寰椎側(cè)塊螺釘與樞椎弓根螺釘徒手植入技術(shù)的研究與應(yīng)用

1、寰椎側(cè)塊螺釘與樞椎弓根螺釘徒手植入技術(shù)的研究與應(yīng)用         08-07-02 15:39:00     編輯：studa20            作者：郝定均，賀寶榮，雷偉，吳起寧，賀增良，周勁松 【關(guān)鍵詞】  寰樞椎     摘  要：目的探討徒手植入寰椎側(cè)塊螺釘與樞椎椎弓根螺釘方法，總結(jié)臨床應(yīng)用

2、效果。方法新鮮成人寰樞椎標(biāo)本各50具，男女各25具，用尖嘴咬骨鉗咬除進(jìn)釘點(diǎn)骨皮質(zhì)，先后分別用15、25 mm克氏針制備釘?shù)溃儆缅N子將導(dǎo)錐順著制造的釘?shù)佬⌒膿羧?，待有落空感時(shí)停止；寰椎側(cè)塊螺釘進(jìn)釘點(diǎn)選擇在寰椎后結(jié)節(jié)中點(diǎn)旁開1820 mm，與后弓下緣以上2 mm的交點(diǎn)，釘?shù)婪较蛟诠跔蠲娲怪?，矢狀面上螺釘頭端向頭側(cè)傾斜約5°。樞椎進(jìn)釘點(diǎn)為樞椎下關(guān)節(jié)突根部中點(diǎn)，釘?shù)琅c矢狀面夾角約15°，橫斷面夾角約30°。臨床寰樞椎不穩(wěn)患者26例，男15例，女11例，平均395歲；應(yīng)用釘棒系統(tǒng)17例，釘板系統(tǒng)9例。術(shù)前JOA評分51106分，平均75分。結(jié)果術(shù)后無1例發(fā)生脊髓和椎動(dòng)脈損

3、傷。隨訪932個(gè)月，平均15個(gè)月，JOA評分129165分，平均145分，改善率876%。植骨塊全部融合，無內(nèi)固定斷裂、松動(dòng)。結(jié)論寰椎側(cè)塊螺釘與樞椎椎弓根螺釘徒手植入技術(shù)簡單、可靠，值得推廣。    關(guān)鍵詞：寰樞椎；  螺釘；  徒手技術(shù)；  內(nèi)固定    Abstract：ObjectiveTo summary the methods and results of free hand insertion with the lateral mass screw of atlas and vertebra

4、dentata pedicle screw.MethodFifty samples of fresh adult atlas and dentate were used.There were 25 males and 25 females samlpes.Then rongeur forceps was used to bite the bone of entrance.The way of screw was made by Kirschner wire of 1.5mm and 2.5mm in diameter.Guide pin was inserted along the way.T

5、he screws were placed in lateral mass of atlas beside the posterior arch of atlas about 1820mm and the point of intersection above 2mm inferior boarder of posterior arch.Vertical with coronal plane,the tip of the screw was made 5° to side of head in sagittal plane.The site of the screws placed

6、in vertebra dentate was divided equally the inferior articular process of axis,made 15°with sagittal plane and 30°with cross section.There were 26 patients with Atlantoaxial vertebra unsteadiness,15 males and 11 females,with an average age of 39.5 years.Seventeen cases were used with screw

7、s and rod system and 9 patients were used screws and plate system.Preoperative JOA scores were from 5.1 to 10.6,with an average of 7.6.ResultThere were no cases with spinal cord and vertebral artery injury after surgery.Followup duration was from 10 to 25 months,with an average of 14 months.The post

8、operative JOA scores were from 12.9 to 16.5,with an average of 14.8.The improve rate was 87.6 percent.The plant bones all fused and there were no internal fixation rupture and mobiled.ConclusionThe technique of free hand insertion with the lateral mass screw of atlas and vertebra dentata pedicle scr

9、ew is simple,fixation is reliability and is well worth to spreading.    Key words: Atlantoaxial;  Screw;  Free hand insertion;  Internal fixation    后路短節(jié)段固定是治療寰樞椎不穩(wěn)常采用的方法，主要包括Gallie鋼絲、Brooks鋼絲、椎板夾等。近年來寰椎側(cè)塊螺釘與樞椎椎弓根螺釘?shù)膽?yīng)用亦可見報(bào)道1，但這一技術(shù)要求高，常常在導(dǎo)航系統(tǒng)或者C型臂X線機(jī)下完成。自1

10、999年1月作者通過50例標(biāo)本研究寰椎側(cè)塊螺釘與樞椎椎弓根螺釘?shù)耐绞种踩爰夹g(shù)，并通過26例患者的臨床應(yīng)用效果滿意。    1  資料與方法    11  標(biāo)本研究    111  新鮮成人寰樞椎標(biāo)本各50具，男女各25具，年齡1875歲。按手術(shù)俯臥體位固定于實(shí)驗(yàn)臺上，寰椎側(cè)塊進(jìn)釘點(diǎn)選擇在寰椎后結(jié)節(jié)中點(diǎn)旁開1820 mm，與后弓下緣以上2 mm的交點(diǎn)。用尖嘴咬骨鉗咬除寰椎后弓進(jìn)釘點(diǎn)骨皮質(zhì)，冠狀面垂直，矢狀面向頭側(cè)傾斜約5°，先后分別用15、25 mm克氏針緩慢錐入，如

11、遇到阻力較大，稍微調(diào)整錐入方向，當(dāng)進(jìn)針深度>20 mm，阻力增大而停止錐入。再用錘子將導(dǎo)錐順著前面制造的釘?shù)佬⌒膿羧?，待有落空感時(shí)停止。對側(cè)同樣操作。樞椎進(jìn)釘點(diǎn)為下關(guān)節(jié)突根部中點(diǎn)，咬除入釘點(diǎn)的骨皮質(zhì)，同樣分別先后用15、25 mm克氏針，沿與椎弓峽部的上面和內(nèi)面皮質(zhì)下逐漸錐入達(dá)到椎弓根，此時(shí)釘?shù)琅c矢狀面夾角約15°，橫斷面夾角約30°，亦用錘子將導(dǎo)錐順著前面制造的釘?shù)佬⌒膿羧?，待有落空感時(shí)停止。釘?shù)乐圃旌笮蠿線片、CT掃描，評價(jià)其準(zhǔn)確性。    112  結(jié)果    48具寰椎標(biāo)本，49具樞椎標(biāo)本的

12、釘?shù)谰鶞?zhǔn)確成功得以制備，寰椎側(cè)塊釘?shù)篱L2832 mm，樞椎椎弓根螺釘釘?shù)篱L2226 mm。在起初的3具寰椎，2具樞椎釘?shù)赖闹苽渲?，因用力過大致使8次將克氏針折彎，2具寰椎釘?shù)婪较虿患眩?具樞椎的1側(cè)釘?shù)来唐谱倒瞧べ|(zhì)。    2  臨床應(yīng)用    2.1  一般資料    本組26例，男15例，女11例，年齡1558歲，平均395歲。陳舊性齒狀突骨折9例，C型2齒狀突新鮮骨折7例，先天性游離齒狀突4例，類風(fēng)濕性關(guān)節(jié)炎6例。所有患者均伴有寰樞椎半脫位或不穩(wěn)。表現(xiàn)為不同程度的頸枕區(qū)疼痛，

13、活動(dòng)受限，按JOA17分評分法術(shù)前評分51106分，平均75分。術(shù)后6個(gè)月再行JOA評分，并計(jì)算改善率。    2.2  術(shù)前準(zhǔn)備    術(shù)前行顱骨牽引，床頭抬高30°，重量為35 kg。定時(shí)拍床頭片了解復(fù)位情況，調(diào)整牽引重量及角度，復(fù)位后改用253 kg維持。    2.3  手術(shù)方法    全麻后俯臥位，調(diào)整頭頸部位置，C型臂X光機(jī)下觀察寰樞椎位置，待關(guān)系滿意后用1 kg重量維持牽引。枕骨粗隆下至C3后正中縱切口，顯露出寰樞椎后弓，沿寰椎后弓

14、向其根部剝離，用神經(jīng)剝離子探查寰椎側(cè)塊的內(nèi)外緣及其中點(diǎn)，將C2神經(jīng)根和靜脈叢向下推開，顯露出寰椎后弓下面與側(cè)塊相延續(xù)的部位。進(jìn)釘點(diǎn)選擇在寰椎后結(jié)節(jié)中點(diǎn)旁開1820mm，與后弓下緣以上2mm的交點(diǎn)。用尖嘴咬骨鉗咬除寰椎后弓進(jìn)釘點(diǎn)骨皮質(zhì)，先后分別用15、25 mm克氏針向寰椎側(cè)塊鉆孔，釘?shù)婪较蛟诠跔蠲娲怪?，矢狀面上螺釘頭端向頭側(cè)傾斜約5°，深度控制在25 mm左右，球形探子探查后，用錘子將導(dǎo)錐順著前面制造的釘?shù)佬⌒膿羧?，待有落空感時(shí)停止，對側(cè)同樣操作。用神經(jīng)剝離子將C2神經(jīng)根和靜脈叢挑起，顯露出樞椎椎板、雙側(cè)側(cè)塊及椎弓峽部的上面和內(nèi)緣，以樞椎下關(guān)節(jié)突根部中點(diǎn)為進(jìn)釘點(diǎn)，咬除入釘點(diǎn)的骨皮質(zhì)，分別先后用1.5、25 mm克氏針，沿與椎弓峽部的上面和內(nèi)面皮質(zhì)下逐漸錐入達(dá)到椎弓根，球探探查無誤后，亦用錘子將導(dǎo)錐順著前面制造的釘?shù)佬⌒膿羧耄新淇崭袝r(shí)停止，此刻釘?shù)琅c矢狀面夾角約15°，橫斷面夾角約30°，以免損傷椎動(dòng)脈，攻絲后擰入合適長度的螺釘，對側(cè)同樣操作。選擇合適長度的連接棒，預(yù)彎成一定弧度，安裝，擰緊螺母。所有患者選用直徑為35 mm的螺釘，其中釘棒系統(tǒng)17例，釘板系統(tǒng)9例。去除寰椎后弓和樞椎椎板、棘突骨皮質(zhì)，將從髂后上棘