Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana 71130, USA.
J Neurosurg Spine. 2009 Dec;11(6):651-8. doi: 10.3171/2009.7.SPINE0991.
The purpose of this study was to evaluate the feasibility of the criteria described in the literature as the indications for surgery for acute Type II odontoid fractures.
The authors searched the PubMed database for studies in which the fusion rate of acute Type II odontoid fractures following external immobilization (halo vest or collar) or surgery (posterior C1-2 fusion or anterior screw fixation) was reported. The only studies included reported the fusion rate for either 1) groups of patients whose age was either more or less than a certain age range (45-55 years); or 2) groups of patients with a fracture displacement of either more or less than a certain odontoid fracture displacement (4-6 mm) or the direction of displacement (see Methods section of text for more details). A meta-analysis in which the random effect model was used was conducted to analyze the data.
There was a statistically significantly higher fusion rate for operative management compared with external immobilization (85 vs 60%, p = 0.01) for the patients > 45-55 years. However, the overall fusion rate was > 80% for the patients whose age was < 45-55 years, regardless of treatment modality, and no significant differences were observed between surgically and nonsurgically treated patients (89 and 81%, respectively; p = 0.29). The result of operation (overall fusion rate 89%) was superior to external immobilization (44%) when the fracture was posteriorly displaced (p < 0.001), but for anteriorly displaced fractures, the results of operative and nonoperative management were identical (p = 0.15). The overall fusion rate of operative management of both anteriorly and posteriorly displaced fractures proved to be > 85%, and no statistically significant difference was observed (p = 0.50). For all degrees of displacement (either > or < 4-6 mm) the operation proved to provide significantly better results than conservative treatment. The fusion rate of conservatively treated fractures with < 4-6 mm displacement was significantly better than in fractures with > 4-6 mm displacement (76 vs 41%, p = 0.002).
Operative treatment (posterior C1-2 fixation or anterior screw fixation) provides a better fusion rate than external immobilization for acute odontoid Type II fractures, although in certain situations, such as anterior displacement of the fracture and for younger (< 45-55 years of age) patients, conservative management (halo vest or collar immobilization) can be as effective as surgery. Operative management is recommended in older patients, in cases of posterior displacement of the fracture, and when there is displacement of > 4-6 mm.
本研究旨在评估文献中描述的手术适应证标准在急性Ⅱ型齿状突骨折中的可行性。
作者在 PubMed 数据库中检索了有关急性Ⅱ型齿状突骨折采用外固定（颈圈或 halo 背心）或手术（后路 C1-2 融合或前路螺钉固定）治疗后融合率的研究。仅纳入报告了以下分组患者融合率的研究：1）年龄大于或小于特定年龄范围（45-55 岁）的患者组；或 2）骨折移位大于或小于特定齿状突骨折移位（4-6mm）或移位方向的患者组（更多细节请见文本方法部分）。采用随机效应模型进行荟萃分析以分析数据。
对于年龄大于 45-55 岁的患者，手术治疗的融合率明显高于外固定（85%比 60%，p=0.01）。然而，无论治疗方式如何，年龄小于 45-55 岁的患者总体融合率均大于 80%，手术和非手术治疗患者之间无显著差异（分别为 89%和 81%；p=0.29）。对于向后移位的骨折，手术治疗（总体融合率为 89%）优于外固定（44%；p<0.001），但对于向前移位的骨折，手术和非手术治疗的结果相同（p=0.15）。对于前后移位的骨折，手术治疗的总体融合率均大于 85%，且无统计学差异（p=0.50）。对于所有移位程度（无论是大于还是小于 4-6mm），手术治疗均优于保守治疗。保守治疗的骨折中，移位小于 4-6mm 的融合率明显优于移位大于 4-6mm 的骨折（76%比 41%；p=0.002）。
对于急性Ⅱ型齿状突骨折，手术治疗（后路 C1-2 固定或前路螺钉固定）的融合率优于外固定，尽管在某些情况下，如骨折向前移位和患者年龄较小（<45-55 岁），保守治疗（颈圈或 halo 背心固定）与手术同样有效。对于年龄较大的患者、骨折向后移位以及移位大于 4-6mm 的患者，建议进行手术治疗。
