后路内固定融合手术治疗类风湿性寰枢椎不稳

发布时间：2018-06-19 10:01

  本文选题：类风湿性关节炎 + 寰枢椎脱位　； 参考：《中国脊柱脊髓杂志》2017年04期

【摘要】：目的 :评估后路内固定融合节段对治疗类风湿性寰枢椎不稳临床疗效的影响。方法 :2008年1月~2015年3月收治类风湿性寰枢椎不稳患者24例,其中女15例,男9例;年龄37~64岁(50.8±4.3岁)。21例患者入院前已经诊断为类风湿性关节炎(RA),病程2~30年(15.6±7.8年);3例患者本次入院确诊为RA并且伴有寰枢椎不稳。侧位X线片示寰枢椎脱位(AAS)13例;寰枢椎垂直脱位(VS)5例;AAS+VS 2例;AAS+下颈椎半脱位(SAS)1例;后路钢丝固定术后3年钢丝断裂合并下颈椎SAS 1例;寰枢关节破坏无脱位表现2例。均行后路固定融合手术,13例AAS患者10例行后路寰枢椎(C1-2)融合内固定术,2例因C2椎弓根细小行C1-C3固定融合,1例因寰椎后弓细小及骨质疏松行枕颈融合术(O-C2);7例VS/AAS+VS患者及2例严重枕颈部疼痛的患者行枕颈融合术,O-C2融合3例,O-C3融合6例,其中1例行寰椎后弓切除减压;2例合并SAS的患者行枕颈椎/胸椎(O-C7 1例,O-T1 1例)固定融合,包括1例翻修手术。比较患者术前、术后及末次随访时的Ranawat神经功能分级、VAS和JOA评分。结果 :24例患者手术均顺利完成,无术中并发症;术后伤口浅表感染2例,经换药和使用敏感抗菌素治愈。24例患者均获得随访,随访时间12~45个月(24.1±10.3个月)。VAS评分由术前的6.6±1.2分下降到术后的2.6±0.9分,末次随访时1.8±0.7分(P0.05)。JOA评分由术前的平均11.5±1.9分增加到术后的平均13.6±2.0分,末次随访时14.5±1.1分(P0.05)。Ranawat神经损伤分级:3例术前Ⅰ级无恢复;5例Ⅱ级者4例恢复至Ⅰ级,1例无恢复;15例Ⅲa级恢复至Ⅰ级13例,Ⅱ级2例;1例Ⅲb级恢复至Ⅲa级。术后3个月植骨融合率为29%(7例),术后6个月为79%(19例),术后12个月为100%(24例)。术后继发SAS 3例,脱位部位:C3/4 2例,C4/5 1例。结论:类风湿性寰枢椎不稳患者行后路内固定融合手术治疗效果满意,应根据病变累及范围、脱位类型、骨密度和钉道情况选择固定融合范围。
[Abstract]:Objective: to evaluate the effect of posterior internal fixation fusion on rheumatoid atlantoaxial instability. Methods: from January 2008 to March 2015, 24 patients with atlantoaxial instability were treated, including 15 females and 9 males. Patients aged 370.64 years (50.8 卤4.3 years) had been diagnosed as rheumatoid arthritis (RA) before admission. The course of disease ranged from 2 to 30 years (15.6 卤7.8 years) and 3 patients were diagnosed as RA with atlantoaxial instability. Lateral radiographs showed atlantoaxial dislocation in 13 cases, atlantoaxial dislocation in 5 cases (VS) in 5 cases, AAS VS in 2 cases with AAS subluxation of cervical spine in 1 case, posterior wire fixation in 1 case after 3 years of fixation with SAS of lower cervical vertebrae, atlantoaxial joint failure in 2 cases, and no dislocation of atlantoaxial joint in 2 cases. Posterior fixation fusion was performed in 13 patients with AAS and 10 patients with posterior atlantoaxial C1-2) internal fixation was performed in 2 patients with small C2 pedicle and 1 case with occipitocervical fusion due to small posterior arch of atlas and osteoporosis. 7 patients with VS- AAS VS were diagnosed by occipitocervical fusion. Patients and 2 patients with severe occipitocervical pain underwent occipitocervical fusion with O-C2 fusion in 3 cases and O-C 3 fusion in 6 cases. One patient underwent posterior arch resection and decompression of atlas and 2 patients with SAS underwent occipitocervical / thoracic vertebrae O-C 7 (n = 1) fixation and fusion, including revision surgery (n = 1). The VAS and JOA scores of Ranawat neurological function grading were compared before, after operation and at the last follow-up. Results all the 24 cases were successfully operated without intraoperative complications, 2 cases of superficial wound infection were cured by dressing change and sensitive antibiotics, and 24 cases were followed up. The follow-up time ranged from 24.1 卤10.3 months to 2.6 卤0.9, from 6.6 卤1.2 to 2.6 卤0.9, and at the last follow-up, the score of 1.8 卤0.7, P0.05 and JOA increased from 11.5 卤1.9 to 13.6 卤2.0, respectively. At the last follow-up, 14.5 卤1.1 min. P 0.05U .Ranawat nerve injury grade: 3 cases had no recovery in grade 鈪，

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