环椎骨折手术

环椎骨折Ringvertebralfractures贺州广济医院骨二科朱福良环枢椎后面观环枢椎前面观环椎：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;52:1017–24环椎骨折占：所有脊柱骨折的1–2%颈椎骨折2-13%严重的颈痛，但没有神经症状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报道环椎骨折JeffersonG.Fractureofthealtasvertebra:Reportoffourcasesandareviewofthosepreviouslyreported.BrJSurg.1920;7:407–422.发生机制轴向压力或过伸损伤JeffersonG.Fractureofthealtasvertebra:Reportoffourcasesandareviewofthosepreviouslyreported.BrJSurg.1920;7:407–422.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,1998:55–57.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;239:53–68.typicallyoccuratthejunctionoftheposteriorarchand

thelateralmassesmostvulnerablewherethearchisthinned

andwherethevertebralarterycourses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Lateralmassfracturesusuallyconsistofafracturelineanteriorandposteriortothejointsurface.Openmouth

radiograph

demonstratesdisplacementof1C1lateralmassonC2withnormal

anatomicrelationshipofthe

contralateralside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Jeffersonfracture机制图Jefferson骨折分型:a4部分骨折，b部分骨折，c部分骨折稳定型Jefferson-Fracture不稳定型Jefferson骨折导致动脉栓塞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临床表现外伤病史

枕下颈痛

颈痛或颈部僵硬无神经症状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;52:543–549.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8–12周IsolatedFracturesoftheAtlasinAdults.Guidelinesforthemanagementofacutecervicalspineandspinalcordinjuries.Neurosurgery2002;50(Suppl.3):S120–4(chapter16)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;239:53–68.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.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;34:2505–2509.手术方法C1侧块钉棒固定:

有效复位并可靠固定HeikoKoller,HerbertResch,MarkTauber.AbiomechanicalrationaleforC1-ringo