| 陈源权,莫少东,徐 敬,付索超,张 宇,艾福志.寰枢椎后路椎弓根钉棒内固定技术在幼儿上颈椎疾患中的应用[J].中国脊柱脊髓杂志,2023,(7):584-591. |
| 寰枢椎后路椎弓根钉棒内固定技术在幼儿上颈椎疾患中的应用 |
| 中文关键词: 幼儿（1～5岁） 上颈椎疾患 颅颈交界畸形 寰枢椎脱位 颅底凹陷症 椎弓根钉棒内固定技术 |
| 中文摘要: |
| 【摘要】 目的：探讨后路寰枢椎椎弓根钉棒内固定技术在1～5岁幼儿上颈椎疾患中的应用效果。方法：回顾性研究本团队2013年5月～2022年3月采用寰枢椎椎弓根钉棒内固定技术治疗的上颈椎疾患幼儿13例，男10例，女3例；年龄15～68个月，平均43.85±17.56个月；体重9～22.5kg，平均16.32±3.23kg。患儿的主要临床表现为颈部疼痛伴活动受限，其中2例患儿伴有四肢乏力，1例患儿颈部偏斜为主要表现；术前美国脊髓损伤协会（American Spinal Injury Association，ASIA）分级C级2例，D级1例，E级10例。术前常规行张口位正侧位以及动力位X线片、CT骨三维重建、椎动脉CT血管造影（CT angiography，CTA）、MRI平扫或增强检查。常规行床边枕颌带或颅骨牵引，麻醉下颅骨牵引，13例患儿皆可获得完全或大部分复位，遂行后路寰枢椎复位椎弓根钉棒内固定术，所有椎弓根螺钉直径为3.5mm；除外4例新鲜单纯Ⅱ型齿状突骨折伴寰枢椎脱位患儿，其他病例皆行自体髂骨植骨融合；对3例因颅颈交界畸形或寰枢椎发育异常无法行寰枢椎椎弓根钉棒内固定术患儿采用枕颈固定融合方式治疗。结果：所有患儿手术过程顺利，未发生硬脊膜、脊髓、椎动脉或神经根损伤。共置入颈椎后路螺钉50枚，枕骨钢板3个；其中寰枢椎椎弓根螺钉41枚，枢椎椎板螺钉3枚，C3、C4侧块螺钉6枚。手术时长100～180min，平均136.92±30.38min；术中出血30～150ml，平均73.33±35.43ml，均未输血。住院时间5～31d，平均15.58±8.37d。所有患儿皆获得随访，随访时间3～109个月，平均47.46±36.26个月。术后寰枢间距减小，椎管最小矢状径增大，与术前相比差异均具有统计学意义（1.19±0.19cm vs 1.81±0.34cm，1.42±0.30cm vs 1.08±0.43cm，P<0.05）。术后3个月随访时，所有患儿均无颈部疼痛，除枕颈固定融合病例颈部活动受影响明显外，其余患儿仅轻微颈部旋转受限；JOA评分与术前比较差异无统计学意义（17.00±0.00 vs 16.23±0.48，P>0.05）；术前1例脊髓功能ASIA C级，2例ASIA D级患儿末次随访时恢复至E级。所有行融合手术患儿骨性融合时间为2.5～6个月，平均4.15±1.60个月。4例行单纯寰枢椎椎弓根钉棒内固定患儿，齿状突骨折愈合后返院拆除内固定，在后续随访中，寰枢椎无不稳并恢复正常功能。结论：直径3.5mm成人椎弓根螺钉能够安全有效应用于大部分上颈椎疾患幼儿，长期随访疗效满意。对于部分寰枢椎发育不良或颅颈交界畸形患儿，寰椎椎弓根螺钉联合枢椎椎板螺钉或枕颈固定融合是有效的补救方式。 |
Application of posterior atlantoaxial pedicle screw-rod internal fixation in young children with upper cervical disorders |
| 英文关键词:Yound children(1-5 years old) Upper cervical disorders Craniocervical junction deformity Atlantoaxial dislocation Basilar invagination Pedicle screw rod internal fixation |
| 英文摘要: |
| 【Abstract】 Objectives: To investigate the application effect of posterior atlantoaxial pedicle screw-rod internal fixation in 1-5 year old children with upper cervical disorders. Methods: 13 children with upper cervical disorders treated by our team with atlantoaxial pedicle screw-rod internal fixation were studied retrospectively, which consisted of 10 boys and 3 girls, aged 43.85±17.56 months(15-68 months) old, and weighted 16.32±3.23kg(9-22.5kg). The main clinical manifestation of the children with upper cervical disorders combined with atlantoaxial dislocation was neck pain and limitation of neck motion, besides, limb weakness occurred in 2 patients and neck deviation as the main manifestation occurred 1 patient; 2 patients were of American Spinal Injury Association(ASIA) grade C, 1 patient was of grade D, and 10 were of grade E before operation. Frontal and lateral open mouth and dynamic X-ray, CT bone three-dimensional reconstruction, vertebral artery CT angiography(CTA), MRI plain or enhanced examination were performed before operation. All the 13 children patients underwent posterior atlantoaxial vertebral reduction and pedicle screw-rod internal fixation(3.5mm in diameter for pedicle screw) since the dislocation could be completely or mostly reduced after routine bedside occipital jaw band or skull traction and skull traction under anesthesia. Except for 4 cases of fresh type Ⅱ odontoid fracture with atlantoaxial dislocation, the other patients were treated with autologous iliac bone graft fusion. Occipito-cervical fixation and fusion were performed on the 3 patients who were unable to undergo atlantoaxial pedicle screw-rod fixation due to craniocervical junction deformity or atlantoaxial dysplasia. Results: All the operations went smoothly without dura, spinal cord, vertebral artery or nerve root injury. A total of 50 posterior cervical screws and 3 occipital plates were implanted, including 41 atlantoaxial pedicle screws, 3 axial lamina screws, and 6 C3 and C4 lateral mass screws. The operative time was 136.92±30.38min(100-180min), and intraoperative blood loss was 73.33±35.43ml(30-150ml) without blood transfusion. The length of hospital stay was 15.58±8.37 days(5-31 days). All the patients were followed up 47.46±36.26 months(3-109 months). After the operation, the atlantoaxial distance was decreased and the minimum sagittal diameter of spinal canal was increased significantly compared with the preoperative ones respectively(1.19±0.19cm vs 1.81±0.34cm, 1.42±0.30cm vs 1.08±0.43cm, P<0.05). None complained of neck pain or limitation of neck motion at 3-month follow-up after surgery; and except for the patients recieved occipital-cervical fixation and fusion, the rest patients only complained of slight neck rotation limitation. There was significant difference in JOA score between follow-up and preoperation(17.00±0.00 vs 16.23±0.48, P>0.05). 1 patient of ASIA grade C and 2 patients of grade D improved to grade E at the final follow-up. The period for bony fusion of all the patients received autogenous iliac bone graft fusion was 4.15±1.60 months(2.5-6 months). The 4 patients received simple atlantoaxial pedicle screw fixation returned to the hospital for removal of internal fixation after odontoid fracture healed, and no atlantoaxial instability was found and normal function was restored during follow-up. Conclusions: The 3.5mm diameter pedicle screw can be applied safely and effectively on most of the yound children(≥1 year and 3 months old) with upper cervical disorders, and the long-term efficacy is satisfactory. For some children with atlantoaxial dysplasia or craniocervical junction deformity, atlantoaxial pedicle screw combined with axial laminar screw or occipital-cervical fixation and fusion serves an effective remedy. |
| 投稿时间：2022-10-17 修订日期：2023-07-05 |
| DOI： |
| 基金项目:广州市科技计划项目（202201020364） |
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