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目的探讨采用椎弓根螺钉系统内固定治疗儿童寰枢区不稳的疗效。方法 2005年7月-2012年1月,收治19例寰枢区不稳患儿。男10例,女9例;年龄4~15岁,平均7.5岁。X线片、CT及MRI检查示枕颈区畸形9例,先天性齿突不连3例,齿突骨折(Ⅱ型)1例,寰枢椎横韧带断裂2例,寰枢椎骨折脱位4例;颈脊髓损伤8例,根据美国脊髓损伤协会(ASIA)分级标准:B级1例、C级2例、D级5例。其中17例经颅骨牵引或枕颌带牵引复位后行颈后路椎弓根螺钉系统固定(采用寰枢椎融合固定12例,枕颈融合固定5例);2例牵引复位失败后行经口腔入路寰枢松解、颈后路椎弓根螺钉系统固定(寰枢椎融合固定)。结果手术均顺利完成。手术时间平均89 min,术中出血量平均95 mL,术后引流量平均73 mL,住院时间平均14 d。19例均获随访,随访时间6~27个月,平均18.3个月。患儿寰枢椎均获满意融合;植骨均融合,融合时间3~7个月,平均4.5个月。随访期间无断钉、断棒以及寰枢椎再脱位发生。末次随访时,5例行枕颈融合固定患儿左、右侧颈椎旋转活动度(cervical range of motion,CROM)分别为(62.0±5.9)°和(63.9±3.8)°,与同龄正常儿童左、右侧CROM[分别为(72.3±7.0)°和(74.1±7.6)°]比较,差异有统计学意义(t=—3.915,P=0.018;t=—5.954,P=0.004);14例行寰枢椎融合固定患儿左、右侧CROM分别为(70.5±5.8)°和(72.7±4.9)°,与同龄正常儿童左、右侧CROM比较差异无统计学意义(t=—1.417,P=0.180;t=—1.021,P=0.323)。末次随访时疼痛视觉模拟评分(VAS)为(3.5±0.8)分,较术前(7.8±1.1)分显著改善(t=17.267,P=0.000)。8例脊髓损伤患儿末次随访时ASIA分级:C级2例,D级1例,E级5例。结论经颈后路椎弓根螺钉系统内固定治疗儿童寰枢区不稳可取得较好效果,能明显缓解枕颈部疼痛、活动受限、神经功能损伤等症状。
Objective To investigate the effect of pedicle screw system internal fixation for atlantoaxial instability in children. Methods From July 2005 to January 2012, 19 children with atlantoaxial instability were treated. 10 males and 9 females; aged 4 to 15 years, mean 7.5 years. X-ray, CT and MRI showed 9 cases of occipital deformity, 3 cases of congenital odontoid process, 1 case of odontoid fracture (type Ⅱ), 2 cases of atlantoaxial transverse ligament rupture, atlantoaxial fracture-dislocation 4 Cases of cervical spinal cord injury in 8 cases, according to American Society of Spinal Cord Injury (ASIA) grading standards: B in 1 case, C in 2 cases, D in 5 cases. Among them, 17 cases were fixed by cranial pedicle screw system after traction reduction or occipital-maxillofacial traction reduction (using 12 cases of atlantoaxial fusion fixation and 5 cases of occipitocervical fusion fixation) after traction reduction. 2 cases failed to undergo traction reduction through the oral cavity Road atlantoaxial release, posterior cervical pedicle screw fixation (atlantoaxial fusion fixation). Results The operation was completed successfully. The average operation time was 89 min. The average amount of bleeding during operation was 95 mL. The mean postoperative drainage volume was 73 mL and the average hospital stay was 14 days. All 19 patients were followed up for 6-27 months with an average of 18.3 months. Children atlantoaxial joint were satisfied fusion; bone fusion, fusion time of 3 to 7 months, an average of 4.5 months. No broken nails, broken rods and atlantoaxial dislocation occurred during follow-up. At the last follow-up, left and right cervical spine rotation activities (CROM) were (62.0 ± 5.9) ° and (63.9 ± 3.8) °, respectively, in 5 patients who underwent occipitocervical fusion. (72.3 ± 7.0) ° and (74.1 ± 7.6) °, respectively, with significant difference (t = -3.915, P = 0.018; t = -5.954, P = 0.004) The left and right CROMs were (70.5 ± 5.8) ° and (72.7 ± 4.9) ° respectively in pedicles with atlantoaxial fixation. There was no significant difference in CROM between left and right normal children (t = -1.417, P = 0.180; t = -1.021, P = 0.323). The pain visual analogue scale (VAS) at the final follow-up was (3.5 ± 0.8) points, significantly improved compared with preoperative (7.8 ± 1.1) points (t = 17.267, P = 0.000). In the 8 children with spinal cord injury at the final follow-up ASIA classification: 2 cases of grade C, 1 case of grade D and 5 cases of grade E. Conclusions Transjugular pedicle screw system internal fixation for children with atlantoaxial instability can achieve better results, which can significantly relieve the symptoms of occipital neck pain, limited mobility and nerve function impairment.