后路枕颈融合术中联合应用后枕颈角和枕颈角调整枕颈固定角度的临床研究
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摘要
目的探讨联合应用后枕颈角(posterior occipitocervical angle,POCA)及枕颈角(occipital-C_2angle,O-C_2角)指导后路枕颈融合术中枕颈固定角度调整的临床疗效。方法回顾分析2013年3月—2016年1月联合应用POCA及O-C_2角指导后路枕颈融合术中枕颈固定角度调整的22例患者临床资料。其中男7例,女15例;年龄20～63岁,平均44.4岁。诊断为颅底凹陷伴寰枢椎脱位20例,类风湿关节炎2例。术前日本骨科协会(JOA)评分为(13.2±2.0)分,疼痛视觉模拟评分(VAS)为(6.3±0.9)分。术中首先通过POCA指导钉棒系统预弯,使12例术前POCA为非正常值患者的POCA恢复到正常值范围;然后术中透视确认上述患者O-C_2角是否在正常范围之内(其中4例为非正常值,2例需要术中调整);调整后POCA及O-C_2角都在正常范围之内。记录手术相关并发症,采用JOA及VAS评分评估患者术后脊髓神经功能恢复情况及疼痛缓解程度;影像学观察评价植骨融合情况,术后POCA和O-C_2角及下颈椎曲度(Cobb角)变化情况。结果 22例患者均获随访,随访时间12～48个月,平均24个月。无严重手术相关并发症及再手术发生。末次随访时VAS评分和JOA评分分别为(2.9±0.8)分和(15.4±0.9)分,均较术前显著改善(t=15.870,P=0.000;t=6.587,P=0.000)。影像学检查示22例患者枕颈部骨性融合,内固定物位置良好,未见松动、断裂等情况发生,枕颈部稳定性良好。术后3 d及末次随访时POCA和O-C_2角均在正常范围之内,与术前比较差异有统计学意义(P<0.05);术后3 d与末次随访时比较差异无统计学意义(P>0.05)。手术前后各时间点间下颈椎Cobb角比较差异均无统计学意义(P>0.05)。结论后路枕颈融合术中联合应用POCA及O-C_2角选择合理的枕颈固定角度可确保更好的手术疗效。
Objective To assess the application and the effectiveness of a strategy of combining posterior occipitocervical angle(POCA) with occipital-C_2(O-C_2) angle for adjustment of occipitocervical fixation angle in posterior instrumented occipitocervical fusion. Methods The clinical data of 22 patients undergoing posterior instrumented occipitocervical fusions between March 2013 and January 2016 were retrospectively analysed, and all patients were performed by using a strategy combining with POCA and O-C_2 angle for adjustment of occipitocervical fixation angle. All patients suffered from occipitocervical instability, including 7 males and 15 females with an average age of 44.4 years(range, 20-63 years). The patients were diagnosed as skull base depression with atlantoaxial dislocation in 20 cases and rheumatoid arthritis in 2 cases. The preoperative Japanese Orthopaedic Association(JOA) score was 13.2±2.0, and the visual analogue scale(VAS) score was 6.3±0.9. The POCA was first used to guide the pre-bending of the nail-rod system during the operation, so that POCA of 12 patients with abnormal preoperative POCA could be restored to the normal range; then intraoperative fluoroscopy was used to confirm whether the O-C_2 angle was within the normal range(4 cases were abnormal and 2 cases needed intraoperative adjustment); finally, POCA and O-C_2 angles were within normal range after adjustment. The postoperative complications were recorded, and the JOA and VAS scores were used to evaluate the recovery of spinal nerve function and the degree of pain relief after operation. The radiological data were collected to evaluate the bone graft fusion, the changes of postoperative POCA, O-C_2 angle, and lower cervical curvature(Cobb angle).Results All 22 patients were followed up 12-48 months, with an average of 24 months. No serious complications and reoperation occurred. At last follow-up, the VAS score and JOA score were 2.9±0.8 and 15.4±0.9 respectively, which were significantly improved when compared with preoperative ones(t=15.870, P=0.000; t=6.587, P=0.000). Imaging examination showed that 22 patients had occipitocervical osseous fusion, good position of internal fixator without loosening or fracture, and good occipitocervical stability. The POCA and O-C_2 angles were within the normal range at 3 days after operation and at last follow-up, and there were significant differences when compared with preoperative ones(P<0.05); but no significant difference was found in POCA and O-C_2 angles between at 3 days after operation and at last follow-up(P>0.05). There was no significant difference in Cobb angle of lower cervical spine between before and after operation(P>0.05). Conclusion The strategy of combination POCA and O-C_2 angle for adjustment of occipitocervical fixation angle during operation can ensure a better effectiveness.
Objective To assess the application and the effectiveness of a strategy of combining posterior occipitocervical angle(POCA) with occipital-C_2(O-C_2) angle for adjustment of occipitocervical fixation angle in posterior instrumented occipitocervical fusion. Methods The clinical data of 22 patients undergoing posterior instrumented occipitocervical fusions between March 2013 and January 2016 were retrospectively analysed, and all patients were performed by using a strategy combining with POCA and O-C_2 angle for adjustment of occipitocervical fixation angle. All patients suffered from occipitocervical instability, including 7 males and 15 females with an average age of 44.4 years(range, 20-63 years). The patients were diagnosed as skull base depression with atlantoaxial dislocation in 20 cases and rheumatoid arthritis in 2 cases. The preoperative Japanese Orthopaedic Association(JOA) score was 13.2±2.0, and the visual analogue scale(VAS) score was 6.3±0.9. The POCA was first used to guide the pre-bending of the nail-rod system during the operation, so that POCA of 12 patients with abnormal preoperative POCA could be restored to the normal range; then intraoperative fluoroscopy was used to confirm whether the O-C_2 angle was within the normal range(4 cases were abnormal and 2 cases needed intraoperative adjustment); finally, POCA and O-C_2 angles were within normal range after adjustment. The postoperative complications were recorded, and the JOA and VAS scores were used to evaluate the recovery of spinal nerve function and the degree of pain relief after operation. The radiological data were collected to evaluate the bone graft fusion, the changes of postoperative POCA, O-C_2 angle, and lower cervical curvature(Cobb angle).Results All 22 patients were followed up 12-48 months, with an average of 24 months. No serious complications and reoperation occurred. At last follow-up, the VAS score and JOA score were 2.9±0.8 and 15.4±0.9 respectively, which were significantly improved when compared with preoperative ones(t=15.870, P=0.000; t=6.587, P=0.000). Imaging examination showed that 22 patients had occipitocervical osseous fusion, good position of internal fixator without loosening or fracture, and good occipitocervical stability. The POCA and O-C_2 angles were within the normal range at 3 days after operation and at last follow-up, and there were significant differences when compared with preoperative ones(P<0.05); but no significant difference was found in POCA and O-C_2 angles between at 3 days after operation and at last follow-up(P>0.05). There was no significant difference in Cobb angle of lower cervical spine between before and after operation(P>0.05). Conclusion The strategy of combination POCA and O-C_2 angle for adjustment of occipitocervical fixation angle during operation can ensure a better effectiveness.
引文
1Meng Y, Chen H, Lou J, et al. Posterior distraction reduction and occipitocervical fixation for the treatment of basilar invagination and atlantoaxial dislocation. Clin Neurol Neurosurg, 2016, 140:60-67.
2孟阳,戎鑫,陈华,等.后路切开复位枕颈融合术治疗颅底凹陷症合并寰枢椎脱位.中华骨科杂志, 2016, 36(10):591-597.
3孟阳,刘浩,戎鑫,等.颅底凹陷症合并寰枢椎脱位患者枕颈角与下颈椎曲度的关系.中国脊柱脊髓杂志, 2017, 27(1):25-30.
4Ding X, Abumi K, Ito M, et al. A retrospective study of congenital osseous anomalies at the craniocervical junction treated by occipitocervical plate-rod systems. Eur Spine J, 2012, 21(8):1580-1589.
5Bhatia R, Desouza RM, Bull J, et al. Rigid occipitocervical fixation:indications, outcomes, and complications in the modern era. J Neurosurg Spine, 2013, 18(4):333-339.
6Garrido BJ, Sasso RC. Occipitocervical fusion. Orthop Clin North Am, 2012, 43(1):1-9.
7Pan J, Huang D, Hao D, et al. Occipitocervical fusion:fix to C2 or C3? Clin Neurol Neurosurg, 2014, 127:134-139.
8Yoshida M, Neo M, Fujibayashi S, et al. Upper-airway obstruction after short posterior occipitocervical fusion in a flexed position.Spine(Phila Pa 1976), 2007, 32(8):E267-E270.
9Sakuraya F, Mayumi T, Kenmotsu O. A case of tracheotomy due to upper airway obstruction after posterior cervical fusion. Nihon Shuchu Chiryo Igakukai Zasshi, 2002, 9(suppl 1):103.
10李广州,刘浩,唐超,等.不同年龄健康人群正常枕颈角度的影像学测量及临床意义.中国骨伤, 2018, 31(7):608-611.
11 Bagley CA, Witham TF, Pindrik JA, et al. Assuring optimal physiologic craniocervical alignment and avoidance of swallowingrelated complications after occipitocervical fusion by preoperative halo vest placement. J Spinal Disord Tech, 2009, 22(3):170-176.
12Matsunaga S, Onishi T, Sakou T. Significance of occipitoaxial angle in subaxial lesion after occipitocervical fusion. Spine(Phila Pa1976), 2001, 26(2):161-165.
13Logroscino CA, Genitiempo M, Casula S. Relevance of the cranioaxial angle in the occipitocervical stabilization using an original construct:a retrospective study on 50 patients. Eur Spine J,2009, 18 Suppl 1:7-12.
14朱文俊,杨军,倪斌.枕颈融合术对下颈椎曲度及退变影响的研究进展.中国脊柱脊髓杂志, 2015, 25(7):662-665.
15Takami T, Ichinose T, Ishibashi K, et al. Importance of fixation angle in posterior instrumented occipitocervical fusion. Neurol Med Chir(Tokyo), 2008, 48(6):279-282.
16Shoda N, Takeshita K, Seichi A, et al. Measurement of occipitocervical angle. Spine(Phila Pa 1976), 2004, 29(10):E204-E208.
17Phillips FM, Phillips CS, Wetzel FT, et al. Occipitocervical neutral position. Possible surgical implication. Spine(Phila Pa 1976), 1999,24(8):775-778.
18Riel RU, Lee MC, Kirkpatrick JS. Measurement of a posterior occipitocervical fusion angle. J Spinal Disord Tech, 2010, 23(1):27-29.
19Maulucci CM, Ghobrial GM, Sharan AD, et al. Correlation of posterior occipitocervical angle and surgical outcomes for occipitocervical fusion. Evid Based Spine Care J, 2014, 5(2):163-165.
20 Tan J, Liao G, Liu S. Evaluation of occipitocervical neutral position using lateral radiographs. J Orthop Surg Res, 2014, 9:87.
2孟阳,戎鑫,陈华,等.后路切开复位枕颈融合术治疗颅底凹陷症合并寰枢椎脱位.中华骨科杂志, 2016, 36(10):591-597.
3孟阳,刘浩,戎鑫,等.颅底凹陷症合并寰枢椎脱位患者枕颈角与下颈椎曲度的关系.中国脊柱脊髓杂志, 2017, 27(1):25-30.
4Ding X, Abumi K, Ito M, et al. A retrospective study of congenital osseous anomalies at the craniocervical junction treated by occipitocervical plate-rod systems. Eur Spine J, 2012, 21(8):1580-1589.
5Bhatia R, Desouza RM, Bull J, et al. Rigid occipitocervical fixation:indications, outcomes, and complications in the modern era. J Neurosurg Spine, 2013, 18(4):333-339.
6Garrido BJ, Sasso RC. Occipitocervical fusion. Orthop Clin North Am, 2012, 43(1):1-9.
7Pan J, Huang D, Hao D, et al. Occipitocervical fusion:fix to C2 or C3? Clin Neurol Neurosurg, 2014, 127:134-139.
8Yoshida M, Neo M, Fujibayashi S, et al. Upper-airway obstruction after short posterior occipitocervical fusion in a flexed position.Spine(Phila Pa 1976), 2007, 32(8):E267-E270.
9Sakuraya F, Mayumi T, Kenmotsu O. A case of tracheotomy due to upper airway obstruction after posterior cervical fusion. Nihon Shuchu Chiryo Igakukai Zasshi, 2002, 9(suppl 1):103.
10李广州,刘浩,唐超,等.不同年龄健康人群正常枕颈角度的影像学测量及临床意义.中国骨伤, 2018, 31(7):608-611.
11 Bagley CA, Witham TF, Pindrik JA, et al. Assuring optimal physiologic craniocervical alignment and avoidance of swallowingrelated complications after occipitocervical fusion by preoperative halo vest placement. J Spinal Disord Tech, 2009, 22(3):170-176.
12Matsunaga S, Onishi T, Sakou T. Significance of occipitoaxial angle in subaxial lesion after occipitocervical fusion. Spine(Phila Pa1976), 2001, 26(2):161-165.
13Logroscino CA, Genitiempo M, Casula S. Relevance of the cranioaxial angle in the occipitocervical stabilization using an original construct:a retrospective study on 50 patients. Eur Spine J,2009, 18 Suppl 1:7-12.
14朱文俊,杨军,倪斌.枕颈融合术对下颈椎曲度及退变影响的研究进展.中国脊柱脊髓杂志, 2015, 25(7):662-665.
15Takami T, Ichinose T, Ishibashi K, et al. Importance of fixation angle in posterior instrumented occipitocervical fusion. Neurol Med Chir(Tokyo), 2008, 48(6):279-282.
16Shoda N, Takeshita K, Seichi A, et al. Measurement of occipitocervical angle. Spine(Phila Pa 1976), 2004, 29(10):E204-E208.
17Phillips FM, Phillips CS, Wetzel FT, et al. Occipitocervical neutral position. Possible surgical implication. Spine(Phila Pa 1976), 1999,24(8):775-778.
18Riel RU, Lee MC, Kirkpatrick JS. Measurement of a posterior occipitocervical fusion angle. J Spinal Disord Tech, 2010, 23(1):27-29.
19Maulucci CM, Ghobrial GM, Sharan AD, et al. Correlation of posterior occipitocervical angle and surgical outcomes for occipitocervical fusion. Evid Based Spine Care J, 2014, 5(2):163-165.
20 Tan J, Liao G, Liu S. Evaluation of occipitocervical neutral position using lateral radiographs. J Orthop Surg Res, 2014, 9:87.