Vanek Petr, Bradac Ondrej, de Lacy Patricia, Pavelka Karel, Votavova Martina, Benes Vladimir
Department of Neurosurgery and Neurooncology, Military University Hospital and Charles University, First Medical Faculty, Prague, Czech Republic.
Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK.
Acta Neurochir (Wien). 2017 Sep;159(9):1791-1801. doi: 10.1007/s00701-017-3274-1. Epub 2017 Jul 27.
The main aim of this study was to analyse the compex clinical and radiographic findings in a group of RA patients with atlanto-axial slip (AAS) treated with free-hand short C1 lateral mass and C2 trans-pedicular screw fixation. The surgical technique used and the pathology treated were the same in all patients, producing a very homogeneous cohort of patients This allowed the study and measurement of radiographic parameters and fusion process.
Twenty-nine patients (21 female, 8 male, mean age 54.9 years, duration of RA 17.3 years) with AAS and without CS were treated by short C1/2 fixation. Mean follow-up was 4.5 years. Pain intensity was monitored using VAS. Radiographic assessment consisted of lateral cervical radiographs in neutral and dynamic views, MR and CT of the cervical spine. The AADI, PADI, AAA, sub-axial cervical Cobb angle and canal-clivus angle (CCA) were measured pre-operatively and during the follow-up.
Significant malposition was recorded in 4 (3.4%) out of 116 inserted screws. AADI, PADI, AAA and CCA values changed significantly after surgery and remained stable during follow-up. The Cobb C angle value showed no significant change after surgery. There was a significant decrease of the VAS after the surgery. Fusion or a stable situation was achieved in all patients at 2-year follow-up. Pannus regression was observed in the vast majority of patients; only in two cases was rheumatic tissue detected on MR at 2 years post-operatively.
C1 lateral mass and C2 trans-pedicular fixation with polyaxial screws followed by an autograft between C1 and C2 lamina allowed, with an acceptable complication rate and favourable clinical results, adequate slip reposition, introduction of optimal sagittal alignment in terms of the final AAA with no radiographic consequences for the sub-axial cervical spine and assurance of long-term stability.
本研究的主要目的是分析一组采用徒手置入短节段C1侧块和C2椎弓根螺钉固定治疗的类风湿性关节炎（RA）伴寰枢椎半脱位（AAS）患者的复杂临床和影像学表现。所有患者采用相同的手术技术和治疗病变，形成了一个非常同质化的患者队列。这使得能够研究和测量影像学参数及融合过程。
29例患有AAS且无颈椎脊髓受压（CS）的患者接受了短节段C1/C2固定治疗（21例女性，8例男性，平均年龄54.9岁，RA病程17.3年）。平均随访时间为4.5年。使用视觉模拟评分法（VAS）监测疼痛强度。影像学评估包括中立位和动态位颈椎侧位X线片、颈椎磁共振成像（MR）和计算机断层扫描（CT）。术前及随访期间测量寰枢椎前间隙距离（AADI）、枢椎椎弓根内径（PADI）、寰枢关节角（AAA）、下颈椎Cobb角和椎管-斜坡角（CCA）。
116枚置入螺钉中有4枚（3.4%）记录到明显的位置不当。术后AADI、PADI、AAA和CCA值发生显著变化，随访期间保持稳定。Cobb C角值术后无显著变化。术后VAS显著降低。所有患者在2年随访时均实现融合或处于稳定状态。绝大多数患者观察到血管翳消退；术后2年仅2例在MR上检测到风湿组织。
采用多轴螺钉进行C1侧块和C2椎弓根固定，随后在C1和C2椎板间进行自体骨移植，并发症发生率可接受且临床效果良好，能实现充分的半脱位复位，在最终AAA方面引入最佳矢状位对线，对下颈椎无影像学影响，并确保长期稳定性。
