Bedou GL, Pindaudeau M. Treatment of pedicular fractures of the axis.A clinical study and screw fixation technique. J Neurosurg,1984;60:88-93
26. Yarbrough BE, Hendey GW. Hangman's fracture resulting from improper seat belt use. South Med J,1990; 83(7):843-845
27. Ebraheim NA, Fow J, Xu R, et al.The location of the pedicle and pars interarticularis in the axis. Spine,2001,26(4):E34-E37
28.侯黎升,贾连顺,谭军,等.枢椎各结构的解剖学部位研究.中国临床解剖学杂志,2005；23(1)：44-47
29. Nadefi S, Arman C, Guvencer M, et al.An anatomical study of the C-2 pedicle. J Neurosurg Spine,2004; 1 (3):306-310
30. Mandel IM, Kambach BJ, Petersilge CA, et al.Morphologic considerations of C2 isthmus dimensions for the placement of transarticular screws.Spine,2000;25(12):1542-1547
31. Xu R, Nadaud MC, Ebraheim NA et al.Morphology of the second cervical vertebra and the posterior projection of the C2 pedicle axis.Spine,1995,20(3):259-263
32.瞿东滨,钟世镇,徐达传.枢椎椎弓根及其内固定的临床应用解剖.中国临床解剖学杂志.1999,17：153-154
33. Howington JU,Kruse JJ.Awasthi D.Surgical anatomy of the C2 pedicle.J Neurosurg, 2001,95(1 Suppl):88-92
34.候黎升,贾连顺,谭军,等.枢椎侧方椎弓的临床解剖学测量.中国临床解剖学杂志,2004,,2(6)：578-582
35.贾连顺,袁文.颈椎外科学[C].北京：人民卫生出版社,2009：340-375
36.夏虹,钟世镇,赵卫东,等.寰椎横韧带的形态特点及其生物力学特性研究.中国临床解剖杂志.2003,23(3)：266—269.
37. DohertyBJ,HeggenessMH,Essessl.A biomechanical study of odontoid fractures and fracture fixation. Spine,1993,15(2):178-184
38.何达,韩骁,陶剑锋,田伟.颈椎人工间盘置换与颈椎内固定置人对相邻节段退变的生物力学影响.中国组织工程研究与临床康复,2008,12(22)：4229-4232.
39. Pickett GE,Sekhon LH,Sears WR,et al.Complications with cervicalarthraplasty.J Neurosurg Spine,2006,4(2):98-105.
40. GoodmanSB.The effects of micromotion and Particulate materials on Tissue differentiation. Aeta OrthoPSeand,1994,65(258suppl):1-43
41.王以进、王介麟编著,骨科生物力学[M].北京：人民军医出版社,1989.P.189-201
42. TominagaT.Dickman CA.Sonntag VK.et al. Comparative anatomy of the baboon and the human cervical spine. Spine,1995,20(2):131-137
43. Deliganis AV. Baxter AB, Hanson JA, et al. Radiologic spectrum of craniocervical distraction injufies[J]. Radiographics,2000,20:237-250.
44.袁文,贾连顺,丁祖泉.寰椎横韧带断裂对枕颈部稳定性的影响.第二军医大学学报,1995,16(6)：563-566
45.瞿东滨,钟世镇.骨科生物力学的发展及前沿领域.中华外科杂志,2010,48 (4)：311-313
46.陈庄洪,黄卫兵,蔡贤华,等.前路经寰枢关节螺钉内固定术治疗寰枢椎不稳定的生物力学及临床研究.中华实验外科杂志,2011,28(8)：1390-1394.
1侯铁胜,李明,赵杰,等.Apofix颈椎后路内固定系统治疗颈椎骨折脱位的初步报告[J].中国创伤骨科杂志,2000,2：19-22.
2 Goel A,Laberi V.Plate and screw fixation for atlantoaxial subluxanon[J].Acta Ncurochir(Wicn),1994,129:47-53.
3 Melcher RP,Puttlitz CM,Kleinstueck FS,et al.Biomechanical testing of posterior atlantoaxial fixation techniques[J].Spine.2002,2:2435-2440.
4党耕町,王超,阎明,等.后路寰枢椎侧块钉板固定植骨融的临床初探[J].中国脊柱脊髓杂志,2003,13：7-10.
5李雷,王欢,崔少千,等.经后路寰椎椎弓根螺钉系统内固定融合术治疗上颈椎疾患[J].中国修复重建外科杂志,2007,5(21)：463-464.
6马维虎,刘观燚,孙韶华,等.经后路寰枢椎椎弓根螺钉内固定治疗C1-2不稳[J].中国脊柱脊髓杂志,2009,1(19)：47-51.
7 Maciejczak A,Radek A Screw fixation of craniocervical junction[J].Niurol Ncurochi Pol,1999,33:1403-1413.
8 Harms J,Meleher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation[J]. Spine,2001,21:2417-2471.
9ValeFl,OliwerM,CahillDW.Rigidoccipito-cervieel fusion[J]. J Neurosurg,1999,91:144-150.
10 Hoh T, Tsuji H, Kotoh Y, et al.Occipital cervical fusion rein forced by Luques segmental spinal instrumentation for rheumatoid disease[J]. Spine,1988,13:1234-1238.
11 Ransfard AD, Crockard HA, Pozo JL.et al.Cranio-eeervicalinstability treated by contoured loop fixation [J].J Bone&Joint Surg(Br),1986,68:173-177.
12马维虎,徐荣明,孙韶华.枕颈固定技术在上颈椎不稳的应用[J].中华创伤杂志2005,21：383-385.
13袁峰,杨惠林,郭开今,等.经枢椎椎板交叉螺钉技术解剖学研究[J].徐州医学院学报,2008,6(22)：433-435.
14马向阳,尹庆水,吴增晖,等.枢椎椎板螺钉与椎弓根螺钉抗拔出强度的比较[J].中国脊柱脊髓杂志,2007,2(21)：163-164.
15马维虎,胡勇,孙绍华,等.枢椎椎板螺钉治疗上颈椎不稳的临床研究[J].中国骨与关节外科,2009,6(2)459-464。
16马维虎,刘观燚,徐荣明,等.寰椎椎弓根螺钉及枢椎椎板螺钉固定植骨融合治疗创伤性上颈椎不稳.中国脊柱脊髓杂志,2010,3(20)：214-218.
17徐荣明,刘观燚,马维虎.经枢椎椎板关节突关节螺钉固定的解剖学研究[J].中华创伤杂志,2008,11(24)：874-876.
18谭军,贾连顺,候黎升,等.C2椎弓根拉力螺钉选择性治疗Hangman骨折[J].中华骨科杂志,2002,22：653-656.
19胡勇,马维虎,徐荣明,等.枢椎椎弓根拉力螺钉内固定技术治疗Hangman骨折[J].中国骨伤,2008,9(9),678-680.
20瞿东滨,钟世镇,徐达传.枢椎椎弓根及其内固定的临床应用解剖[J].中国临床解剖杂志,1999,17：153-154.
21 Howington JU,Kruse JJ,Awasthi D. Surgical anatomy of the C2 pedicle [J]. J Neurosurg,2001,95:88-92.
22马维虎,徐荣明,孙韶华等.C2,3椎弓根固定治疗不稳定性Hangman骨折[J].中华骨科杂志,2006,9(26)：590-592.
23吕厚山,主译.脊柱内固定[M].第2版,北京：中国医药科技出版社,2001,88-89.
24 McGuire RA, Harkey HL. Modification of technique and results of atlantoaxial transfacet stabilization. Orthopedics.1995,18:1029-1032.
25 Bohler J. Anterior stabilization for acute fractures and non-unions of the dens[J]. J Bone Joint Surg,1982,64A:18-27.
26 Dickman CA, Sonntag VKH, Marcotte PJ. Techniques of screw fixation of the cervical spine[J]. Barrow Neurological Institute Quarterly,1992,8:9-12.
27 Dantas FL, Prandini MN, Caircs AC, et al. Management of odontoid fractures using anterior screw fixation:analysis of 15 ease[J]. Arq Ncuropsiquiat(Sr),2002,1(3):823-829.
28 Graziao G. Jaem C, Lee M, et al.A comparative study of fixation tech uniques for type fractures of the odontoid process[J].Spine,1993,18(16):2382-2387.
29贾连顺,李家顺.枕颈部外科学[M].上海：上海科学技术出版社,2003.
30 Lu J, Ebraheim NA, Yang H, et al.Anatomic considerations of anterior transarticular screw fixation far atlantoaxial instability [J].Spine,1998,23:1229-1236.
31 Vender JR, Harrison SJ, McDonnell DE. Fusion and instrumentation at C1-3 via the high anterior cervical approach[J].J Neurosurg,2000,92(1):24-29.
32 Vieweg U, Meyer B, Schramm J. Differential treatment in acute upper cervical spine injuries:a critical review of a single-institution series [J]. Surg-Neurol, 2000,54(3):203-210;discussion 210-211.
33 Schmelzle R,Harms J, Stoltze D. Osteosynthesen im occipitoccnr-ealem ubergang wom transoral enzugangans [J]. World Congress Abstracts. Munich:Demter-Verlag,1987:27-28.
34 Kandziora FP, flugmacher R, Ludwig K, et al.Biomechanical comparison of four anterior atlantoaxial plate systems[J].J Neurosurg,2002,96(SSupp 1):313-315.
35艾福志,尹庆水,夏虹,等.经口咽前路寰枢椎复位钢板的生物力学评价[J].骨与关节损伤杂志,2003,18(5)：330-334.
2.项良碧祖启明,上颈椎内固定技术及其进展[J].中华骨科杂志,2005,6(25)375-378
3. Stulik J, V vskocil T, Sebesta P, et al. Atlantoaxial fixation using the polyaxial screw-rod system[J]. Eur Spine J,2007,16(4):479-484
4.马维虎,刘观燚,徐荣明,等.寰椎椎弓根螺钉及枢椎椎板螺钉固定植骨融合治疗创伤性上颈椎不稳[J].中国脊柱脊髓杂志,2010.3(20)：214-21 8
5.马维虎,刘观燚,孙韶华,等.经后路寰枢椎椎弓根螺钉内固定治疗C1-2不稳定[J].中国脊柱脊髓杂志,2009,1(19)：47-51
6. M.Stoll,Giues,Dubois,et al.The dynamic neutralization system for the spine:a multi-center study of a novel non-fusion system [J]. Eur Spine J,2002,11(2):170-172
7.曹正霖,钟世镇,刘景发,等.人工寰齿关节置换术的生物力学研究[J].中国矫形外科杂志,2003,11：240-242
8.陈坚,刘浩,杨志明.人工寰枢关节的研制及应用解剖研究[J].中国临床解剖学杂志,1999,17：150-152
9.胡勇,杨述华,谢辉,寰齿关节定量解剖研究及人工寰齿关节的研制[J].中华创伤杂志,2006,11：858-863
10.覃海飚,韦蒙,刘义斌,等.后路寰椎钉板系统内固定治疗不稳定型Jefferson骨折中国脊柱脊髓杂志,2012,22(20)：123-125
11.马维虎,刘观燚,孙韶华,等.经后路寰枢椎椎弓根螺钉内固定治疗C1-2不稳.中国脊柱脊髓杂志,2009,19：47-51
12.徐荣明,胡勇,马维虎,等.寰枢椎后路三种组合固定技术治疗寰枢关节不稳的临床评估.中华创伤杂志,2010,26(6)：516-522.
13.马向阳,钟世镇,刘景发,等.寰枢椎后路椎弓根螺钉固定的生物力学评价.中国脊椎脊髓杂志,2003,13(12)：735-738.
14. Xiao ZM, Zhan XL, Gong DF, et al. C2 pedicle screw and plate combined with C1 titanium cable fixation for the treatment of atlantoaxial instability not suitable for placement of C1 screw. JSpinal Disord Tech,2008,21:514-517.
15. Kandziora F, Schnake K, Hoffmann R. Surgical procedures to stabilize the upper cervical spine. Unfallchirurg,2010,113:845-858.
16. Nassos JT, Ghanayem AJ, Sasso RC, et al. Biomechanical evaluation of segmental occipitoatlantoaxial stabilization techniques. Spine (Phila Pa 1976),2009,34:2740-2744
17. Richter M, Schmidt R,Claes L et a 1.Posterior atlantoaxial fixation:biomechanical in vitro comparison of six different techniques.Spine.2002 Aug15,27(16):1724-1732
18.同德强,谢志军,于有德,等.颈椎弓根螺钉内固定的解剖学研究.中华骨科杂志,2002,22(11)：657-661.
19. Doherty BJ, Heggeness MH, The quantitative anatomy of the atlas. Spine,1994; 19(22): 2497-2500
20.曹正霖,钟世镇,徐达传.寰枢椎的解剖学测量及其临床意义.中国临床解剖学杂志,2000；18(4)：299-301
21.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
22.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
23. Resnick DK, Benzel EC.C1-C2 pedicle screw fixation with rigid cantilever beam construct:case report and technical note. Neurosurg,2002;50(2):426-428.
24.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
25. Borne GM, Bedou GL, Pindaudeau M. Treatment of pedicular fractures of the axis.A clinical study and screw fixation technique. J Neurosurg,1984;60:88-93
26. Yarbrough BE, Hendey GW. Hangman's fracture resulting from improper seat belt use. South Med J,1990; 83(7):843-845
27. Ebraheim NA, Fow J, Xu R, et al.The location of the pedicle and pars interarticularis in the axis. Spine,2001,26(4):E34-E37
28.侯黎升,贾连顺,谭军,等.枢椎各结构的解剖学部位研究.中国临床解剖学杂志,2005；23(1)：44-47
29. Nadefi S, Arman C, Guvencer M, et al.An anatomical study of the C-2 pedicle. J Neurosurg Spine,2004; 1 (3):306-310
30. Mandel IM, Kambach BJ, Petersilge CA, et al.Morphologic considerations of C2 isthmus dimensions for the placement of transarticular screws.Spine,2000;25(12):1542-1547
31. Xu R, Nadaud MC, Ebraheim NA et al.Morphology of the second cervical vertebra and the posterior projection of the C2 pedicle axis.Spine,1995,20(3):259-263
32.瞿东滨,钟世镇,徐达传.枢椎椎弓根及其内固定的临床应用解剖.中国临床解剖学杂志.1999,17：153-154
33. Howington JU,Kruse JJ.Awasthi D.Surgical anatomy of the C2 pedicle.J Neurosurg, 2001,95(1 Suppl):88-92
34.候黎升,贾连顺,谭军,等.枢椎侧方椎弓的临床解剖学测量.中国临床解剖学杂志,2004,,2(6)：578-582
35.贾连顺,袁文.颈椎外科学[C].北京：人民卫生出版社,2009：340-375
36.夏虹,钟世镇,赵卫东,等.寰椎横韧带的形态特点及其生物力学特性研究.中国临床解剖杂志.2003,23(3)：266—269.
37. DohertyBJ,HeggenessMH,Essessl.A biomechanical study of odontoid fractures and fracture fixation. Spine,1993,15(2):178-184
38.何达,韩骁,陶剑锋,田伟.颈椎人工间盘置换与颈椎内固定置人对相邻节段退变的生物力学影响.中国组织工程研究与临床康复,2008,12(22)：4229-4232.
39. Pickett GE,Sekhon LH,Sears WR,et al.Complications with cervicalarthraplasty.J Neurosurg Spine,2006,4(2):98-105.
40. GoodmanSB.The effects of micromotion and Particulate materials on Tissue differentiation. Aeta OrthoPSeand,1994,65(258suppl):1-43
41.王以进、王介麟编著,骨科生物力学[M].北京：人民军医出版社,1989.P.189-201
42. TominagaT.Dickman CA.Sonntag VK.et al. Comparative anatomy of the baboon and the human cervical spine. Spine,1995,20(2):131-137
43. Deliganis AV. Baxter AB, Hanson JA, et al. Radiologic spectrum of craniocervical distraction injufies[J]. Radiographics,2000,20:237-250.
44.袁文,贾连顺,丁祖泉.寰椎横韧带断裂对枕颈部稳定性的影响.第二军医大学学报,1995,16(6)：563-566
45.瞿东滨,钟世镇.骨科生物力学的发展及前沿领域.中华外科杂志,2010,48 (4)：311-313
46.陈庄洪,黄卫兵,蔡贤华,等.前路经寰枢关节螺钉内固定术治疗寰枢椎不稳定的生物力学及临床研究.中华实验外科杂志,2011,28(8)：1390-1394.
1侯铁胜,李明,赵杰,等.Apofix颈椎后路内固定系统治疗颈椎骨折脱位的初步报告[J].中国创伤骨科杂志,2000,2：19-22.
2 Goel A,Laberi V.Plate and screw fixation for atlantoaxial subluxanon[J].Acta Ncurochir(Wicn),1994,129:47-53.
3 Melcher RP,Puttlitz CM,Kleinstueck FS,et al.Biomechanical testing of posterior atlantoaxial fixation techniques[J].Spine.2002,2:2435-2440.
4党耕町,王超,阎明,等.后路寰枢椎侧块钉板固定植骨融的临床初探[J].中国脊柱脊髓杂志,2003,13：7-10.
5李雷,王欢,崔少千,等.经后路寰椎椎弓根螺钉系统内固定融合术治疗上颈椎疾患[J].中国修复重建外科杂志,2007,5(21)：463-464.
6马维虎,刘观燚,孙韶华,等.经后路寰枢椎椎弓根螺钉内固定治疗C1-2不稳[J].中国脊柱脊髓杂志,2009,1(19)：47-51.
7 Maciejczak A,Radek A Screw fixation of craniocervical junction[J].Niurol Ncurochi Pol,1999,33:1403-1413.
8 Harms J,Meleher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation[J]. Spine,2001,21:2417-2471.
9ValeFl,OliwerM,CahillDW.Rigidoccipito-cervieel fusion[J]. J Neurosurg,1999,91:144-150.
10 Hoh T, Tsuji H, Kotoh Y, et al.Occipital cervical fusion rein forced by Luques segmental spinal instrumentation for rheumatoid disease[J]. Spine,1988,13:1234-1238.
11 Ransfard AD, Crockard HA, Pozo JL.et al.Cranio-eeervicalinstability treated by contoured loop fixation [J].J Bone&Joint Surg(Br),1986,68:173-177.
12马维虎,徐荣明,孙韶华.枕颈固定技术在上颈椎不稳的应用[J].中华创伤杂志2005,21：383-385.
13袁峰,杨惠林,郭开今,等.经枢椎椎板交叉螺钉技术解剖学研究[J].徐州医学院学报,2008,6(22)：433-435.
14马向阳,尹庆水,吴增晖,等.枢椎椎板螺钉与椎弓根螺钉抗拔出强度的比较[J].中国脊柱脊髓杂志,2007,2(21)：163-164.
15马维虎,胡勇,孙绍华,等.枢椎椎板螺钉治疗上颈椎不稳的临床研究[J].中国骨与关节外科,2009,6(2)459-464。
16马维虎,刘观燚,徐荣明,等.寰椎椎弓根螺钉及枢椎椎板螺钉固定植骨融合治疗创伤性上颈椎不稳.中国脊柱脊髓杂志,2010,3(20)：214-218.
17徐荣明,刘观燚,马维虎.经枢椎椎板关节突关节螺钉固定的解剖学研究[J].中华创伤杂志,2008,11(24)：874-876.
18谭军,贾连顺,候黎升,等.C2椎弓根拉力螺钉选择性治疗Hangman骨折[J].中华骨科杂志,2002,22：653-656.
19胡勇,马维虎,徐荣明,等.枢椎椎弓根拉力螺钉内固定技术治疗Hangman骨折[J].中国骨伤,2008,9(9),678-680.
20瞿东滨,钟世镇,徐达传.枢椎椎弓根及其内固定的临床应用解剖[J].中国临床解剖杂志,1999,17：153-154.
21 Howington JU,Kruse JJ,Awasthi D. Surgical anatomy of the C2 pedicle [J]. J Neurosurg,2001,95:88-92.
22马维虎,徐荣明,孙韶华等.C2,3椎弓根固定治疗不稳定性Hangman骨折[J].中华骨科杂志,2006,9(26)：590-592.
23吕厚山,主译.脊柱内固定[M].第2版,北京：中国医药科技出版社,2001,88-89.
24 McGuire RA, Harkey HL. Modification of technique and results of atlantoaxial transfacet stabilization. Orthopedics.1995,18:1029-1032.
25 Bohler J. Anterior stabilization for acute fractures and non-unions of the dens[J]. J Bone Joint Surg,1982,64A:18-27.
26 Dickman CA, Sonntag VKH, Marcotte PJ. Techniques of screw fixation of the cervical spine[J]. Barrow Neurological Institute Quarterly,1992,8:9-12.
27 Dantas FL, Prandini MN, Caircs AC, et al. Management of odontoid fractures using anterior screw fixation:analysis of 15 ease[J]. Arq Ncuropsiquiat(Sr),2002,1(3):823-829.
28 Graziao G. Jaem C, Lee M, et al.A comparative study of fixation tech uniques for type fractures of the odontoid process[J].Spine,1993,18(16):2382-2387.
29贾连顺,李家顺.枕颈部外科学[M].上海：上海科学技术出版社,2003.
30 Lu J, Ebraheim NA, Yang H, et al.Anatomic considerations of anterior transarticular screw fixation far atlantoaxial instability [J].Spine,1998,23:1229-1236.
31 Vender JR, Harrison SJ, McDonnell DE. Fusion and instrumentation at C1-3 via the high anterior cervical approach[J].J Neurosurg,2000,92(1):24-29.
32 Vieweg U, Meyer B, Schramm J. Differential treatment in acute upper cervical spine injuries:a critical review of a single-institution series [J]. Surg-Neurol, 2000,54(3):203-210;discussion 210-211.
33 Schmelzle R,Harms J, Stoltze D. Osteosynthesen im occipitoccnr-ealem ubergang wom transoral enzugangans [J]. World Congress Abstracts. Munich:Demter-Verlag,1987:27-28.
34 Kandziora FP, flugmacher R, Ludwig K, et al.Biomechanical comparison of four anterior atlantoaxial plate systems[J].J Neurosurg,2002,96(SSupp 1):313-315.
35艾福志,尹庆水,夏虹,等.经口咽前路寰枢椎复位钢板的生物力学评价[J].骨与关节损伤杂志,2003,18(5)：330-334.