口咽入路小钛板固定治疗不稳定寰椎骨折的可行性分析

doi:10.11958/20220476

摘要/Abstract

摘要：

目的研究口咽入路小钛板固定治疗不稳定寰椎骨折的可行性分析。方法选取64例不稳定寰椎骨折患者，其中30例采用口咽入路小钛板固定治疗为观察组，34例采用后路寰枢椎椎弓根钉内固定治疗为对照组。比较2组术中指标：手术时间、出血量；术后指标：住院时间、并发症（颈部慢性疼痛、切口感染、吞咽困难）发生情况，术前、术后1个月、末次随访的疼痛视觉模拟（VAS）评分、日本骨科协会（JOA）评分以及颈椎后伸、前屈、左旋、右旋活动度。结果观察组手术时间、出血量均显著低于对照组（P<0.05），住院时间差异无统计学意义；2组颈部慢性疼痛、切口感染和吞咽困难发生率差异无统计学意义；2组术后1个月、末次随访VAS评分低于术前，JOA评分高于术前（P<0.05），组间比较差异均无统计学意义；2组术后1个月、末次随访后伸、前屈、左旋、右旋活动度均较术前增加（P<0.05）；观察组术后1个月、末次随访后伸、前屈、左旋、右旋活动度均高于对照组（P<0.05）。结论口咽入路小钛板固定治疗不稳定寰椎骨折创伤小，手术时间短，且较传统后路寰枢椎椎弓根钉内固定治疗能够最大程度上保留颈椎活动度。

关键词: 骨折固定术, 内, 颈寰椎, 口咽, 钛, 手术后期间

Abstract:

Objective To study the feasibility of small titanium plate fixation through oropharyngeal approach in the treatment of unstable atlas fracture. Methods Sixty-four patients with unstable atlas fracture were selected, of which 30 patients were treated with small titanium plate fixation through oropharyngeal approach were used as the observation group, and 34 patients were treated with posterior atlantoaxial pedicle screw internal fixation were used as the control group. Intraoperative indexes including operation time, blood loss, postoperative indicators, length of hospital stay, occurrence of complications (chronic neck pain, incision infection and dysphagia), visual analogue pain (VAS) score, Japanese Orthopaedic Association (JOA) score before surgery, 1 month after surgery and at the last follow-up and cervical extension, flexion, left and right rotation range of motion were compared between the two groups. Results The operation time and blood loss were significantly lower in the observation group than those in the control group (P<0.05), and there was no significant difference in the length of hospital stay between the two groups. There were no significant differences in the incidence of chronic neck pain, incision infection and dysphagia between the two groups. The VAS score was lower and the JOA score was higher 1 month after surgery and at the last follow-up than those before surgery (P<0.05), and there was no significant difference between the two groups. The extension, flexion, dextral and dextral movements were all increased one month after surgery and at the last follow-up in the two groups (P<0.05). The cervical extension, flexion, left rotation and right rotation of the observation group were higher than those of the control group one month after surgery and the last follow-up (P<0.05). Conclusion The oropharyngeal approach with small titanium plate fixation for unstable atlantic fracture is less invasive and shorter operation time, and can retain cervical spine mobility to the greatest extent than traditional posterior atlantoaxial pedicle screw fixation.

Key words: fracture fixation, internal, cervical atlas, oropharynx, titanium, postoperative period

中图分类号:

R687.3

图/表 6

参考文献 14

[1]	唐晓明, 柳超, 黄凯, 等. 寰枢椎复合骨折三维有限元模型模拟分析[J]. 中华医学杂志, 2018, 98(19):1484-1488.
	TANG X M, LIU C, HUANG K, et al. Analysis of a three-dimensional finite element model of atlas and axis complex fracture[J]. Natl Med J China, 2018, 98(19):1484-1488. doi:10.3760/cma.j.issn.0376-2491.2018.19.006.
[2]	胡勇, 徐荣明. 寰椎骨折的研究进展[J]. 中华创伤杂志, 2011, 27(2):133-136.
	HU Y, XU R M. Research progress in the atlas fracture[J]. Chin J Trauma, 2011, 27(2):133-136. doi:10.3760/cma.j.issn.1001-8050.2011.02.009.
[3]	杨敏, 古辉云, 钟厚成, 等. 后路寰枢椎椎弓根螺钉内固定植骨融合治疗成人不稳定性寰椎骨折的效果[J]. 中国脊柱脊髓杂志, 2020, 30(2):136-141.
	YANG M, GU H Y, ZHONG H C, et al. Posterior atlantoaxial pedicle screws fixation combined C1/2 fusionin adultunstable atlas fracture[J]. Chinese Journal of Spine and Spinal Cord, 2020, 30(2):136-141. doi:10.3969/j.issn.1004-406X.2020.02.07.
[4]	常恒瑞, 李祥宇, 赵若宇, 等. 后路寰枢椎固定技术的生物力学研究进展[J]. 中国脊柱脊髓杂志, 2022, 32(4):369-373.
	CHANG H R, LI X Y, ZHAO R Y, et al. Research progress in biomechanics of posterior atlantoaxial fixation[J]. Chinese Journal of Spine and Spinal Cord, 2022, 32(4):369-373. doi:10.3969/j.issn.1004-406X.2022.04.12.
[5]	邹小宝, 马向阳, 杨进城, 等. 寰枢椎脱位不同植骨材料及内固定方式对植骨后融合时间的影响[J]. 中国组织工程研究, 2017, 21(11):1688-1694.
	ZOU X B, MA X Y, YANG J C, et al. Effects of different graft materials and internal fixation methods on the intervertebral fusion time in atlantoaxial dislocation surgery[J]. Chinese Journal of Tissue Engineering Reserach, 2017, 21(11):1688-1694. doi:10.3969/j.issn.2095-4344.2017.11.009.
[6]	王力冉, 赵刘军, 马维虎. 经口咽入路单节段固定治疗不稳定性寰椎骨折的研究进展[J]. 中国骨伤, 2017, 30(1):93-96.
	WANG L R, ZHAO L J, MA W H. Research progress on reatment of unstable atlas fracture with single-segment fixation by transoral approach[J]. China J Oahop Trauma, 2017, 30(1):93-96. doi:10.3969/j.issn.1003-0034.2017.01.022.
[7]	ELERAKY M A, DUONG H T, ESP E, et al. Expandable versus nonexpandable cages for thoracolumbar burst fracture[J]. World Neurosurg, 2011, 75(1):149-154. doi:10.1016/j.wneu.2010.09.018.
[8]	李柯柯, 姚蒙蒙, 张英东, 等. 新鲜不稳定寰椎骨折的手术策略及疗效分析[J]. 中国骨与关节损伤杂志, 2018, 33(5):449-453.
	LI K K, YAO M M, ZHANG Y D, et al. Clinical results and surgical tactics of fresh and unstable atlas fractures[J]. Chin J of Bone Joint Injury, 2018, 33(5):449-453. doi:10.7531/j.issn.1672-9935.2018.05.001.
[9]	赵士杰, 全仁夫, 翟晓军, 等. 经口咽入路微型钛板内固定治疗不稳定寰椎骨折[J]. 中华创伤杂志, 2017, 33(3):241-246.
	ZHAO S J, QUAN R F, ZHAI X J, et al. Unstable atlas fractures treated by minitype titanium plate fixation through transoral approach[J]. Chin J Trauma, 2017, 33(3):241-246. doi:10.3760/cma.j.issn.1001-8050.2017.03.011.
[10]	韩应超, 杨明杰, 潘杰, 等. 单纯寰椎侧块螺钉固定选择性治疗不稳定寰椎骨折的生物力学分析[J]. 中国脊柱脊髓杂志, 2014(1):68-72,73.
	HAN Y C, YANG M J, PAN J, et al. Biomechanical analysis of direct posterior C1 screws compression reduction in the selective treatment of unstable atlas fractures[J]. Chinese Journal of Spine and Spinal Cord, 2014(1):68-72, 73. doi:10.3969/j.issn.1004-406X.2014.01.13.
[11]	马向阳, 杨进城, 邹小宝, 等. 经口单开门小钛板复位固定治疗寰椎前后弓骨折[J]. 脊柱外科杂志, 2018, 16(2):66-70.
	MA X Y, YANG J C, ZOU X B, et al. Transoral reduction and fixation of anterior-posterior arch fractures of C1 with open-door mini titanium plate[J]. J Spinal Surg, 2018, 16(2):66-70. doi:10.3969/j.issn.1672-2957.2018.02.002.
[12]	赵朵, 李小峰, 农桔安, 等. 经口咽微型钢板与后路钉板单节段内固定治疗不稳定型Jefferson骨折的疗效比较[J]. 中国骨与关节杂志, 2018, 7(6):407-412.
	ZHAO D, LI X F, NONG J A, et al. A comparison of effects of transoral mini plate and posterior nail plate single segment fixation in the treatment of Jefferson fractures[J]. Chinese Journal of Bone and Joint, 2018, 7(6):407-412. doi:10.3969/j.issn.2095-252X.2018.06.002.
[13]	李小峰, 冀晶, 农桔安, 等. 经口咽入路重建钢板单节段内固定治疗不稳定性寰椎骨折[J]. 脊柱外科杂志, 2019, 17(3):158-162.
	LI X F, JI J, NONG J A, et al. Treatment of unstable atlas fracture with reconstruction plate single-segmental internal fixation via oropharyngeal approach[J]. J Spinal Surg, 2019, 17(3):158-162. doi:10.3969/j.issn.1672-2957.2019.03.002.
[14]	HE B, YAN L, ZHAO Q, et al. Self-designed posterior atlas polyaxial lateral mass screw-plate fixation for unstable atlas fracture[J]. Spine J, 2014, 14(12):2892-2896. doi:10.1016/j.spinee.2014.04.020.

组别	n	骨折类型（前1/2Jefferson/ 半环Jefferson）	性别（男/女）	年龄/岁
对照组	34	20/14	19/15	44.04±6.02
观察组	30	17/13	17/13	43.11±3.23
χ²或t		0.030	0.004	0.782

组别	n	骨折类型（前1/2Jefferson/ 半环Jefferson）	性别（男/女）	年龄/岁
对照组	34	20/14	19/15	44.04±6.02
观察组	30	17/13	17/13	43.11±3.23
χ²或t		0.030	0.004	0.782

组别	n	手术时间/min	出血量/mL	住院时间/d
对照组	34	94.12±8.22	168.88±12.93	9.03±2.03
观察组	30	86.22±7.23	120.44±9.12	8.87±1.45
t		4.090^＊＊	17.469^＊＊	0.367

组别	n	手术时间/min	出血量/mL	住院时间/d
对照组	34	94.12±8.22	168.88±12.93	9.03±2.03
观察组	30	86.22±7.23	120.44±9.12	8.87±1.45
t		4.090^＊＊	17.469^＊＊	0.367

组别	n	VAS评分/分								JOA评分/分
组别	n	术前		术后1个月		末次随访		F		术前		术后1个月	末次随访	F
对照组	34	6.80±1.03		2.36±0.37^A		1.40±0.21^A		681.630^＊＊		12.50±2.50		18.98±2.22^A	24.02±1.20^A	269.590^＊＊
观察组	30	6.76±1.07		2.32±0.24^A		1.37±0.14^A		609.630^＊＊		12.45±2.67		19.32±2.10^A	24.12±1.03^A	245.750^＊＊
t		0.152		0.519		0.680				0.077		0.629	0.359
组别	后伸/°								前屈/°
组别	术前		术后1个月		末次随访		F		术前		术后1个月		末次随访	F
对照组	10.80±2.43		20.31±3.31^A		36.58±4.45^A		472.840^＊＊		11.54±4.53		18.24±2.12^A		32.18±3.35^A	312.07^＊＊
观察组	10.76±2.35		25.11±3.23^A		39.87±4.66^A		506.160^＊＊		11.42±4.27		19.56±2.54^A		34.07±4.04^A	327.44^＊＊
t	0.067		5.865^＊＊		2.879^＊				0.109		2.265^＊		2.044^＊
组别	左旋/°								右旋/°
组别	术前		术后1个月		末次随访		F		术前		术后1个月		末次随访	F
对照组	20.75±3.65		41.11±5.02^A		57.21±4.88^A		546.260^＊＊		20.90±4.59		41.93±6.67^A		57.09±3.43^A	435.700^＊＊
观察组	20.88±3.54		45.21±5.11^A		60.77±5.66^A		514.710^＊＊		21.12±4.76		46.11±4.65^A		61.12±4.12^A	599.910^＊＊
t	0.144		3.230^＊＊		2.677^＊				0.188		2.934^＊		4.220^＊＊