環(huán)椎骨折手術(shù)

環(huán)椎骨折Ringvertebralfractures賀州廣濟(jì)醫(yī)院骨二科朱福良環(huán)樞椎后面觀環(huán)樞椎前面觀環(huán)椎：位于枕骨下、周圍韌帶的保護(hù)作用，骨折相對發(fā)生較少SherkHH,NicholsonJT.Fracturesoftheatlas.JBoneJointSurg(Am)1970;52:1017–24環(huán)椎骨折占：所有脊柱骨折的1–2%頸椎骨折2-13%嚴(yán)重的頸痛，但沒有神經(jīng)癥狀ScharenS,JeanneretB.Atlasfractures.DerOrthopade1999;28(5):385–93.SherkHH,NicholsonJT.Fracturesoftheatlas.JBoneJointSurg(Am)1970;52:1017–24.1822年SirAstleyCooper首先描述CooperA.Atreatiseondislocations,andonfracturesof

joints.London,UnitedKingdom,Longman,HurstRees,OrmeBrowne,E.CoxandSon,1822:542.1920年GeoffreyJefferson報道環(huán)椎骨折JeffersonG.Fractureofthealtasvertebra:Reportoffourcasesandareviewofthosepreviouslyreported.BrJSurg.1920;7:407–422.發(fā)生機(jī)制軸向壓力或過伸損傷JeffersonG.Fractureofthealtasvertebra:Reportoffourcasesandareviewofthosepreviouslyreported.BrJSurg.1920;7:407–422.Punjabi、Sandler報道過伸時輕度軸向壓力就可以引起寰椎骨折PunjabiMJD,SandlerA.Cervicalspinekinematicsandinstability,inClarkCR,DuckerTB;CervicalSpineResearchSocietyEditorialCommittee(eds):TheCervicalSpine.Philadelphia,Lippincott-Raven,1998:55–57.分型單純前弓骨折單純后弓骨折(最常見)合并前后弓粉碎性骨折(Jeffersonfracture)單純側(cè)塊骨折橫突骨折LevineAM,EdwardsCC.Traumaticlesionsoftheoccipitoatlantoaxialcomplex.ClinOrthopRelatRes.1989;239:53–68.typicallyoccuratthejunctionoftheposteriorarchand

thelateralmassesmostvulnerablewherethearchisthinned

andwherethevertebralarterycourses常發(fā)生在后弓與側(cè)塊連接處：骨細(xì)、頸動脈跨過單純后弓骨折，容易漏診Lateralmassfracturesusuallyconsistofafracturelineanteriorandposteriortothejointsurface.Openmouth

radiograph

demonstratesdisplacementof1C1lateralmassonC2withnormal

anatomicrelationshipofthe

contralateralside可能導(dǎo)致枕骨髁向骨折間隙內(nèi)半脫位側(cè)塊不穩(wěn)定容易導(dǎo)致斜頸畸形經(jīng)關(guān)節(jié)面的側(cè)塊骨折Jefferson骨折。一個典型的四部分骨折，2骨折在前環(huán)和2骨折在在后環(huán)。

橫韌帶的完整性決定了骨折的穩(wěn)定性

該Jefferson骨折很少導(dǎo)致因向外移位骨折類型的神經(jīng)損傷Jeffersonfracture機(jī)制圖Jefferson骨折分型:a4部分骨折，b部分骨折，c部分骨折穩(wěn)定型Jefferson-Fracture不穩(wěn)定型Jefferson骨折導(dǎo)致動脈栓塞C1前弓骨折通常發(fā)生在軸向平面通過的結(jié)節(jié)，并代表頸長肌撕脫。這些傷害發(fā)生在過伸時刻。前弓水平骨折(arrow)合并齒狀突骨折(curvedarrow)伴脫位橫突骨折可以是單側(cè)或雙側(cè)，一個側(cè)向屈曲損傷造成對側(cè)撕脫骨折臨床表現(xiàn)外傷病史

枕下頸痛

頸痛或頸部僵硬無神經(jīng)癥狀輔助檢查標(biāo)準(zhǔn)頸椎正側(cè)位片頸椎張口位片Computedtomography(CT)：冠狀位、矢狀位重建Magneticresonanceimaging(MRI):評估橫韌帶損傷，椎動脈橫向（環(huán)椎橫韌帶）損傷標(biāo)志著不穩(wěn)定環(huán)椎側(cè)塊的骨折超越C2的側(cè)塊6.9mm，橫韌帶很可能被損傷SpenceKF,DeckerS,SellKW.Burstingatlantalfractureassociatedwithruptureofthetransverseligament.JBoneJointSurgAm.1970;52:543–549.保守治療側(cè)塊移位不超過7mm，無旋轉(zhuǎn)不穩(wěn)定單純前弓、后弓骨折撕脫性骨折橫突骨折

頸圍制動8–12周IsolatedFracturesoftheAtlasinAdults.Guidelinesforthemanagementofacutecervicalspineandspinalcordinjuries.Neurosurgery2002;50(Suppl.3):S120–4(chapter16)保守治療粉碎性或明顯移位的側(cè)塊骨折可以先行頸矯形支具或牽引復(fù)位，復(fù)位后用halovest固定LevineAM,EdwardsCC.Traumaticlesionsoftheoccipitoatlantoaxialcomplex.ClinOrthopRelatRes.1989;239:53–68.手術(shù)治療不穩(wěn)定Jefferson骨折，側(cè)塊移位大于8.1mm提示橫韌帶損傷粉碎性Jefferson骨折:internalfixation(osteosynthesis),occiput-C1fusionorC1-C2fusion.手術(shù)方法C1-C2融合：C1側(cè)塊和C2椎弓根釘棒

Magerl釘

輔助側(cè)塊復(fù)位、減少動脈損傷TanJ,LiL,SunG,etal.C1lateralmass-C2pediclescrewsandcrosslinkcompressionfixationforunstableatlasfracture.Spine.2009;34:2505–2509.手術(shù)方法C1側(cè)塊釘棒固定:

有效復(fù)位并可靠固定HeikoKoller,HerbertResch,MarkTauber.AbiomechanicalrationaleforC1-ringo