复杂枢椎骨折中保留寰枢关节功能的手术治疗策略及疗效观察

发布时间：2018-03-08 09:13

本文选题：枢椎骨折　切入点：骨折固定术　出处：《湖北中医药大学》2015年硕士论文　论文类型：学位论文

【摘要】：目的:探讨复杂枢椎骨折的临床特点及诊断,分析前路经枢椎有限内固定术(即经C2-3锁定钛板内固定或经齿状突空心螺钉内固定+C2或C2-3锁定钛板内固定)及应用一期后路C1-3钉棒系统内固定+C2-3椎板间植骨融合术、二期行寰椎内固定取出术的手术方式,探讨尽可能地保留寰枢关节旋转功能的可行性,为复杂枢椎骨折的手术治疗方式提供较好的选择及新的思路。方法:利用广州军区武汉总医院病例检索系统及PACS影像学系统收集该院骨科自2005年2月至2013年1月收治复杂枢椎骨折患者的病例、影像学资料及门诊随访资料,并进行整理、分析。从符合复杂枢椎骨折诊断的病例中依据特定方法确定病例选择标准和剔除标准,对纳入研究范围的患者进行定期随访,随访内容包括患者证状、体征及影像学资料,除去脱落病例后,确定研究的最终对象。本课题中所有患者均为新鲜骨折。骨折类型诊断主要依靠影像学资料,包括颈椎正、侧位和张口位X线片、CT平扫+三维重建及MRI,本课题中所涉及的骨折类型包含:齿状突Ⅱ型骨折合并枢椎椎体矢状面骨折伴寰枢关节不稳1例,齿状突Ⅱ型骨折合并枢椎椎体冠状面骨折伴C1-3不稳4例,齿状突Ⅱ型骨折合并HangmanⅡ型骨折伴C1-3不稳2例,齿状突Ⅱ型骨折合并HangmanⅢ型骨折伴C1-3不稳1例,HangmanⅡ型骨折合并枢椎椎体下端水平粉碎骨折伴C1-3不稳2例,HangmanⅡ型骨折合并枢椎椎体矢状面骨折伴C2-3不稳2例,HangmanⅡ型骨折合并枢椎椎体冠状面骨折合并C2-3不稳5例,枢椎椎体冠状面骨折向前滑脱合并HangmanⅠ型骨折伴C1-3不稳1例。根据枢椎骨折情况、C1-3稳定程度及脊髓受压方向分别予以前路齿状突螺钉+C2前路钢板内固定(1例),前路齿状突螺钉+C2-3前路椎间盘切除植骨融合钢板内固定(9例),C2-3前路椎间盘切除植骨融合钢板内固定(7例),后路C1-3钉棒系统内固定+C2-3椎间植骨融合术,二期行寰椎螺钉取出术(1例)。术后结合患者自身素质情况,予以佩戴颈托或头颈胸支具或石膏外固定保护3个月。并定期行X线片及CT检查,观察并记录患者不同时期的证状、体征,收集影像学资料检查等,对患者颈椎活动度及神经功能改善情况进行随访分析。结果:所有患者获术后12-72个月(平均18.44±14.14个月)随访,其中,术后3月,17例患者获骨性愈合,1例伴有齿状突骨折患者出现延迟愈合,继续行颈托固定6个月后也获得骨性愈合。X线片及CT复查提示骨折复位良好C1-3序列恢复,颈椎稳定性良好,所有患者颈椎活动功能恢复满意,其中前曲33.17°±1.543°,后伸32.89°±2.026°,侧屈53.26°±5.466°,旋转118.12°±8.772°。脊髓损伤患者术后均得到不同程度改善:脊髓神经恢复情况根据ASIA分级:12例脊髓损伤患者中有10例获得改善,其中1例B级患者改善为D级,5例C级患者中2例改善为D级,2例改善为E级,6例D级患者中5例改善为E级,其余6例E级患者未出现明显变化。结论:复杂枢椎骨折中寰枢椎功能保留的关键在于充分利用伤椎及其修复能力,前路经伤椎有限内固定疗效可靠,而“先期固定非融合,二期取出内固定”的颈椎后路手术策略很好地补充了前路内固定技术的不足。对部分复杂枢椎骨折可采取有限内固定或分期手术方法实现寰枢椎功能的保留
[Abstract]:Objective: To investigate the clinical characteristics and diagnosis of complicated atlantoaxial fracture, analysis of anterior atlantoaxial fixation (i.e. limited by C2-3 or by locking titanium plate internal fixation of odontoid cannulated screw fixation in +C2 or C2-3 locking titanium plate fixation) and application of posterior C1-3 pedicle screw fixation +C2-3 laminectomy with interbody fusion, two for the atlas internal fixation methods of operation, to explore as much as possible to retain the feasibility of rotation of atlantoaxial joint, provide a better choice and new ideas for the surgical treatment of complicated atlantoaxial fractures. Methods: the Wuhan General Hospita of Guangzhou Military Region case retrieval system and PACS imaging system to collect the Department of orthopedics in our hospital from February 2005 to January 2013 were complex axis fracture cases, imaging data and follow-up data, and sort out. From the analysis of complex axis fracture diagnosis cases on the basis of specific methods To determine the case selection criteria and exclusion criteria, regular follow-up of the patients included in the study, the follow-up including symptoms, signs and imaging data, remove the cases after the final to determine the object of study. In this study all patients were fresh fractures. Fracture type diagnosis mainly depends on imaging data, including cervical spine, lateral and mouth X-ray films, CT scan and 3D reconstruction and MRI, involved in this subject include: the type of fracture of odontoid fracture with atlantoaxial vertebral sagittal with atlantoaxial instability fracture in 1 cases, type II odontoid fracture combined with atlantoaxial vertebral coronal fractures with C1-3 instability 4 cases of odontoid fracture with Hangman type II fracture with C1-3 instability in 2 cases, type II odontoid fracture with Hangman type III fractures with C1-3 instability in 1 cases, Hangman type II fracture combined with atlantoaxial vertebral bone comminuted fracture with the lower level of C1-3 Stable in 2 cases, Hangman type II fracture combined with atlantoaxial vertebral sagittal fracture with C2-3 instability in 2 cases, Hangman type II fracture combined with atlantoaxial vertebral fractures with coronal C2-3 instability in 5 cases of coronal fracture, atlantoaxial vertebral spondylolisthesis and forward type Hangman fractures with C1-3 instability in 1 cases. According to the fold axis. The stability of C1-3 and spinal cord compression direction received anterior odontoid screw +C2 anterior plate internal fixation (1 cases), anterior odontoid screw +C2-3 anterior cervical discectomy and interbody fusion and plate fixation (9 cases), C2-3 anterior cervical discectomy and interbody fusion and plate fixation (7 cases), C1-3 pedicle screw rod +C2-3 system internal fixation and interbody fusion, two patients underwent removal of atlantoaxial screw (1 cases). The postoperative patients with their own quality, to wear a neck collar or chest neck brace or plaster external fixation for 3 months. And regularly underwent X-ray and CT examination, observe and record the patient Different period of symptoms, signs, imaging data collection test, follow-up analysis of cervical activity and improve the neurological function. Results: all patients were 12-72 months postoperatively (mean 18.44 + 14.14 months) follow-up, which, after March, 17 cases were healed, 1 patients with odontoid fracture patients had delayed healing, underwent cervical fixation 6 months after bone healing. X-ray and CT examination showed good fracture reduction sequence of C1-3 recovery, good cervical stability, all the features of cervical spine patients recovered, the song before the 33.17 degrees - 1.543 degrees, 32.89 degrees of flexion. 2.026 degrees, lateral flexion 53.26 degrees - 5.466 degrees rotate 118.12 degrees - 8.772 degrees. Spinal cord injury patients after operation were improved in different degrees: spinal cord nerve recovery according to ASIA classification: 12 cases of patients with spinal cord injury in 10 cases was improved, which improved 1 cases of patients with grade B grade D 5 cases of grade C, 2 cases improved to grade D, 2 cases were improved to grade E, 6 cases of D patients in 5 cases improved to grade E, the other 6 cases of grade E patients did not change significantly. Conclusion: the key to preserve the function of complex atlas atlantoaxial atlantoaxial fracture is to fully utilize the vertebral and repair ability, anterior vertebral internal fixation and the curative effect is reliable, "early fixation and non fusion, two from posterior cervical surgery strategy fixed" good complement to the anterior internal fixation technology. On the part of complicated atlantoaxial fracture can be taken to reserve a fixed or staging operation method of atlantoaxial function in Co.

【学位授予单位】：湖北中医药大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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