颅底凹陷症患者枢椎畸形的分类探讨
发布时间：2018-09-08 21:42
【摘要】：目的:颅底凹陷症系枕颈区发育异常,脊髓腹侧受到压迫导致患者出现双手精细动作迟缓,双足行走时有踩棉感,四肢肌张力升高,病理征存在等临床表现和体征。治疗方法以手术治疗为主,而手术治疗的首选方法是枕骨大孔减压和枕颈融合手术。在进行枕颈融合手术时,需要对枕骨和颈椎进行内固定,但由于颅底凹陷症患者常常伴有枢椎发育异常,因此在枢椎进行内固定时会遇到很多困难,影响了手术策略的选择。因此本研究的目的是研究颅底凹陷症患者的枢椎以及附属结构发育畸形特点,并对其进行分型,使得每一位病人的治疗呈现个体化,选择最优的手术固定方式,从而避免术中损伤椎动脉及神经等周围重要结构,降低手术风险。方法:在本次研究中,我们收录了 26名颅底凹陷症病人的病历资料,时间范围自2013年12月至2016年12月来我院就诊的。其中男性10例,女性16例,患者的平均年龄为41.8岁(25-63岁),其中50岁以下者为18人,占总人数的69.23%,50岁以上者8人(30.76%)。所有26名病人首要诊断均是颅底凹陷症,起病缓慢,本文26例患者起病平均时间约2年,最长者为13年。临床表现以四肢麻木无力、双手精细动作迟缓、四肢肌张力升高、病理征存在、腱反射亢进等为主,同时伴有身材矮小、短颈等特殊体征。所有患者入院后均遵照医嘱完善术前检查,包括颈椎正侧位X线平片、颈椎间盘CT平扫(包括骨窗)、颈髓磁共振等检查。颅底凹陷症诊断标准:Chamberlain线:齿状突高于此线3-4mm;麦氏线:硬腭后缘至枕骨鳞部下缘的连线,齿突正常不超过此线7mm,若超过7mm说明有颅底凹陷;乳突连线:齿状突的尖部若超过两侧乳突连线大于2mm说明有颅底凹陷症;Boogard角:侧位头颅片上,枕骨大孔前后缘的连线与斜坡之间的角度,正常位120-130°,大于此角度为颅底凹陷。手术方法:在26名患者中,2名患者未行手术治疗,1名行颈椎后路单开门手术,1名行枕肌下减压术,其余22名患者均在全身麻醉下行枕骨大孔减压和枕颈融合手术。在该22名行枕颈融合手术治疗患者中,12名在C2行双侧椎弓根置钉,2名患者在C2行侧块螺钉,1名患者在C2单侧行椎弓根置钉而对侧未置钉,1名患者在C2右侧行椎弓根置钉而左侧行侧块螺钉,6名患者未在C2置钉而在C3-4行侧块螺钉,所有患者在手术后均恢复良好,并顺利出院。双侧椎弓根的宽度和双侧侧块矢状径的测量:枢椎椎弓根宽度的测量是在颈椎CT轴位片上,选取椎弓根扫描层面处于椎弓根中部的CT片。我们通过PACS影像系统工作站,利用软件自身的测量尺工具测量椎弓根的宽度,即椎动脉孔的内侧缘到椎弓根的内缘之间最小垂直距离,分别测量左右两侧。侧块矢状径即指自椎动脉孔后缘做一水平线,自侧块进钉点做该水平线的垂线,测量两线交点到侧块进钉点的的直线距离。结果:在本次研究的26例患者中,Ⅰ型发育正常无明显畸形者11例,Ⅱ型侧块发育不良者共3例,Ⅲ型椎弓根发育不良者共12例,其中包括单侧或双侧单纯椎弓根发育不良以及合并有侧块发育不良。Ⅳ型合并V型即椎板融合合并有椎体融合者共2例。椎弓根宽度方面测量结果:I型患者左侧椎弓根宽度平均为6.4818±1.3mm,右侧椎弓根宽度平均为7.1909±1.4mm,Ⅱ型患者左侧椎弓根宽度平均为6.43±1.1mm,右侧椎弓根宽度平均为5.93±1.2mm,Ⅲ型患者左侧椎弓根平均宽度为2.7±1.3mm,右侧椎弓根宽度平均为3.283±1.2mm。用spss软件进行分析,Ⅰ型与Ⅲ型、Ⅱ型与Ⅲ型患者之间左右两侧的椎弓根宽度相比均具有统计学意义P0.01,Ⅰ型与Ⅱ型之间右侧有意义,左侧无统计学意义。侧块矢状径测量结果:Ⅰ型患者左侧侧块有效长径平均为12.127±1.3mm,右侧侧块有效长径平均为13.091 ± 1.2mm,Ⅱ型患者左侧侧块有效长径平均为6.58± 1.2mm,右侧侧块有效长径平均为6.75±1.4mm,Ⅲ型患者左侧侧块有效长径宽度为8.5±1.4mm,右侧侧块有效长径平均为9.25±1.3mm。用spss软件进行分析,Ⅰ型与Ⅱ型、Ⅰ型与Ⅲ型、Ⅱ型和Ⅲ型之间患者右两侧的侧块有效长径相比均具有统计学意义P0.01,Ⅱ型和Ⅲ型患者之间左侧无统计学差异。11例I型患者中,9例患者均行双侧椎弓根置钉,1例患者行颈椎后路单开门椎管成形术,1例患者行枕肌下减压术,未应用内固定装置。Ⅱ型患者共3例,均行双侧椎弓根钉固定。Ⅲ型椎弓根发育不良患者共12例,其中1例患者未手术直接出院,2例患者行双侧侧块螺钉固定,1例是单侧椎弓根发育不良(仅左侧),遂行右侧椎弓根螺钉和左侧侧块螺钉固定。其余8例为侧块发育不良合并椎弓根发育不良者,其中1例患者未手术直接出院,1例为双侧侧块发育不良合并单侧椎弓根发育不良,遂行单侧椎弓根置钉而对侧未进行内固定;其余6例因椎弓根和侧块均不适合进行内固定,因此未在C2进行内固定,于C3-4行侧块螺钉固定。结论:对于颅底凹陷症患者,对枕颈区行彻底的减压、稳定的固定是治疗的关键。在枢椎行内固定必须充分认识枢椎的发育特点,枢椎发育畸形将极大地影响脊柱外科医生的手术策略的选择,还会导致严重的并发症。结合患者的椎弓根和侧块发育特点,我们将颅底凹陷症患者的枢椎可以分为5型,其中I型发育尚可,其椎弓根宽度处于正常人的正常范围的下限。Ⅱ型是指单纯侧块发育不良。根据单侧或双侧发育不良还可以分为ⅡA型和ⅡB型,ⅡA型主要是单侧侧块发育不良,ⅡB型是双侧侧块发育不良。Ⅲ型主要是椎弓根发育不良,并且将其分为ⅢA型、ⅢB型和ⅢC型,ⅢA型是指单侧椎弓根发育不良,ⅢB型是指双侧椎弓根发育不良,ⅢC型是指合并有侧块发育不良。Ⅳ型(椎板融合)和Ⅴ型(椎体融合)病例数较少,对枕颈融合术影响也较小。椎动脉高跨也是影响枢椎置钉的危险因素,它可以导致椎弓根和侧块变形。颅底凹陷症患者的影像学资料中,常常出现椎动脉的走行异常,由于椎动脉与椎弓根相邻,异常走行的椎动脉会向内向后偏移,位于椎弓根内侧或内后侧,因此挤压椎弓根变形,甚至穿过侧块中心并向上走行穿过侧块入颅。此时侧块螺钉具有较大的风险,会破坏椎动脉,影响颅内血供,最佳手术方式是旷置C2,于C3-4置钉。因此对于颅底凹陷症患者,枢椎置钉方式的选择要考虑以下几个因素:椎弓根宽度是否满足椎弓根螺钉最低要求;侧块形态和大小;椎动脉的走行情况。该分型就以上述几个因素为基础,意在帮助脊柱外科医生了解颅底凹陷症患者的枢椎发育情况,为置钉手术策略提供一定依据,对每个病人的提供个体化治疗方案,选择最佳的置钉方式,从而降低手术的风险。
[Abstract]:Objective: skull base depression is a kind of occipitocervical dysplasia, which is caused by compression of the ventral side of the spinal cord, resulting in fine movement retardation of both hands, feeling of stepping on cotton when walking on both feet, elevated muscle tension of the extremities, pathological signs and other clinical manifestations and signs. Fusion surgery. Internal fixation of occipital and cervical vertebrae is necessary in occipitocervical fusion surgery. However, the development of the axis is often abnormal in patients with skull base depression, so there are many difficulties in the internal fixation of the axis, affecting the choice of surgical strategy. Methods: In this study, 26 patients with basilar invagination were enrolled in the medical records. Materials: From December 2013 to December 2016, there were 10 males and 16 females with an average age of 41.8 years (25-63 years). Among them, 18 were under 50 years old, accounting for 69.23% of the total, and 8 were over 50 years old (30.76%). The average duration of the disease was about 2 years and the longest was 13 years.The clinical manifestations were numbness of limbs, slow fine movement of both hands, elevated muscle tension of limbs, pathological features, hyperreflexia of tendons, etc. CT plain scan of cervical intervertebral disc (including bone window), magnetic resonance imaging of cervical spinal cord, etc. Diagnostic criteria of skull base depression: Chamberlain line: odontoid process higher than this line 3-4 mm; Maxwell line: hard palate posterior margin to occipital squamous lower margin of the line, odontoid process normal not more than 7 mm, if more than 7 mm, indicating a skull base depression; mastoid line: odontoid process tip if more than two sides of the breast Boogard angle: the angle between the anterior and posterior margin of the foramen magnum and the clivus of the occipital bone on the lateral cranial slices, 120-130 degrees in the normal position, greater than this angle is the basilar depression. Among the 22 patients who underwent occipitocervical fusion, 12 underwent bilateral pedicle screw placement at C2, 2 underwent lateral mass screw placement at C2, 1 underwent unilateral pedicle screw placement at C2, and 1 underwent pedicle screw placement at C2 right and left. The width of bilateral pedicles and sagittal diameter of bilateral pedicles were measured: the width of the axis of the axis of the vertebral pedicle was measured on the cervical vertebral CT, and the CT film of the middle of the pedicle was selected on the scan plane of the vertebral pedicle. We measured the width of the pedicle through the workstation of the PACS imaging system and the minimal vertical distance between the medial margin of the vertebral artery foramen and the internal margin of the pedicle by the measuring ruler of the software itself. Results: Among the 26 cases studied, 11 cases had normal type I development without obvious deformity, 3 cases had type II lateral mass dysplasia, and 12 cases had type III pedicle dysplasia, including unilateral or bilateral simple pedicle dysplasia and combined with lateral mass dysplasia. The average width of the left pedicle was 6.4818 (+ 1.3 mm) in type I, 7.1909 (+ 1.4 mm) in right pedicle, 6.43 (+ 1.1 mm) in left pedicle, 5.93 (+ 1.2 mm) in right pedicle, and 5.93 (+ 1.2 mm) in type I I. The average width of the left and right pedicles was 2.7 (+ 1.3 mm) and 3.283 (+ 1.2 mm) respectively. The results of SPSS analysis showed that the width of the left and right pedicles was statistically significant (P 0.01) between type I and type III, and between type II and type III. There was no significant difference between type I and type II. Diameter measurements: The mean effective length of the left lateral mass was 12.127 (+ 1.3 mm) in type I, 13.091 (+ 1.2 mm) in right lateral mass, 6.58 (+ 1.2 mm) in type II, 6.75 (+ 1.4 mm) in right lateral mass, 8.5 (+ 1.4 mm) in left lateral mass and 8.5 (+ 1.4 mm) in right lateral mass. The mean effective length was 9.25 (+ 1.3 mm). The results of SPSS analysis showed that the effective length of the right lateral mass in patients with type I and type I I, type I and type I I I, type I I and type I I I were statistically significant (P 0.01). There was no significant difference between type I I and type I I I on the left side. All patients were treated with bilateral pedicle screw fixation. Twelve patients with type III pedicle dysplasia were treated with bilateral pedicle screw fixation. The other 8 cases were lateral mass dysplasia with pedicle dysplasia. One of them was discharged without operation, and the other was bilateral mass dysplasia with unilateral pedicle dysplasia. Six cases were not fixed in C2 because the pedicle and lateral mass were not suitable for internal fixation, so the lateral mass screw fixation was performed in C3-4. Conclusion: For patients with skull base depression, complete decompression of occipitocervical region and stable fixation are the key to treatment. Combined with the characteristics of pedicle and lateral mass development, the axis of patients with skull base depression can be divided into five types, of which type I is still well developed and the pedicle width is in the lower limit of normal range. Type I I refers to the development of simple lateral mass. According to unilateral or bilateral dysplasia can also be divided into type II A and type II B, type II A is mainly unilateral mass dysplasia, type II B is bilateral mass dysplasia. Type III is mainly pedicle dysplasia, and it is divided into type III A, type III B and type III C, type III A is unilateral pedicle dysplasia, type III B is bilateral pedicle dysplasia. Dysplasia, type III C, refers to the presence of lateral mass dysplasia. Type IV (lamina fusion) and type V (vertebral fusion) have fewer cases and less impact on occipitocervical fusion. Vertebral artery spacing is also a risk factor for axial screw placement, which can lead to pedicle and lateral mass deformation. Imaging data of patients with basilar indentation often appear. Because the vertebral artery is adjacent to the pedicle, the abnormal vertebral artery will deviate inward and backward, located in the medial or posterior part of the pedicle, so the pedicle is compressed and deformed, even through the center of the lateral mass and upward through the lateral mass into the skull. For patients with skull base depression, the following factors should be considered in the selection of axial screw placement: whether the pedicle width meets the minimum requirements of pedicle screw; the shape and size of lateral mass; the course of vertebral artery. This classification is based on the above factors and is intended to help the spine. Column surgeons understand the development of the axis in patients with skull base depression, provide a basis for the strategy of screw placement, provide individual treatment for each patient, and select the best screw placement method to reduce the risk of surgery.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3
本文编号：2231780
[Abstract]:Objective: skull base depression is a kind of occipitocervical dysplasia, which is caused by compression of the ventral side of the spinal cord, resulting in fine movement retardation of both hands, feeling of stepping on cotton when walking on both feet, elevated muscle tension of the extremities, pathological signs and other clinical manifestations and signs. Fusion surgery. Internal fixation of occipital and cervical vertebrae is necessary in occipitocervical fusion surgery. However, the development of the axis is often abnormal in patients with skull base depression, so there are many difficulties in the internal fixation of the axis, affecting the choice of surgical strategy. Methods: In this study, 26 patients with basilar invagination were enrolled in the medical records. Materials: From December 2013 to December 2016, there were 10 males and 16 females with an average age of 41.8 years (25-63 years). Among them, 18 were under 50 years old, accounting for 69.23% of the total, and 8 were over 50 years old (30.76%). The average duration of the disease was about 2 years and the longest was 13 years.The clinical manifestations were numbness of limbs, slow fine movement of both hands, elevated muscle tension of limbs, pathological features, hyperreflexia of tendons, etc. CT plain scan of cervical intervertebral disc (including bone window), magnetic resonance imaging of cervical spinal cord, etc. Diagnostic criteria of skull base depression: Chamberlain line: odontoid process higher than this line 3-4 mm; Maxwell line: hard palate posterior margin to occipital squamous lower margin of the line, odontoid process normal not more than 7 mm, if more than 7 mm, indicating a skull base depression; mastoid line: odontoid process tip if more than two sides of the breast Boogard angle: the angle between the anterior and posterior margin of the foramen magnum and the clivus of the occipital bone on the lateral cranial slices, 120-130 degrees in the normal position, greater than this angle is the basilar depression. Among the 22 patients who underwent occipitocervical fusion, 12 underwent bilateral pedicle screw placement at C2, 2 underwent lateral mass screw placement at C2, 1 underwent unilateral pedicle screw placement at C2, and 1 underwent pedicle screw placement at C2 right and left. The width of bilateral pedicles and sagittal diameter of bilateral pedicles were measured: the width of the axis of the axis of the vertebral pedicle was measured on the cervical vertebral CT, and the CT film of the middle of the pedicle was selected on the scan plane of the vertebral pedicle. We measured the width of the pedicle through the workstation of the PACS imaging system and the minimal vertical distance between the medial margin of the vertebral artery foramen and the internal margin of the pedicle by the measuring ruler of the software itself. Results: Among the 26 cases studied, 11 cases had normal type I development without obvious deformity, 3 cases had type II lateral mass dysplasia, and 12 cases had type III pedicle dysplasia, including unilateral or bilateral simple pedicle dysplasia and combined with lateral mass dysplasia. The average width of the left pedicle was 6.4818 (+ 1.3 mm) in type I, 7.1909 (+ 1.4 mm) in right pedicle, 6.43 (+ 1.1 mm) in left pedicle, 5.93 (+ 1.2 mm) in right pedicle, and 5.93 (+ 1.2 mm) in type I I. The average width of the left and right pedicles was 2.7 (+ 1.3 mm) and 3.283 (+ 1.2 mm) respectively. The results of SPSS analysis showed that the width of the left and right pedicles was statistically significant (P 0.01) between type I and type III, and between type II and type III. There was no significant difference between type I and type II. Diameter measurements: The mean effective length of the left lateral mass was 12.127 (+ 1.3 mm) in type I, 13.091 (+ 1.2 mm) in right lateral mass, 6.58 (+ 1.2 mm) in type II, 6.75 (+ 1.4 mm) in right lateral mass, 8.5 (+ 1.4 mm) in left lateral mass and 8.5 (+ 1.4 mm) in right lateral mass. The mean effective length was 9.25 (+ 1.3 mm). The results of SPSS analysis showed that the effective length of the right lateral mass in patients with type I and type I I, type I and type I I I, type I I and type I I I were statistically significant (P 0.01). There was no significant difference between type I I and type I I I on the left side. All patients were treated with bilateral pedicle screw fixation. Twelve patients with type III pedicle dysplasia were treated with bilateral pedicle screw fixation. The other 8 cases were lateral mass dysplasia with pedicle dysplasia. One of them was discharged without operation, and the other was bilateral mass dysplasia with unilateral pedicle dysplasia. Six cases were not fixed in C2 because the pedicle and lateral mass were not suitable for internal fixation, so the lateral mass screw fixation was performed in C3-4. Conclusion: For patients with skull base depression, complete decompression of occipitocervical region and stable fixation are the key to treatment. Combined with the characteristics of pedicle and lateral mass development, the axis of patients with skull base depression can be divided into five types, of which type I is still well developed and the pedicle width is in the lower limit of normal range. Type I I refers to the development of simple lateral mass. According to unilateral or bilateral dysplasia can also be divided into type II A and type II B, type II A is mainly unilateral mass dysplasia, type II B is bilateral mass dysplasia. Type III is mainly pedicle dysplasia, and it is divided into type III A, type III B and type III C, type III A is unilateral pedicle dysplasia, type III B is bilateral pedicle dysplasia. Dysplasia, type III C, refers to the presence of lateral mass dysplasia. Type IV (lamina fusion) and type V (vertebral fusion) have fewer cases and less impact on occipitocervical fusion. Vertebral artery spacing is also a risk factor for axial screw placement, which can lead to pedicle and lateral mass deformation. Imaging data of patients with basilar indentation often appear. Because the vertebral artery is adjacent to the pedicle, the abnormal vertebral artery will deviate inward and backward, located in the medial or posterior part of the pedicle, so the pedicle is compressed and deformed, even through the center of the lateral mass and upward through the lateral mass into the skull. For patients with skull base depression, the following factors should be considered in the selection of axial screw placement: whether the pedicle width meets the minimum requirements of pedicle screw; the shape and size of lateral mass; the course of vertebral artery. This classification is based on the above factors and is intended to help the spine. Column surgeons understand the development of the axis in patients with skull base depression, provide a basis for the strategy of screw placement, provide individual treatment for each patient, and select the best screw placement method to reduce the risk of surgery.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3
【参考文献】
相关期刊论文 前10条
1 魏富鑫;刘少喻;王乐;梁春祥;龙厚清;孙海兴;崔尚斌;潘鹤海;黄阳亮;;术前牵引后路枕颈复位固定融合治疗颅底凹陷症并可复性寰枢椎脱位[J];中国脊柱脊髓杂志;2013年05期
2 朱如森;冯世庆;刘岩;;脊柱内固定椎弓根螺钉置入后生物力学的稳定性[J];中国组织工程研究;2013年17期
3 许建强;栾文忠;;脊髓空洞症的分类及手术治疗[J];中国临床神经外科杂志;2012年09期
4 王建华;夏虹;尹庆水;艾福志;吴增晖;马向阳;章凯;;经口咽前路寰椎侧块置钉固定治疗合并寰枕融合畸形颅底凹陷症的临床疗效[J];中国脊柱脊髓杂志;2012年06期
5 王建华;尹庆水;夏虹;艾福志;吴增晖;马向阳;章凯;;颅底凹陷症的分型及其意义[J];中国脊柱脊髓杂志;2011年04期
6 刘洋;权正学;;寰枢椎椎弓根解剖及个体化置钉研究进展[J];颈腰痛杂志;2010年02期
7 刘金有;;原发性颅底凹陷症的影像学诊断进展[J];中国实用医药;2009年32期
8 李洪珂;王文军;;脊髓空洞症的外科治疗进展[J];中国脊柱脊髓杂志;2008年01期
9 王建华;尹庆水;夏虹;吴增辉;;枢椎椎动脉孔分型对枢椎椎弓根置钉的临床意义[J];中国脊柱脊髓杂志;2007年08期
10 何俐;陈小燕;;脊髓空洞症的诊断和治疗进展[J];中国全科医学;2007年12期
，本文编号：2231780
本文链接：https://www.wllwen.com/yixuelunwen/waikelunwen/2231780.html
最近更新
教材专著
