CAJ | 학술논문

目的：评价经口寰枢椎复位钢板（TARP）内固定在颅底凹陷症伴寰枢椎脱位后路减压术后翻修手术中的应用价值。方法2008年9月至2012年6月广州军区广州总医院采用TARP内固定翻修手术治疗30例颅底凹陷症伴寰枢椎脱位后路减压术后症状无改善或加重的患者。通过手术前后颈椎过伸过屈位X线片、上颈椎CT扫描及三维重建、MRI检查观察寰枢椎脱位和颈脊髓压迫改善情况，根据日本骨科学会（JOA）评分标准评估患者术后神经功能恢复情况。结果所有翻修手术成功完成，手术时间120～250 min，平均手术时间150 min；术中出血量50～200 mL，平均出血量120 mL。随访6～39个月，平均随访时间16个月。30例患者寰枢椎脱位均获得满意减压复位，脊髓压迫完全解除，术后3～6个月均达到骨性愈合。寰齿间隙从术前的（9.1±1.4）mm降至术后的（1.6±1.4）mm，颈髓角从术前（116.5±12.0）°提高到术后（149.3±10.4）°，手术前后比较，差异有统计学意义（t=18.842，P=0.000；t=-16.520，P=0.000）。29例神经功能获得改善、1例无变化；JOA评分由术前的（10.8±2.3）分提高至术后6个月的（14.5±1.9）分，手术前后比较，差异有统计学意义（t=-17.440，P=0.000）。随访期内无寰枢椎再次脱位或症状加重表现；1例术后2周出现肺部感染，术后1个月枢椎螺钉松动，予抗感染治疗及螺钉调整术后痊愈出院。结论TARP内固定是颅底凹陷症伴寰枢椎脱位安全有效的治疗方式之一，对于后路减压术后内固定及植骨融合困难的翻修病例具有较好的应用价值。
목적：평개경구환추추복위강판（TARP）내고정재로저요함증반환추추탈위후로감압술후번수수술중적응용개치。방법2008년9월지2012년6월엄주군구엄주총의원채용TARP내고정번수수술치료30례로저요함증반환추추탈위후로감압술후증상무개선혹가중적환자。통과수술전후경추과신과굴위X선편、상경추CT소묘급삼유중건、MRI검사관찰환추추탈위화경척수압박개선정황，근거일본골과학회（JOA）평분표준평고환자술후신경공능회복정황。결과소유번수수술성공완성，수술시간120～250 min，평균수술시간150 min；술중출혈량50～200 mL，평균출혈량120 mL。수방6～39개월，평균수방시간16개월。30례환자환추추탈위균획득만의감압복위，척수압박완전해제，술후3～6개월균체도골성유합。환치간극종술전적（9.1±1.4）mm강지술후적（1.6±1.4）mm，경수각종술전（116.5±12.0）°제고도술후（149.3±10.4）°，수술전후비교，차이유통계학의의（t=18.842，P=0.000；t=-16.520，P=0.000）。29례신경공능획득개선、1례무변화；JOA평분유술전적（10.8±2.3）분제고지술후6개월적（14.5±1.9）분，수술전후비교，차이유통계학의의（t=-17.440，P=0.000）。수방기내무환추추재차탈위혹증상가중표현；1례술후2주출현폐부감염，술후1개월추추라정송동，여항감염치료급라정조정술후전유출원。결론TARP내고정시로저요함증반환추추탈위안전유효적치료방식지일，대우후로감압술후내고정급식골융합곤난적번수병례구유교호적응용개치。
Objective To evaluate clinical efficacy of revision surgery of transoral atlantoaxial reduction plate (TARP) fixation for the treatment of basilar invagination (BI) with atlantoaxial dislocation (AAD) after failed posterior decompression. Methods From September 2008 to June 2012, 30 patients who suffered from BI with AAD followed by unsuccessful posterior decompression underwent one-stage revision surgery by TARP fixation in Guangzhou General Hospital of Guangzhou Military Command. Pre- and postoperative dynamic cervical X-rays, CT and MRI were performed to assess the status of dislocation and ventral compression of cervical spinal cord. The neurological status was evaluated by Japanese Orthopaedic Association (JOA) scoring system. Results All cases underwent revision surgeries successfully. The average operative time was 150 min (120-250 min), and the intraoperative estimate blood loss was 120 mL (50-200 mL). All patients were followed up with the average time of 16 months (range, 6-39 months), and for all of the cases, satisfied decompression and reduction had been achieved, and they obtained bone fusion within 3-6 months. Atlanto-dens interval and cervicomedullary angle improved from preoperative (9.1 ± 1.4) mm, (116.5 ± 12.0)°, to postoperative (1.6 ± 1.4) mm, (149.3 ± 10.4)° respectively, there were statistical differences between preoperation and postoperation (t = 18.842, P = 0.000; t = -16.520, P = 0.000). Clinical symptoms were resolved in 29 patients and stabilised in 1 patient. JOA score increased from preoperative 10.8 ± 2.3 to 14.5 ± 1.9 at 6 months after the surgery, the difference between preoperative and postoperative results had statistical significance (t = -17.440, P = 0.000). During the follow-up, no atlantoaxial redislocation or symptom aggravation were found. Lung infection occurred in 1 case 2 weeks after the surgery, and axial screw loosening was found 1 months postoperatively, finally the patient was cured by antibiotics therapy and screw adjustment. Conclusion Considering an effective and safe method for patients suffered from BI and AAD, revision procedure of TARP internal fixation is valuable for those who confronted the difficulties of posterior fusion and internal fixation after unsuccessful posterior decompression.