齿突骨折与迟发性寰枢椎脱位Eng课件.ppt

Odontoid Fracture and Delayed Atlantoaxial Dislocation,Chang Zheng Hospital ShanghaiJia Lianshun,Preface,Dens axis Atlantoaxial stability Most important axial bone structureOdontoid fracture Atlantoaxial instability Secondary SCI,Odontoid fracture,710%of cervical spine fracturecause SCI instantly Respiratory dysfunction Even deathSpecial structures and functionHigh ununion rate after fracture,Odontoid fracture,Lack of effective treatmentNot treatedUnstable factors existAtlas lost the restriction of Dens axis and ligamentsDelayed atlantoaxial dislocation,Clinical information,Male 41 cases Female 15 casesAge range 1558 yrs Average 37.5 yrs 1120 yrs 5 cases 2131yrs 16 cases 31 40yrs 23 cases 4150yrs 7 cases 5058yrs 5 cases,Injury causes,Accidental falls 15 cases building work accident 12 cases drop from bed 3 cases Motor vehicle accident 11 casesSports-related injury 13 cases water dive 7 casesTumble on ground 7 casesWeight hurt 10 cases,Course of diseases,Time from injury to treatment shortest 4 weeks longest 26 months 13M 23 cases 4 6M 15 cases 79M 11 cases 1012M 4 cases 1 yrs 3 cases,Treatment course,not treated after injury 12 casesno diagnosis when admitted 7 casesskull traction 23W stabilized by collars 16 casesonly collars stabilization 21 cases,Local features,Uncomfortable and pain of neck and nape 37 cases Middle or bilateral area of the occipitocervical Possible feeling of hyperesthesia or pain at fields dominated by great occipital or great auricular nerveSkull and neck motor limitation 21 casesTilt stiffness of head and neck 14 cases,Motor function,Normal gait,no motor limitation work properly 16 casesWeakness of legs,clumsy action,but can walk weakness of hands grasping function not affected 21 casesunstable gait need support,weakness of upper limbs,capable of grasping,13 casesincapable of standing and walking stay in bed 6 cases,Neurologic examination,normal or almost normal 9 casesSymmetric tendon reflexes No pathological reflexNo paresthesia or hyperesthesia appearances of upper cervical nerve injurypain,anaesthesia of GAN and GON 15 casestendon hyperreflex,muscle hypertension muscle force decrease 23 grades 32 casesHoffman抯 sign positive 19 casesBabinski抯 sign positive 8 cases Both 6 cases,Radiological examination,Routine X-ray programhead-neck AP lateraldynamic lateral filmsopen mouth viewAll case showed odontoid fractureAccording to Anderson-D扐lonzo classificatonType 47 cases Type 9 cases,Dislocation status,no displacement 8 casesForeward displacement 4mm 14cases 57mm 20 cases 810mm 8 cases 1112mm 3 casesDorsal displacement 3 casesDynamic reducible dislocation 14casesflexiondislocation extensionreduction,MRI examination 41 cases,No significant abnormal 8 casesSpinal cord compression 33 cases SC signals increasing 5cases,Treatment All received operation,Before operation Skull traction routinely1W later X rays observe reduction trend possible reductionkeep traction until restored impossible reductiongive up tractionReducible dislocation need no continuous traction receive operation directly,Atlanoaxial posterior structure bone graft and wire fixation,Modified Gallie method 17 cases Modified Brooks method 14 casesAutogenous iliac bone clip to be 揟?shapeThe convex of bone graft is inserted into the gap between the posterior arch of atlas and the base of C2 lamina and spinous Distance=810 mm Inter-arches&Over-surface bone graft+Wire fixation,Atlas posterior arch resection+Occipital-cervical fusion,Resect each side of the dislocated atlas posterior arch 10mm beside the posterior tubercleAutogenous iliac grafts between the occipital and the base of C2 spinous processes Total 25 cases,Results,No death caseAll be followed-upAverage follow-up time 3yrs and 6MShortest 11M Longest 10yrs and 8M,Assessment arcording tospinal cord function and image,Excellent:no abnormal feelingNormal or near normal of limbs Bone graft unionNo significant difficulty of head and neck motionGood:feel goodUncomfortable on head or neck occasionallySometimes weakness of extremities,normal gait Neurologic examination hypersensitive of tendon reflex pathologic reflex may exist,Better:symptoms and signs improved Limbs motor deficit,unstable gaitno-change:no change of symptoms and signs or feelings Bone grafts un-union,Results of treatment,Atlantoaxial fusionExcellent 14 cases Good 11 casesBetter 4 cases No change 2 cases*1 case bone graft ununion and displacedOccipitocervical fusion Excellent 12 cases Good 8 casesBetter 3 cases No change 2 cases*bone graft ununion and displaced,Discussion:Features of Odontoid fracture and delayed atlantoaxial dislocation,Odontoid fracture Atlas-axis loss restriction of bone structure Results in instability between atlas and axisEspecially Anderson-D扐lozon typeor type fracture Many cases died instantly for severe cervical spinal cord injury and respiratory failure,Main causes of early mis-diagnosis,Survivals of odontoid fracture only complicated with mild dislocation or no dislocation of atlasclinical symptoms are mild not enough to take patient抯 attentionthe illegible radiography show overlapping of bone structure between atlas and axis,Pathological changes,Intensive related factorsTraumatic force formTraumatic force strengthAnatomic structure,Anatomy about odontoid,The apical ligament and the alar ligament extend from the tip and the two sides of the dens body weaving with anterior atlanto-occipital membraneThe posterior part of alar ligament attaches to the anterior rim of occipital foramen magnum and the occipital condyles Odontoid jointed with the posterior side of atlas anterior arch,keeping stable with the strong transverse ligament and alar ligament which restrict the motor range of odontoid,Anatomy about odontoid,Sagittal diameter of C1 canal=30 mmDiameter of cord=10 mmDiameter of dens=10 mmSafe space for cord=10 mmConsiderable buffering space is available,Mechanism of odontoid fracture,Skull flexion injury is one of the major causesTraumatic forces head bended suddenlyOdontoid Anterior arch of C1 Transverse ligamentImpacting forward togetherTransverse shear force Vertical compress forceSeparate the connection between odontoid and C2 bodyOdontoid fractureOutside shear force Outside tear force,Mechanism of delayed atlas dislocation,Unstable status caused by odontoid fractureSkull has trends of inclining forward and moving continuouslyAtlas move forward progressively with dens axisDelayed atlas dislocation Direct operative decompression Moving forward equably or Moving forward rotately Potential risks of SCI Contributed factors odontoid ligaments around articular capsule,Discussion Clinical features of odontoid fracture,Local symptomsneck and nape pain early restricted to upper cervical spinemotor dysfunction of head and neck especially the rotation functionNeurologic symptoms mild at early stage,easy to be overlookeddelayed spinal cord compression paralysis,respiration failure Nerve root compression nimbleness,pain and stiffness of occipital-cervical area,Diagnosis of odontoid fracture&atlas dislocation,Historyinjury,treatment courselocal and neurologic examinationimage examination routine X-rays filmsSkull-neck AP films Open-mouth films Lateral flexion and extension filmsX-ray tomography CT MRIDifferentiate with the odontoid dysplasia and its deformity complicationFacilitate choosing the treatment plan and assessing prognosis,Discussion Treatment,Odontoid fracture self-healing difficultCan hardly heal at the displaced siteNon-operation treatments are ineffectiveSurgical treatment is the first choiceOperative procedure choice according to pathologic changes and clinical features,Atlantoaxial fusion an ideal method,ConditionsReduction completely or almost restored after skull tractionAtlas is not dislocated or can restore while extension,Occipital-cervical arthrodesis a common operative procedure,Restricting the skull-neck motor function in some extent Indications those who needs posterior arch resection obvious atlantoaxial dislocationposterior arch of atlas is the chief compressoratlas anterior dislocation is smallsevere symptoms of SCI exist,Methods of rebuilding the stability,Modified Gallie and Brooks techniqueProcedures of wire technicalRevising and placing of bone graftsDistance between the posterior arch and laminae and spinous of C2 is 8mmwhen atlas is at neutral position under normal physical conditionRelatively constant keeping the ligament tension between atlas and axis and the stability of joints related to dens axis,Advantages of the posterior structure fusion,inter-arches bone grafting over-surface bone graftingThe posterior arch of atlas the surface of posterior archThe base of spinous processes the C2 laminas Increasing the contact area of bone graftsIncreasing the stability of fixation,Principles of fusion and fixation procedures,Distinguish anatomic structures carefullyDetach the atlas which sink in the canal Sufficient exposure for the posterior arch tubercleDo not push with a periosteum separatorDetach the upper and lower posterior arch clearly,Principles of fusion and fixation procedures,Operate carefully to avoid SCIIf dislocation remained do not reduce with instrument fusion at original place to avoid SCIOccipital-cervical fusion procedure make intensive attachment of bone grafts assure the healing of bone grafts,