目的 探讨内镜辅助下经高位颈前咽后入路治疗颅颈交界区脊椎病变的可行性和临床疗效.方法 2007年4月至2009年10月,治疗19例颅颈交界区脊椎病变患者,男9例,女10例;年龄16～62岁,平均41.6岁;陈旧性齿突骨折合并脱位5例,单纯寰椎脱位2例,游离齿突6例,Marfan综合征1例,Kippel-Feil综合征合并颅底凹陷1例,枢椎肿瘤3例,寰枢关节类风湿关节炎1例.均采用内镜辅助下经高位颈前咽后人路完成前路手术操作,其中8例行寰枢关节前路松解复位,8例行齿突切除减压,3例行肿瘤全切与重建.同时一期行后路固定植骨融合术,其中13例采用寰枢椎椎弓根钉固定融合,4例行枕颈融合,2例行C1～C3椎弓根固定融合.结果 8例复位患者均获得解剖复位,8例齿突切除患者行部分或全部齿突切除,3例肿瘤病灶均完全切除.随访6～36个月,平均14个月,全部病例均获骨性融合.14例术前有脊髓症状者末次随访时日本矫形外科学会(Japanese Orthopaedic Association,JOA)评分从术前(9.1±3.3)分提高到术后(14.1±2.9)分JOA改善率优7例,良5例,可1例,差1例.术中出现硬膜破裂1例,经生物蛋白凝胶封堵及术后腰椎蛛网膜下腔置管引流1周后治愈;术后出现吞咽障碍3例,均静脉应用地塞米松及甘露醇,术后3个月内均恢复正常.末次随访时,无一例患者发生感染及内固定松动.结论 内镜辅助经高位颈前咽后入路是治疗颅颈交界区病变的安全、有效、微创的方法.%Objective To assess the feasibility and clinical results of video-assisted high anterior transcervical approach (Smith-Robinson) in treatment of spinal lesions of the craniovertebral junction. Methods Between April 2007 to October 2009, nineteen consecutive patients with spinal lesions of the craniovertebral junction were included in the study. There were 9 males and 10 females aged from 16 to 62 years old with a mean of 32 years. The primary pathologies included 4 cases with chronic odontiod fracture, 2 cases with purely irreducible atlantoaxial dislocation, 6 cases with os odonteideum, 1 case with Marfan synd rome, 1 case with primary basilar invagination from Kippel-Feil syndrome, 3 case with axis tumor and 1 case with irreducible rheumatoid atlantoaxial dislocation. All of the patients underwent combined video-assisted high anterior transcervical procedure and posterior fixation at one-stage. The anterior procedure included atlantoaxil release and reduction (8 cases), odontoidectomy (8 cases), and intralesional extracapsular excision and reconstruction (3 tumor cases). The posterior technique were C1-C2 pedicle screw fixation (13 cases), C1-C3 pedicle screw fixation (2 cases), and occipitalcervical fusion (4 cases). Results Anatomical reduction was achieved in eight cases with anterior release and reduction. Tumors were completely removed in three cases with axial tumor. The mean follow-up was 14 months (6-36 months). All of them achieved solid bone fusion. In the 14 patients with symptoms of spinal cord dysfunction, the average Japanese Orthopaedic Association (JOA)score had improved from 9.1±3.3 preoperatively to 14.1±2.9 postperatively. The improvement rate was excellent for 7 cases, good for 5 cases, fair for lcase and poor for 1 case. One patient experienced leakage of cerebrospinal fluid which was resolved by bioprotein gelatin blocking and lumbar subarachnoid continuous drainage within 1 week. Dysphagia which occurred in 3 cases responded well to dexamethason and mannitol.No infection and hardware failure were observed. Conclusion Video-assisted high anterior transcervical procedure is a safe and effective alternative for treating spinal lesions in the craniovertebral junction.
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