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目的:探讨术前判别寰枢椎解剖类型对上颈椎后路置钉策略的意义。方法:2012年3月~2015年10月对86例上颈椎疾病患者实施后路寰枢椎内固定手术,其中颅颈交界畸形合并寰枢椎脱位33例,创伤性寰枢椎脱位18例,寰枢椎椎管内肿瘤14例,寰枢椎结核合并寰枢椎脱位9例,类风湿关节炎合并寰枢椎脱位12例。在颈椎侧位X线片上测量寰椎后弓的高度,对后弓高度≥3.5mm的A型寰椎选择寰椎椎弓根螺钉固定,对后弓高度<3.5mm的B型寰椎选择寰椎椎板钩固定。CT薄层扫描测量枢椎椎动脉孔入口至枢椎椎管内壁的距离(a),数层法识别椎动脉孔球部开始出现的层数,计算e值(层数×层厚);根据a、e值确定枢椎椎动脉孔的类型:a>4.5mm、e≥4.5mm为Ⅰ型,a≤4.5mm、e<4.5mm为Ⅱ型,a≤4.5mm、e≥4.5mm为Ⅲ型,a>4.5mm、e<4.5mm为Ⅳ型;Ⅱ型选择枢椎椎板螺钉固定,Ⅰ、Ⅲ、Ⅳ型选择经椎弓根螺钉固定。结果:86例患者中,寰椎后弓A型146侧,B型26侧;枢椎椎动脉孔Ⅱ型32侧,Ⅰ、Ⅲ、Ⅳ型140侧。手术共置入寰椎椎板钩26枚,寰椎椎弓根螺钉146枚,枢椎椎板螺钉32枚,枢椎椎弓根螺钉140枚;施行寰椎椎弓根螺钉-棒-枢椎椎弓根螺钉内固定术(57例)、寰椎椎弓根螺钉-棒-枢椎椎板螺钉内固定术(16例)和寰椎椎板钩-棒-枢椎椎弓根螺钉内固定术(13例)三种类型的个性化内固定组合手术。手术均顺利完成,手术时间95~156min(130±25min),手术出血量105~188ml(150±35ml)。术后复査X线片显示寰枢椎均达到理想复位,随访8~18个月(13±5.5个月),末次随访CT检査结果显示,除1例寰椎椎板钩固定病例出现内固定松动外,其余患者均获得骨性融合。结论:术前应用影像技术对患者寰枢椎解剖类型进行综合判断并制定个性化的置钉策略和固定方式,有助于提高手术安全性。
Objective: To investigate the significance of preoperative identification of atlantoaxial anatomical types in posterior cervical spine placement strategy. METHODS: From March 2012 to October 2015, 86 patients with upper cervical disease underwent posterior atlantoaxial fixation. Among them, 33 cases of cranial deformity combined with atlantoaxial dislocation, 18 cases of traumatic atlantoaxial dislocation, Atlantoaxial spinal canal tumor in 14 cases, atlantoaxial tuberculosis with atlantoaxial dislocation in 9 cases, rheumatoid arthritis with atlantoaxial dislocation in 12 cases. The height of the posterior arch of the atlas was measured on the lateral cervical X-ray, the atlas pedicle screw fixation was applied to the atlas of the posterior arch ≥ 3.5mm, the atlas of the atlas was selected for the atlas of the posterior arch <3.5mm Vertebral plate hook fixed. The distance between the entrance of the vertebral artery and the inner wall of the vertebral canal was measured by thin-slice CT (a). The number of layers that began to appear in the vertebral foramen was identified by several layers, and the e value (number of layers × thickness) was calculated. a, e value to determine the type of vertebral artery hole: a> 4.5mm, e ≥ 4.5mm for type Ⅰ, a ≤ 4.5mm, e <4.5mm for type Ⅱ, a ≤ 4.5mm, e ≥ 4.5mm for the Ⅲ Type, a> 4.5mm, e <4.5mm for the type Ⅳ; type Ⅱ choice of vertebral screw fixation, Ⅰ, Ⅲ, Ⅳ type of choice by pedicle screw fixation. Results: Among the 86 patients, there were 146 sides of atlas type A at the posterior arch of the atlas, 26 sides of type B, 32 sides of type Ⅱ of the axis of vertebral artery, 140 sides of type Ⅰ, Ⅲ and Ⅳ. A total of 26 operations were performed with atlas laminar hooks, 146 atlas pedicle screws, 32 vertebral laminas screws and 140 pedicle screw pedicles. Atlas pedicle screws, rods and axons Pedicle screw fixation (57 cases), atlas pedicle screw - rod - axis plate fixation (16 cases) and atlas lamina hook - rod - axis pedicle screw fixation Surgery (13 cases) three types of personalized internal fixation combined surgery. The operation was completed successfully. The operation time was 95-156min (130 ± 25min) and the amount of surgical bleeding was 105-188ml (150 ± 35ml). Postoperative reexamination of X-ray showed that atlantoaxial all achieved the ideal reduction. The follow-up ranged from 8 to 18 months (13 ± 5.5 months). The CT findings at the last follow-up showed that in addition to one case of atlas laminar hook fixation Fixed loose, the rest of the patients were bony fusion. Conclusion: Preoperative application of imaging techniques to determine the type of atlantoaxial anatomy in patients and to develop personalized strategies and fixation screw placement, help to improve the safety of surgery.