發(fā)布時(shí)間：2018-09-08 21:42

【摘要】：目的:顱底凹陷癥系枕頸區(qū)發(fā)育異常,脊髓腹側(cè)受到壓迫導(dǎo)致患者出現(xiàn)雙手精細(xì)動(dòng)作遲緩,雙足行走時(shí)有踩棉感,四肢肌張力升高,病理征存在等臨床表現(xiàn)和體征。治療方法以手術(shù)治療為主,而手術(shù)治療的首選方法是枕骨大孔減壓和枕頸融合手術(shù)。在進(jìn)行枕頸融合手術(shù)時(shí),需要對(duì)枕骨和頸椎進(jìn)行內(nèi)固定,但由于顱底凹陷癥患者常常伴有樞椎發(fā)育異常,因此在樞椎進(jìn)行內(nèi)固定時(shí)會(huì)遇到很多困難,影響了手術(shù)策略的選擇。因此本研究的目的是研究顱底凹陷癥患者的樞椎以及附屬結(jié)構(gòu)發(fā)育畸形特點(diǎn),并對(duì)其進(jìn)行分型,使得每一位病人的治療呈現(xiàn)個(gè)體化,選擇最優(yōu)的手術(shù)固定方式,從而避免術(shù)中損傷椎動(dòng)脈及神經(jīng)等周圍重要結(jié)構(gòu),降低手術(shù)風(fēng)險(xiǎn)。方法:在本次研究中,我們收錄了 26名顱底凹陷癥病人的病歷資料,時(shí)間范圍自2013年12月至2016年12月來我院就診的。其中男性10例,女性16例,患者的平均年齡為41.8歲(25-63歲),其中50歲以下者為18人,占總?cè)藬?shù)的69.23%,50歲以上者8人(30.76%)。所有26名病人首要診斷均是顱底凹陷癥,起病緩慢,本文26例患者起病平均時(shí)間約2年,最長(zhǎng)者為13年。臨床表現(xiàn)以四肢麻木無力、雙手精細(xì)動(dòng)作遲緩、四肢肌張力升高、病理征存在、腱反射亢進(jìn)等為主,同時(shí)伴有身材矮小、短頸等特殊體征。所有患者入院后均遵照醫(yī)囑完善術(shù)前檢查,包括頸椎正側(cè)位X線平片、頸椎間盤CT平掃(包括骨窗)、頸髓磁共振等檢查。顱底凹陷癥診斷標(biāo)準(zhǔn):Chamberlain線:齒狀突高于此線3-4mm;麥?zhǔn)暇�:硬腭后緣至枕骨鱗部下緣的連線,齒突正常不超過此線7mm,若超過7mm說明有顱底凹陷;乳突連線:齒狀突的尖部若超過兩側(cè)乳突連線大于2mm說明有顱底凹陷癥;Boogard角:側(cè)位頭顱片上,枕骨大孔前后緣的連線與斜坡之間的角度,正常位120-130°,大于此角度為顱底凹陷。手術(shù)方法:在26名患者中,2名患者未行手術(shù)治療,1名行頸椎后路單開門手術(shù),1名行枕肌下減壓術(shù),其余22名患者均在全身麻醉下行枕骨大孔減壓和枕頸融合手術(shù)。在該22名行枕頸融合手術(shù)治療患者中,12名在C2行雙側(cè)椎弓根置釘,2名患者在C2行側(cè)塊螺釘,1名患者在C2單側(cè)行椎弓根置釘而對(duì)側(cè)未置釘,1名患者在C2右側(cè)行椎弓根置釘而左側(cè)行側(cè)塊螺釘,6名患者未在C2置釘而在C3-4行側(cè)塊螺釘,所有患者在手術(shù)后均恢復(fù)良好,并順利出院。雙側(cè)椎弓根的寬度和雙側(cè)側(cè)塊矢狀徑的測(cè)量:樞椎椎弓根寬度的測(cè)量是在頸椎CT軸位片上,選取椎弓根掃描層面處于椎弓根中部的CT片。我們通過PACS影像系統(tǒng)工作站,利用軟件自身的測(cè)量尺工具測(cè)量椎弓根的寬度,即椎動(dòng)脈孔的內(nèi)側(cè)緣到椎弓根的內(nèi)緣之間最小垂直距離,分別測(cè)量左右兩側(cè)。側(cè)塊矢狀徑即指自椎動(dòng)脈孔后緣做一水平線,自側(cè)塊進(jìn)釘點(diǎn)做該水平線的垂線,測(cè)量?jī)删�交點(diǎn)到側(cè)塊進(jìn)釘點(diǎn)的的直線距離。結(jié)果:在本次研究的26例患者中,Ⅰ型發(fā)育正常無明顯畸形者11例,Ⅱ型側(cè)塊發(fā)育不良者共3例,Ⅲ型椎弓根發(fā)育不良者共12例,其中包括單側(cè)或雙側(cè)單純椎弓根發(fā)育不良以及合并有側(cè)塊發(fā)育不良。Ⅳ型合并V型即椎板融合合并有椎體融合者共2例。椎弓根寬度方面測(cè)量結(jié)果:I型患者左側(cè)椎弓根寬度平均為6.4818±1.3mm,右側(cè)椎弓根寬度平均為7.1909±1.4mm,Ⅱ型患者左側(cè)椎弓根寬度平均為6.43±1.1mm,右側(cè)椎弓根寬度平均為5.93±1.2mm,Ⅲ型患者左側(cè)椎弓根平均寬度為2.7±1.3mm,右側(cè)椎弓根寬度平均為3.283±1.2mm。用spss軟件進(jìn)行分析,Ⅰ型與Ⅲ型、Ⅱ型與Ⅲ型患者之間左右兩側(cè)的椎弓根寬度相比均具有統(tǒng)計(jì)學(xué)意義P0.01,Ⅰ型與Ⅱ型之間右側(cè)有意義,左側(cè)無統(tǒng)計(jì)學(xué)意義。側(cè)塊矢狀徑測(cè)量結(jié)果:Ⅰ型患者左側(cè)側(cè)塊有效長(zhǎng)徑平均為12.127±1.3mm,右側(cè)側(cè)塊有效長(zhǎng)徑平均為13.091 ± 1.2mm,Ⅱ型患者左側(cè)側(cè)塊有效長(zhǎng)徑平均為6.58± 1.2mm,右側(cè)側(cè)塊有效長(zhǎng)徑平均為6.75±1.4mm,Ⅲ型患者左側(cè)側(cè)塊有效長(zhǎng)徑寬度為8.5±1.4mm,右側(cè)側(cè)塊有效長(zhǎng)徑平均為9.25±1.3mm。用spss軟件進(jìn)行分析,Ⅰ型與Ⅱ型、Ⅰ型與Ⅲ型、Ⅱ型和Ⅲ型之間患者右兩側(cè)的側(cè)塊有效長(zhǎng)徑相比均具有統(tǒng)計(jì)學(xué)意義P0.01,Ⅱ型和Ⅲ型患者之間左側(cè)無統(tǒng)計(jì)學(xué)差異。11例I型患者中,9例患者均行雙側(cè)椎弓根置釘,1例患者行頸椎后路單開門椎管成形術(shù),1例患者行枕肌下減壓術(shù),未應(yīng)用內(nèi)固定裝置。Ⅱ型患者共3例,均行雙側(cè)椎弓根釘固定。Ⅲ型椎弓根發(fā)育不良患者共12例,其中1例患者未手術(shù)直接出院,2例患者行雙側(cè)側(cè)塊螺釘固定,1例是單側(cè)椎弓根發(fā)育不良(僅左側(cè)),遂行右側(cè)椎弓根螺釘和左側(cè)側(cè)塊螺釘固定。其余8例為側(cè)塊發(fā)育不良合并椎弓根發(fā)育不良者,其中1例患者未手術(shù)直接出院,1例為雙側(cè)側(cè)塊發(fā)育不良合并單側(cè)椎弓根發(fā)育不良,遂行單側(cè)椎弓根置釘而對(duì)側(cè)未進(jìn)行內(nèi)固定;其余6例因椎弓根和側(cè)塊均不適合進(jìn)行內(nèi)固定,因此未在C2進(jìn)行內(nèi)固定,于C3-4行側(cè)塊螺釘固定。結(jié)論:對(duì)于顱底凹陷癥患者,對(duì)枕頸區(qū)行徹底的減壓、穩(wěn)定的固定是治療的關(guān)鍵。在樞椎行內(nèi)固定必須充分認(rèn)識(shí)樞椎的發(fā)育特點(diǎn),樞椎發(fā)育畸形將極大地影響脊柱外科醫(yī)生的手術(shù)策略的選擇,還會(huì)導(dǎo)致嚴(yán)重的并發(fā)癥。結(jié)合患者的椎弓根和側(cè)塊發(fā)育特點(diǎn),我們將顱底凹陷癥患者的樞椎可以分為5型,其中I型發(fā)育尚可,其椎弓根寬度處于正常人的正常范圍的下限。Ⅱ型是指單純側(cè)塊發(fā)育不良。根據(jù)單側(cè)或雙側(cè)發(fā)育不良還可以分為ⅡA型和ⅡB型,ⅡA型主要是單側(cè)側(cè)塊發(fā)育不良,ⅡB型是雙側(cè)側(cè)塊發(fā)育不良。Ⅲ型主要是椎弓根發(fā)育不良,并且將其分為ⅢA型、ⅢB型和ⅢC型,ⅢA型是指單側(cè)椎弓根發(fā)育不良,ⅢB型是指雙側(cè)椎弓根發(fā)育不良,ⅢC型是指合并有側(cè)塊發(fā)育不良。Ⅳ型(椎板融合)和Ⅴ型(椎體融合)病例數(shù)較少,對(duì)枕頸融合術(shù)影響也較小。椎動(dòng)脈高跨也是影響樞椎置釘?shù)奈ｋU(xiǎn)因素,它可以導(dǎo)致椎弓根和側(cè)塊變形。顱底凹陷癥患者的影像學(xué)資料中,常常出現(xiàn)椎動(dòng)脈的走行異常,由于椎動(dòng)脈與椎弓根相鄰,異常走行的椎動(dòng)脈會(huì)向內(nèi)向后偏移,位于椎弓根內(nèi)側(cè)或內(nèi)后側(cè),因此擠壓椎弓根變形,甚至穿過側(cè)塊中心并向上走行穿過側(cè)塊入顱。此時(shí)側(cè)塊螺釘具有較大的風(fēng)險(xiǎn),會(huì)破壞椎動(dòng)脈,影響顱內(nèi)血供,最佳手術(shù)方式是曠置C2,于C3-4置釘。因此對(duì)于顱底凹陷癥患者,樞椎置釘方式的選擇要考慮以下幾個(gè)因素:椎弓根寬度是否滿足椎弓根螺釘最低要求;側(cè)塊形態(tài)和大小;椎動(dòng)脈的走行情況。該分型就以上述幾個(gè)因素為基礎(chǔ),意在幫助脊柱外科醫(yī)生了解顱底凹陷癥患者的樞椎發(fā)育情況,為置釘手術(shù)策略提供一定依據(jù),對(duì)每個(gè)病人的提供個(gè)體化治療方案,選擇最佳的置釘方式,從而降低手術(shù)的風(fēng)險(xiǎn)。
[Abstract]:Objective: skull base depression is a kind of occipitocervical dysplasia, which is caused by compression of the ventral side of the spinal cord, resulting in fine movement retardation of both hands, feeling of stepping on cotton when walking on both feet, elevated muscle tension of the extremities, pathological signs and other clinical manifestations and signs. Fusion surgery. Internal fixation of occipital and cervical vertebrae is necessary in occipitocervical fusion surgery. However, the development of the axis is often abnormal in patients with skull base depression, so there are many difficulties in the internal fixation of the axis, affecting the choice of surgical strategy. Methods: In this study, 26 patients with basilar invagination were enrolled in the medical records. Materials: From December 2013 to December 2016, there were 10 males and 16 females with an average age of 41.8 years (25-63 years). Among them, 18 were under 50 years old, accounting for 69.23% of the total, and 8 were over 50 years old (30.76%). The average duration of the disease was about 2 years and the longest was 13 years.The clinical manifestations were numbness of limbs, slow fine movement of both hands, elevated muscle tension of limbs, pathological features, hyperreflexia of tendons, etc. CT plain scan of cervical intervertebral disc (including bone window), magnetic resonance imaging of cervical spinal cord, etc. Diagnostic criteria of skull base depression: Chamberlain line: odontoid process higher than this line 3-4 mm; Maxwell line: hard palate posterior margin to occipital squamous lower margin of the line, odontoid process normal not more than 7 mm, if more than 7 mm, indicating a skull base depression; mastoid line: odontoid process tip if more than two sides of the breast Boogard angle: the angle between the anterior and posterior margin of the foramen magnum and the clivus of the occipital bone on the lateral cranial slices, 120-130 degrees in the normal position, greater than this angle is the basilar depression. Among the 22 patients who underwent occipitocervical fusion, 12 underwent bilateral pedicle screw placement at C2, 2 underwent lateral mass screw placement at C2, 1 underwent unilateral pedicle screw placement at C2, and 1 underwent pedicle screw placement at C2 right and left. The width of bilateral pedicles and sagittal diameter of bilateral pedicles were measured: the width of the axis of the axis of the vertebral pedicle was measured on the cervical vertebral CT, and the CT film of the middle of the pedicle was selected on the scan plane of the vertebral pedicle. We measured the width of the pedicle through the workstation of the PACS imaging system and the minimal vertical distance between the medial margin of the vertebral artery foramen and the internal margin of the pedicle by the measuring ruler of the software itself. Results: Among the 26 cases studied, 11 cases had normal type I development without obvious deformity, 3 cases had type II lateral mass dysplasia, and 12 cases had type III pedicle dysplasia, including unilateral or bilateral simple pedicle dysplasia and combined with lateral mass dysplasia. The average width of the left pedicle was 6.4818 (+ 1.3 mm) in type I, 7.1909 (+ 1.4 mm) in right pedicle, 6.43 (+ 1.1 mm) in left pedicle, 5.93 (+ 1.2 mm) in right pedicle, and 5.93 (+ 1.2 mm) in type I I. The average width of the left and right pedicles was 2.7 (+ 1.3 mm) and 3.283 (+ 1.2 mm) respectively. The results of SPSS analysis showed that the width of the left and right pedicles was statistically significant (P 0.01) between type I and type III, and between type II and type III. There was no significant difference between type I and type II. Diameter measurements: The mean effective length of the left lateral mass was 12.127 (+ 1.3 mm) in type I, 13.091 (+ 1.2 mm) in right lateral mass, 6.58 (+ 1.2 mm) in type II, 6.75 (+ 1.4 mm) in right lateral mass, 8.5 (+ 1.4 mm) in left lateral mass and 8.5 (+ 1.4 mm) in right lateral mass. The mean effective length was 9.25 (+ 1.3 mm). The results of SPSS analysis showed that the effective length of the right lateral mass in patients with type I and type I I, type I and type I I I, type I I and type I I I were statistically significant (P 0.01). There was no significant difference between type I I and type I I I on the left side. All patients were treated with bilateral pedicle screw fixation. Twelve patients with type III pedicle dysplasia were treated with bilateral pedicle screw fixation. The other 8 cases were lateral mass dysplasia with pedicle dysplasia. One of them was discharged without operation, and the other was bilateral mass dysplasia with unilateral pedicle dysplasia. Six cases were not fixed in C2 because the pedicle and lateral mass were not suitable for internal fixation, so the lateral mass screw fixation was performed in C3-4. Conclusion: For patients with skull base depression, complete decompression of occipitocervical region and stable fixation are the key to treatment. Combined with the characteristics of pedicle and lateral mass development, the axis of patients with skull base depression can be divided into five types, of which type I is still well developed and the pedicle width is in the lower limit of normal range. Type I I refers to the development of simple lateral mass. According to unilateral or bilateral dysplasia can also be divided into type II A and type II B, type II A is mainly unilateral mass dysplasia, type II B is bilateral mass dysplasia. Type III is mainly pedicle dysplasia, and it is divided into type III A, type III B and type III C, type III A is unilateral pedicle dysplasia, type III B is bilateral pedicle dysplasia. Dysplasia, type III C, refers to the presence of lateral mass dysplasia. Type IV (lamina fusion) and type V (vertebral fusion) have fewer cases and less impact on occipitocervical fusion. Vertebral artery spacing is also a risk factor for axial screw placement, which can lead to pedicle and lateral mass deformation. Imaging data of patients with basilar indentation often appear. Because the vertebral artery is adjacent to the pedicle, the abnormal vertebral artery will deviate inward and backward, located in the medial or posterior part of the pedicle, so the pedicle is compressed and deformed, even through the center of the lateral mass and upward through the lateral mass into the skull. For patients with skull base depression, the following factors should be considered in the selection of axial screw placement: whether the pedicle width meets the minimum requirements of pedicle screw; the shape and size of lateral mass; the course of vertebral artery. This classification is based on the above factors and is intended to help the spine. Column surgeons understand the development of the axis in patients with skull base depression, provide a basis for the strategy of screw placement, provide individual treatment for each patient, and select the best screw placement method to reduce the risk of surgery.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

【參考文獻(xiàn)】

相關(guān)期刊論文 前10條

1 魏富鑫;劉少喻;王樂;梁春祥;龍厚清;孫海興;崔尚斌;潘鶴海;黃陽亮;;術(shù)前牽引后路枕頸復(fù)位固定融合治療顱底凹陷癥并可復(fù)性寰樞椎脫位[J];中國(guó)脊柱脊髓雜志;2013年05期

2 朱如森;馮世慶;劉巖;;脊柱內(nèi)固定椎弓根螺釘置入后生物力學(xué)的穩(wěn)定性[J];中國(guó)組織工程研究;2013年17期

3 許建強(qiáng);欒文忠;;脊髓空洞癥的分類及手術(shù)治療[J];中國(guó)臨床神經(jīng)外科雜志;2012年09期

4 王建華;夏虹;尹慶水;艾福志;吳增暉;馬向陽;章凱;;經(jīng)口咽前路寰椎側(cè)塊置釘固定治療合并寰枕融合畸形顱底凹陷癥的臨床療效[J];中國(guó)脊柱脊髓雜志;2012年06期

5 王建華;尹慶水;夏虹;艾福志;吳增暉;馬向陽;章凱;;顱底凹陷癥的分型及其意義[J];中國(guó)脊柱脊髓雜志;2011年04期

6 劉洋;權(quán)正學(xué);;寰樞椎椎弓根解剖及個(gè)體化置釘研究進(jìn)展[J];頸腰痛雜志;2010年02期

7 劉金有;;原發(fā)性顱底凹陷癥的影像學(xué)診斷進(jìn)展[J];中國(guó)實(shí)用醫(yī)藥;2009年32期

8 李洪珂;王文軍;;脊髓空洞癥的外科治療進(jìn)展[J];中國(guó)脊柱脊髓雜志;2008年01期

9 王建華;尹慶水;夏虹;吳增輝;;樞椎椎動(dòng)脈孔分型對(duì)樞椎椎弓根置釘?shù)呐R床意義[J];中國(guó)脊柱脊髓雜志;2007年08期

10 何俐;陳小燕;;脊髓空洞癥的診斷和治療進(jìn)展[J];中國(guó)全科醫(yī)學(xué);2007年12期

，

本文編號(hào)：2231780