复杂寰枕畸形的基础与临床研究

发布时间：2018-09-19 14:45

【摘要】：第一部分椎动脉与寰枢椎之间的解剖学关系目的了解椎动脉与寰枢椎之间的解剖学关系，为临床手术提供指导。方法10例（20侧）成人尸体标本，其中5例进行彩色硅胶血管灌注，，使用Benzel介绍的解剖学术语：C3横突孔至C2横突孔的椎动脉部分称为V1段，C2横突孔至C1横突孔称为V2段，离开C1横突孔到进入硬膜部分称为V3段。观察椎动脉与周围骨性结构之间的关系，测量椎动脉到中线的距离，椎动脉到C2神经节以及其它手术相关标记的距离。结果椎动脉V2段至C2脊神经节外侧平均距离为7.7mm，至硬膜的平均距离为15.6mm。双侧椎动脉粗细存在明显差异。V1-3段椎动脉并未完全占据横突孔，可在横突孔内相对活动。C2椎动脉管内侧壁到椎体中线平均距离为14.6mm。结论 1、椎动脉在寰枢椎区域连续弯曲走行，使得此区域手术极易损伤椎动脉。 2、详细了解此区域解剖学特点是减少手术损伤椎动脉的基础。第二部分寰枢关节脱位的外科治疗目的总结颈椎后路入路行螺钉-钛棒（板）内固定技术治疗寰枢椎关节脱位的临床经验。方法收集宁夏医科大学总医院神外科2010年1月至2013年11月行颈椎后正中入路寰椎侧块螺钉-钛棒（板）治疗寰枢关节脱位的患者资料。患者术前行颅颈交界区CT三维重建，在矢状位骨窗像下测量寰齿前间距（MADI），如MADI超过3mm即诊断为寰枢椎脱位，术前均进行日本整形外科协会（JOA）评分，手术采用气管插管全身麻醉，俯卧位，头架固定，颈部后正中入路，向两侧分离显露枢椎椎弓峡部和寰枢椎关节突。然后进行寰椎侧块螺钉、枢椎椎弓根螺钉置入，复位寰枢椎脱位，螺钉间钛棒（板）固定。清除寰枢椎侧方关节的关节面软骨，在关节腔内和关节突周围填塞自体松质骨。Chiari畸形患者同时进行枕大孔区减压，骨窗大小为3cm×3cm。术后随诊复查颈椎CT、颈椎MRI及术后三个月的颈髓JOA评分。结果11例患者，其中男3例，女8例，年龄为9~50岁，平均36.8岁。颅底凹陷患者6例，寰枕融合患者2例，扁平颅底患者3例，合并chiari畸形患者7例。平均MADI为5.04±1.74mm。所有患者术后随诊3~5月，平均3.5月。11例患者均在手术后1周内带普通颈围坐起或下床活动，并开始康复治疗；除2例手术后临床症状无明显变化，余9例均明显改善，无一例发生脊髓、神经根或椎动脉损伤。手术后两周内行三维重建CT检查，除1例出现一侧钛棒向外侧稍旋，其余患者螺钉位置良好，无拔出或移位，术前有椎体移位者，术后复位固定良好。术前及术后三个月脊髓JOA评分比较，差异具有统计学意义（t=-8.33，p0.01）。虽然随访时间不同，但植骨均有不同程度生长及融合。结论颈椎后路螺钉-钛棒(板)内固定技术治疗寰枢关节脱位一次手术可以解除延脊髓腹侧、背侧的压迫及枕颈区脊柱的稳定问题，术后患者临床症状改善良好，是一种治疗寰枢关节脱位安全、有效、可靠的手术方法。
[Abstract]:Part I Anatomical relationship between vertebral artery and Atlantoaxial artery objective to understand the anatomical relationship between vertebral artery and atlantoaxial vertebra and to provide guidance for clinical operation. Methods 10 adult cadavers (20 sides) were divided into 10 cadavers and 5 of them were perfused with colored silica vessels. Using the anatomical term introduced by Benzel, the vertebral artery from the transverse foramen of C3 to the foramen of the transverse process of C2 was called V1 segment C2 transverse process foramen and C1 transverse process foramen was called V2 segment. Leaving the C1 transverse foramen to enter the dural part is called the V 3 segment. The relationship between vertebral artery and surrounding bone structure was observed. The distance between vertebral artery and midline, the distance between vertebral artery and C2 ganglion and other operative markers were measured. Results the average distance from the V2 segment of vertebral artery to the lateral part of C2 spinal ganglion was 7.7 mm, and the average distance to dura mater was 15.6 mm. There was significant difference in the thickness of bilateral vertebral artery. The vertebral artery of V1-3 segment did not occupy the transverse foramen completely, and the average distance from the lateral wall to the midline of the vertebral body was 14.6 mm.. Conclusion 1. The vertebral artery bends continuously in the atlantoaxial region, which makes it easy to injure the vertebral artery in this area. 2. Detailed understanding of the anatomical characteristics of this area is the basis of reducing the surgical injury of vertebral artery. The second part: surgical treatment of atlantoaxial dislocation objective to summarize the clinical experience of posterior cervical approach with screw-titanium rod (plate) fixation in the treatment of atlantoaxial dislocation. Methods from January 2010 to November 2013, patients with atlantoaxial dislocation were treated with lateral mass screw and titanium rod (plate) via posterior median cervical approach in the Department of Psychiatry, General Hospital of Ningxia Medical University. Three dimensional reconstruction of craniocervical junction CT was performed before operation. Atlantoaxial dislocation was diagnosed by measuring atlantoodontoid distance (MADI),) under sagittal bone window image if MADI exceeded 3mm. (JOA) score of Japanese Society of plastic surgery was performed before operation. General anesthesia was performed by tracheal intubation. Prone position, head frame fixation, cervical posterior median approach, bilateral separation of axial pedicle isthmus and atlantoaxial articular process. Then the lateral mass screw and pedicle screw were placed and the atlantoaxial dislocation was reduced and the titanium rod (plate) was fixed between the screws. The articular surface cartilage of lateral atlantoaxial joint was removed and autogenous cancellous bone 路Chiari malformation was implanted into the articular cavity and around the articular process for decompression of the occipital foramen region. The bone window size was 3cm 脳 3 cm. Postoperative follow-up examination of cervical CT, cervical MRI and 3 months after the cervical spinal cord JOA score. Results 11 patients, including 3 males and 8 females, aged 950 years (mean 36.8 years). There were 6 cases of skull base depression, 2 cases of atlanto-occipital fusion, 3 cases of flat skull base and 7 cases of chiari malformation. The average MADI was 5.04 卤1.74mm. All the patients were followed up from 3 to 5 months after operation, with an average of 3.5 months. 11 patients had normal neck sitting up or getting out of bed within one week after operation, and began rehabilitation treatment, except for 2 patients who had no obvious change in clinical symptoms after operation, the remaining 9 patients were obviously improved. No spinal cord, nerve root or vertebral artery injury occurred. Three-dimensional reconstruction CT examination was performed within two weeks after operation. Except for one case with a slight lateral rotation of the titanium rod, the screw position of the other patients was good, without pulling out or shifting. The patients with vertebral body displacement before operation had good reduction and fixation after operation. There was significant difference in spinal JOA score between preoperative and postoperative 3 months (t = -8.33, p 0.01). Although the follow-up time is different, the bone grafts have different degrees of growth and fusion. Conclusion the posterior cervical screw and titanium rod (plate) internal fixation can relieve the ventral and dorsal compression of the spinal cord and the stability of the occipitocervical spine. The clinical symptoms of the patients after operation are well improved. It is a safe, effective and reliable method for the treatment of atlantoaxial dislocation.
【学位授予单位】：宁夏医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.3

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