环椎骨折手术PPT课件.ppt

,环椎骨折Ringvertebralfractures,1,2,环枢椎后面观,环枢椎前面观,3,4,环椎：位于枕骨下、周围韧带的保护作用，骨折相对发生较少SherkHH,NicholsonJT.Fracturesoftheatlas.JBoneJointSurg(Am)1970;52:101724环椎骨折占：所有脊柱骨折的12%颈椎骨折2-13%严重的颈痛，但没有神经症状ScharenS,JeanneretB.Atlasfractures.DerOrthopade1999;28(5):38593.SherkHH,NicholsonJT.Fracturesoftheatlas.JBoneJointSurg(Am)1970;52:101724.,5,1822年SirAstleyCooper首先描述CooperA.Atreatiseondislocations,andonfracturesofjoints.London,UnitedKingdom,Longman,HurstRees,OrmeBrowne,E.CoxandSon,1822:542.1920年GeoffreyJefferson报道环椎骨折JeffersonG.Fractureofthealtasvertebra:Reportoffourcasesandareviewofthosepreviouslyreported.BrJSurg.1920;7:407422.,6,发生机制,轴向压力或过伸损伤JeffersonG.Fractureofthealtasvertebra:Reportoffourcasesandareviewofthosepreviouslyreported.BrJSurg.1920;7:407422.Punjabi、Sandler报道过伸时轻度轴向压力就可以引起寰椎骨折PunjabiMJD,SandlerA.Cervicalspinekinematicsandinstability,inClarkCR,DuckerTB;CervicalSpineResearchSocietyEditorialCommittee(eds):TheCervicalSpine.Philadelphia,Lippincott-Raven,1998:5557.,7,分型,单纯前弓骨折单纯后弓骨折(最常见)合并前后弓粉碎性骨折(Jeffersonfracture)单纯侧块骨折横突骨折LevineAM,EdwardsCC.Traumaticlesionsoftheoccipitoatlantoaxialcomplex.ClinOrthopRelatRes.1989;239:5368.,8,typicallyoccuratthejunctionoftheposteriorarchandthelateralmassesmostvulnerablewherethearchisthinnedandwherethevertebralarterycourses常发生在后弓与侧块连接处：骨细、颈动脉跨过,单纯后弓骨折，容易漏诊,9,Lateralmassfracturesusuallyconsistofafracturelineanteriorandposteriortothejointsurface.Openmouthradiographdemonstratesdisplacementof1C1lateralmassonC2withnormalanatomicrelationshipofthecontralateralside可能导致枕骨髁向骨折间隙内半脱位侧块不稳定容易导致斜颈畸形,经关节面的侧块骨折,10,Jefferson骨折。一个典型的四部分骨折，2骨折在前环和2骨折在在后环。横韧带的完整性决定了骨折的稳定性该Jefferson骨折很少导致因向外移位骨折类型的神经损伤,11,Jeffersonfracture机制图,12,Jefferson骨折分型:a4部分骨折，b部分骨折，c部分骨折,13,稳定型Jefferson-Fracture,14,不稳定型Jefferson骨折导致动脉栓塞,15,C1前弓骨折通常发生在轴向平面通过的结节，并代表颈长肌撕脱。这些伤害发生在过伸时刻。,前弓水平骨折(arrow)合并齿状突骨折(curvedarrow)伴脱位,16,横突骨折可以是单侧或双侧，一个侧向屈曲损伤造成对侧撕脱骨折,17,临床表现,外伤病史枕下颈痛颈痛或颈部僵硬无神经症状,18,辅助检查,标准颈椎正侧位片颈椎张口位片Computedtomography(CT)：冠状位、矢状位重建Magneticresonanceimaging(MRI):评估横韧带损伤，椎动脉,19,横向（环椎横韧带）损伤标志着不稳定环椎侧块的骨折超越C2的侧块6.9mm，横韧带很可能被损伤SpenceKF,DeckerS,SellKW.Burstingatlantalfractureassociatedwithruptureofthetransverseligament.JBoneJointSurgAm.1970;52:543549.,20,保守治疗,侧块移位不超过7mm，无旋转不稳定单纯前弓、后弓骨折撕脱性骨折横突骨折颈围制动812周IsolatedFracturesoftheAtlasinAdults.Guidelinesforthemanagementofacutecervicalspineandspinalcordinjuries.Neurosurgery2002;50(Suppl.3):S1204(chapter16),21,保守治疗,粉碎性或明显移位的侧块骨折可以先行颈矫形支具或牵引复位，复位后用halovest固定LevineAM,EdwardsCC.Traumaticlesionsoftheoccipitoatlantoaxialcomplex.ClinOrthopRelatRes.1989;239:5368.,22,手术治疗,不稳定Jefferson骨折，侧块移位大于8.1mm提示横韧带损伤粉碎性Jefferson骨折:internalfixation(osteosynthesis),occiput-C1fusionorC1-C2fusion.,23,手术方法,C1-C2融合：C1侧块和C2椎弓根钉棒Magerl钉辅助侧块复位、减少动脉损伤TanJ,LiL,SunG,etal.C1lateralmass-C2pediclescrewsandcrosslinkcompressionfixationforunstableatlasfracture.Spine.2009;34:25052509.,24,25,26,27,手术方法,C1侧块钉棒固定:有效复位并可靠固定HeikoKoller,HerbertResch,MarkTauber.AbiomechanicalrationaleforC1-ringosteosynthesisastre