枢椎逆向椎弓根螺钉在经口咽入路治疗寰枢椎脱位中的应用
Application of reverse axis pedicle screws in the transoral anterior reduction to treat atlas-axis dislocation
目的 探讨枢椎逆向椎弓根螺钉在经口咽入路治疗寰枢椎脱位中的应用价值.方法 选择2009年3月至2011年10月收治的25例寰枢椎脱位患者,男11例,女14例;年龄17~65岁,平均39岁;其中创伤性寰枢椎脱位17例,游离齿状突合并寰枢椎脱位8例.均实施经口咽入路松解、复位、内固定手术,寰椎采用前路侧块螺钉固定,枢椎采用逆向椎弓根螺钉固定.术后CT扫描观察术后钉道情况,测量螺钉的外倾角、下倾角、螺钉长度等.通过比较手术前、后日本矫形外科学会(JOA)评分、寰齿间隙(ADI)评估疗效.结果 25例患者共置入枢椎逆向椎弓根螺钉50枚,平均手术时间145 min,平均出血量94 mL.枢椎椎弓根螺钉的平均外倾角为20°、下倾角为15 °、螺钉长度为28 mm.24例患者术后获得10~25个月(平均16个月)随访,术后3个月JOA评分(15.7±1.1)分和末次随访时(16.0±0.7)分较术前(8.9±1.7)分均明显提高,差异有统计学意义(P<0.05).ADI由术前(8.7±1.5) mm改善为术后(0.8±0.9)mm,差异有统计学意义(t=2.937,P<0.05).结论 经口咽入路实施枢椎逆向椎弓根螺钉是可行的,但该技术具有一定风险,可以在有条件的医院审慎开展.
更多Objective To investigate the clinical value of reverse axis pedicle screws in the transoral anterior reduction to treat atlas-axis dislocation.Methods From March 2009 to October 2011,25 patients with atlas-axis dislocation were treated in our department.They were 11 men and 14 women,17 to 65 years of age(mean,39 years).There were 17 traumatic atlas-axis dislocations and 8 atlantoaxial dislocations associated with ossification dens.They underwent transoral release,reduction and instrumentation with transoral atlantoaxial reduction plate (TARP).The atlas was fixated with lateral mass screws and the axis with reverse pedicle screws.After operation,all patients got CT scanning to evaluate screw path,outside tilt angle,downside angle and length of pedicle screw.The Japanese Orthopaedic Association (JOA) scoring system was used for evaluation of spinal function improvement.The atlantodens intervals (ADI) were measured pre-and post-operation to evaluate improvement of dislocation.Results Altogether 50 reverse axis pedicle screws were implanted in the 25 patients.The mean operation time ranged from 125 to 155 minutes and the mean blood loss was 94 mL.CT scan showed 47 screws were in a good trajectory in the axis pedicle.One screw violated into the spinal canal without nerve symptoms due to a too small outside tilt,and 2 screws violated into the vertebral artery foramen which gave rise to occlusion of the cerebellum in one patient who died in the end.The outside tilt angles averaged 20°,the downside angles 15° and the screw lengths 28 mm.The JOA scores increased significantly from 8.9 ± 1.7 pre-operation to 15.7 ± 1.1 (P < 0.05) 3 months after operation.The ADI improved significantly from 8.7 ± 1.5 mm pre-operation to 0.8 ± 0.9 mm post-operation (t =2.937,P < 0.05).Conclusions It is feasible to implant a reverse axis pedicle screw via the transoral approach,but this new technique has a potential risk that should be guarded against so that it should be used carefully in qualified hospitals.
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