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下颈椎骨折脱位手术疗效及生物力学的相关研究
中文摘要

第一部分 关节突关节囊及后路经关节螺钉固定对下颈椎稳定性影响的生物力学研究 目的:本研究拟通过对下颈椎关节突关节囊和经关节螺钉固定关节突关节的生物力学实验结果进行分析,验证和评估下颈椎关节突关节囊和经关节螺钉技术对颈椎稳定性的作用,为临床下颈椎关节突关节脱位和颈椎不稳的治疗提供理论依据。 方法:12具成年山羊颈椎标本(C2-C7),剔除标本的肌肉等软组织,完整的保留标本的各条韧带结构和关节突关节囊的完整性。标本制备完成后分为A、B两组。A组标本切除C4-C5水平的一侧关节囊备用。B组标本切除C4-C5水平的两侧关节囊备用。A、B两组标本的制备均在完整颈椎标本生物力学实验完成以后进行。A、B两组切除了关节囊的标本生物力学实验完成以后,分别于切除关节囊处置入关节螺钉制备单侧和双侧经关节螺钉固定的颈椎标本。关节螺钉的置入由同一术者用Klekamp法完成。对各组标本进行垂直压缩和前、后、左、右四个方向的侧方弯曲荷载实验,得出荷载-位移曲线结果。 结果:下颈椎关节突关节囊单侧切除或损伤后,对颈椎稳定性影响不明显;下颈椎关节突关节囊双侧切除或损伤后,会对颈椎稳定性产生显著影响。经关节突关节螺钉固定可以提供良好的生物力学和坚强的内固定,经关节突关节螺钉固定技术可以有效的用于下颈椎不稳的手术治疗。 结论:下颈椎关节突关节囊对维持下颈椎稳定性具有重要作用,双侧关节突关节囊损伤可导致下颈椎发生不稳甚至关节突关节发生骨折脱位。下颈椎经关节突关节螺钉固定技术具有操作简便、安全系数较高、把持力和抗拔出力更高等优点。因此,经关节突关节固定螺钉内固定技术可以广泛的应用于各种原因引起的下颈椎不稳的手术治疗中,尤其对于伴有严重骨质疏松或者先天畸形的病例。 第二部分 全麻下闭合牵引复位联合颈椎前-后路手术治疗下颈椎关节突关节脱位的临床疗效 目的:下颈椎关节突关节脱位是严重的下颈椎损伤类型,常伴有不同程度的脊髓和神经根损伤,甚至危及生命,然而其最佳手术治疗方式一直存在争议。本研究旨在分析评价全麻下闭合牵引复位联合颈椎前-后路手术治疗下颈关节突关节脱位的临床疗效,为下颈椎关节突关节脱位的手术治疗提供理论依据。 方法:本研究回顾性的分析了我院连续四年(2010年1月至2013年12月)应用全身麻醉下即刻闭合牵引复位后联合颈椎前后路手术治疗的下颈椎关节突关节脱位的患者资料。本研究共纳入24例研究对象,交通事故上伤是最主要的致伤原因,损伤节段C4-5(n=8),C5-6(n=10)和C6-7(n=6),单侧关节突关节脱位16例,双侧关节突关节脱位8例。患者术前ASIA损伤分级,其中A级4例,B级4例,C级10例,D级4例,E级2例。所有患者均行全身麻醉下即刻闭合牵引复位后联合颈椎前后路手术治疗。平均随访时间为3.5年。 结果:所有手术均顺利完成。所有患者在术后均未出现血肿、神经功能恶化等严重并发症。在随访期间均未出现钛板、螺钉松动、断裂、移位、植骨不融合、形成假关节等远期并发症。且所有患者末次随访X线显示损伤节段椎间高度和椎体序列恢复满意。所有患者在术后4-6个月实现骨融合,术后神经功能较术前均得到明显改善。完全性脊髓损伤的患者,术后损伤平面的根性症状均有不同程度的恢复,不完全性脊髓损伤的病例术后感觉和运动功能均有不同程度的恢复和改善。 结论:全麻下闭合牵引复位联合颈椎前-后路手术治疗下颈椎关节突关节脱位,全麻下闭合牵引使颅骨牵引复位更加方便,患者痛苦更小;前-后路联合手术可以有实现对损伤节段的彻底减压、提供坚强的内固定,有效的恢复颈椎的椎间高度和生理曲度,使颈椎获得良好的即刻和永久稳定性。总之,全麻下闭合牵引复位联合颈椎前-后路手术可以有效的治疗下颈椎关节突关节脱位,尤其是伴有三柱损伤或存在严重下颈椎不稳患者。 第三部分 颈椎前路椎体次全切加钛网植骨融合内固定术治疗陈旧性下颈椎骨折脱位的临床疗效分析 目的:陈旧性下颈椎骨折脱位的手术治疗方式尚无统一标准。本研究通过分析陈旧性下颈椎骨折脱位的临床特点以及颈椎前路椎体次全切加钛网植骨融合内固定手术治疗陈旧性下颈椎骨折脱位的手术疗效,为临床提供理论依据。 方法:本研究回顾性的分析了我院2008年1月至2013年12月收治的52例(包括男性35名,女性17名)确诊为陈旧性下颈椎骨折脱位并行颈椎前路椎体次全切加钛网植骨融合内固定手术治疗的临床资料。所有患者均随访3-6年,通过分析患者术前及术后影像学资料及JOA评分和ASIA脊髓损伤分级等指标,评估患者后凸畸形矫正效果以及神经功能恢复情况。 结果:所有病例均没有出现术后血肿、伤口感染不愈合、继发性脊髓损伤等严重的并发症。在随访期间,所有病例的损伤节段的椎间高度、稳定性及颈椎生理曲度恢复满意。术后颈椎后凸畸形矫正满意,后凸角(Cobb角)明显小于术前,且在术后3个月至术后1年无明显变化(p> 0.05)。完全性脊髓损伤的患者,术后损伤平面的根性症状均有不同程度的恢复,不完全性脊髓损伤的病例术后感觉和运动功能均有不同程度的恢复和改善。所有患者JOA评分与术前相比显着增加,大多数患者的ASIA分级术后至少提高1个等级。术后所有患者的C/V比值均较术前明显增加,但术后3个月和末次随访无明显变化(p>0.05)。所有病例在随访1年内均完成骨性融合。 结论:颈椎前路椎体次全切加钛网植骨融合内固定术具有减压充分彻底,可以有效的恢复损伤节段颈椎序列和生理曲度等优点,是治疗陈旧性下颈椎骨折脱位首选手术方式。然而对于部分伴有关节突关节融合或后方损伤结构侵入椎管的病例,必要时应采取联合入路手术,以期获得更好的治疗效果。 关键词:下颈椎关节突关节脱位,关节突关节囊,生物力学,经关节螺钉,闭合牵引,内固定,陈旧下颈椎骨折脱位,脊髓损伤

英文摘要

Part 1 The biomechanical study on the stability of the lower cervical spine with facet joint capsule and posterior transarticular facet screw fixation Objective: This study intends to analyze the biomechanical test result of the lower cervical facet joint capsule and transarticular facet screw fixation of the lower cervical facet, and to verify and evaluate the effect of the lower cervical facet joint capsule and transarticular facet screw fixation technology on the stability of the lower cervical spine. In order to provide a theoretical basis of the treatment of lower cervical facet dislocation and the lower cervical instability. Methods: Twelve adult goat cervical specimens (C2-C7) were used. Removed all soft tissues such as muscles from the specimens, complete reserved each ligament structure of all specimens and the integrity of the facet joint capsules. The specimens were divided into A and B groups after preparation.The specimens of group A were resected one-sided facet joint capsule at the level of C4-C5. The specimens of group B were resected both sides of the specimens at the C4-C5 level. The preparation of specimens of both groups A and B was performed after the completion of the biomechanical experiment of complete lower cervical spine specimens. After the completion of the biomechanical experiments of groups A and B, the unilateral and bilateral transarticular facet screw-fixed specimens were prepared by implanting transarticular facet screws at the facet joints where the facet joint capsule was resected. Insertion of transarticular facet screws were performed by the same surgeon using the Klekamp method. Each group of specimens was subjected to vertical compression and lateral bending load tests in the front, rear, left, and right directions to obtain load-displacement curve results. Results: After the unilateral excision or injury of the lower cervical facet joint capsule, the stability of the cervical vertebra is not obvious. However, the bilateral cervical facet joint capsules excision or injury will have a significant impact on the stability of the cervical spine. Transarticular facet screw fixation can provide good biodynamics and stable internal fixation, transarticular facet screw fixation technology can be effectively used for surgical treatment of unstable lower cervical spine. Conclusion: The lower cervical facet joint capsule plays an important role in maintaining the stability of the lower cervical spine. Bilateral facet joint capsule injury can cause instability of the lower cervical spine or even fracture and dislocation of the lower cervical facet. The lower cervical transarticula screw fixation technology has the advantages of simple operation, high safety factor, and high holding force and pull-out resistance. Therefore, the transarticular facet screw fixation technology can be widely used in the surgical treatment of lower cervical instability caused by various reasons, especially cases with severe osteoporosis or congenital malformation. Part 2 Immediate reduction under general anesthesia and combined anterior and posterior fusion in the treatment of lower cervical facet dislocation Objective: Lower cervical facet dislocation is a sever traumatic lesion, frequently resulting in paralysis. The optimal surgical treatment is controversial. It has been a challenge for orthopedic surgeons to manage lower cervical facet dislocation while avoiding the risk of iatrogenic damage. Thus, safer strategies need to be designed and adopted. This study aimed to evaluate the clinical efficacy of immediate reduction under general anesthesia and combined anterior and posterior fusion in the treatment of lower cervical facet dislocation, provide theoretical basis for clinic. Methods: Twenty-four subjects of traumatic lower cervical facet dislocation were retrospectively analyzed from January 2010 to December 2013. Traffic accident was the primary cause of injury, with patients presenting with dislocated segments in C4-5 (n = 8), C5-6 (n = 10), and C6-7 (n = 6). Sixteen patients had unilateral facet dislocation, and 8 had bilateral facet dislocation. Spinal injuries were classified according to the American Spinal Injury Association (ASIA), with 4 cases of grade A, 4 cases of grade B, 10 cases of grade C, 4 cases of grade D, and 2 cases of grade E. On admission, all patients underwent immediate reduction under general anesthesia and combined anterior and posterior fusion. The mean follow-up time was 3.5 years. Results: All operations were completed successfully, with no major complications. Postoperative X-rays showed satisfactory height for the cervical intervertebral space and recovery of the vertebral sequence. Bone fusion was completed within 4 to 6 months after surgeiy. Surgery also significantly improved neurological function in all patients. Conclusion: Immediate reduction under general anesthesia and combined anterior and posterior fusion can be used to successfully treat lower cervical facet dislocation, obtaining completed decompression, safe spinal re-alignment and excellent immediate postoperative stability. Part 3 Clinical efficacy of anterior partial corpectomy and titanium mesh fusion and internal fixation for the treatment of old fracture dislocation of the lower cervical spine Objective: To analyze the clinical features and to evaluate the efficacy of anterior partial corpectomy and titanium mesh fusion and internal fixation of old fracture dislocation of the lower cervical spine. Methods: We retrospectively analyzed the clinical data of 52 patients with old lower cervical fracture and dislocation treated with anterior partial coipectomy and titanium mesh fusion fixation between January 2008 and December 2013 with a mean follow-up period of 4. 1year. There were 35 males and 17 females. Patient radiological data and clinical parameters were recorded and compared before and after operation. Results: The average follow-up was 4.1 years, intervertebral height and physiological curvature were well reconstructed for all cases. No loosening or rupturing of titanium plate or screw occurred. The neurological function of the patients with incomplete spinal cord injury has been significantly improved, and the function of the nerve roots of injury level has also improved in patients with complete spinal cord injury. Bone fusion was completed within 6 months to 1 year after surgery. Conclusion: Completed decompression, sequence and physiological curvature of the cervical vertebra, immediate and long term anterior cervical column support, and nerve function restoration can be achieved by using anterior partial corpectomy and titanium mesh fusion and internal fixation to treat old fracture dislocation of the lower cervical spine. For cases with locked facet joints or posterior structures invading the vertebral canal, the combined anterior and posterior approaches should be performed in order to achieve better results when necessary. Keywords: Lower cervical facet dislocation, Lower cervical facet joint capsule, Biomechanics, Transarticular facet screw, Closed reduction, Internal fixation, Old lower cervical fracture and dislocation, Spinal cord injury

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