个体化手术治疗颈椎类风湿性关节炎

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摘要目的总结个体化手术治疗颈椎类风湿性关节炎的临床经验。方法对2012年6月至2015年6月收治的16例颈椎类风湿性关节炎患者行手术治疗，其中女14例，男2例；年龄41～65岁，平均(55.8±4.3)岁；病程11～20年，平均(15.7±2.8)年。所有患者均有颈椎不稳，按影像学表现分为寰枢椎半脱位(atlantoaxial subluxation，AAS)、垂直半脱位(vertical subluxation，VS)、下颈椎半脱位(subaxial subluxations，SAS)。其中难复性AAS 3例，可复性AAS 9例，VS 2例，SAS 2例。比较术前、术后、随访时颈痛视觉模拟评分(visual analogue scale，VAS)和日本骨科学会(Japanese orthopedic association，JOA)评分及Ranawat分级，测量寰齿后间距(posterior atlanto-odontoid interval，PADI)和颈延髓角(cervicomedullary angle，CMA)，并行统计学分析。结果随访时间为3～36个月，平均(23.2±3.6)个月。15例患者的神经功能获不同程度改善，1例虽无改善但亦无神经损伤加重，术后16例患者的齿突周围血管翳较术前减小。经CT证实均获骨性融合。无内固定松动、断裂，无脊髓、神经根和椎动脉损伤，未发生肾上腺皮质危象。结论对上颈椎类风湿患者选择个体化的手术方案治疗，可有效缓减颈椎类风湿关节炎的炎症破坏过程，改善患者预后，提高生存质量。

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	杨瑞峰1
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	谭俊铭 2

关键词 ：颈椎, 类风湿关节炎, 寰枢椎不稳, 脊柱融合术

Abstract：Objective To summarize the clinical experience of the surgical treatment for rheumatoid arthritis (RA) of cervical spine.Methods Sixteen patients who underwent surgical treatment for cervical spine of rheumatoid arthritis between June 2012 and June 2015 were enrolled in this retrospective study.All patients were cervical vertebral instability by imaging findings into AAS，VS，SAS.Including 9 cases of reducible atlantoaxial subluxation patients were treated with posterior approach fusion with graft and intenal fixation，2 patients with irriducible atlantoaxial dislocation were treated with occipitocervical fusion.Occipitocervical fusion was performed in 1 patient，posterior atlantal arch excision was performed in 1 patient.One irriducible atlantoaxial dislocation were treated with microscopic transoral approach C_1～2 screw fixation，1 irriducible atlantoaxial dislocation(IAAD) were treated with navigation aided microscopic transoral approach combine with ventral decompression onestage C_1～2 posterior approach fusion with graft and intemal fixation，1 case of SAS secondary to AAS underwent multiple segment fusion and internal fixation.2 patients with VS were treated with occipitocervical fixation，1 routine foramen magnum decompression and internal fixation.2 subaxial subluxations (SAS) patients underent multiple segmental fixation fusion.There were 2 men and 14 women with an average age of (55.8±4.3) years (range，41～65 years).The average course of disease was (15.7±2.8) years (range，11～20 years).Pain was evaluated by Visual Analogue Scale (VAS) scores before and after surgery.Ranawat grading scale，Japanese Orthopaedic Association (JOA) scores，posterior atlantoodontoid interval(PADI)，cervicomedullary angle(CMA)were used to determine myelopathy.Clinical and radiological data were collected before surgery，at 3 and (or) 6 months after surgery，and at final follow-up.Results Patients were followed up for 3～36 months (23.2±3.6 months)，15 cases of had a significant neurological improvement，1 cases have no improvement but also no nerve damage aggravated，16 cases of postoperative patients with odontoid pannus around a preoperative decrease.Solid fusion was confirmed by CT in all cases.No internal fixation loosening and fracture，spinal cord and nerve root and vertebral artery injury，adrenocortical crisis happened.Conclusion Individualized surgical planning should be adopted in patients with RA in upper cervical spine，which can effectively slow down the damage process cervical inflammation of rheumatoid arthritis，improve clinical outcomes，improve the quality of life.

Key words： cervical spine rheumatoid arthritis atlantoaxial instability spinal fusion

基金资助:南京军区医药重大基金课题(15DX002)
全军医学科研“十二五”课题(编号CWS11J260)

作者简介: 杨瑞峰(1988－ )，男，研究生在读，安徽医科大学解放军98临床学院，313000。

引用本文:

杨瑞峰1，2，谭俊铭 2. 个体化手术治疗颈椎类风湿性关节炎[J]. 实用骨科杂志, 2017, 23(12): 1057-1061.
Yang Ruifeng 1，2，Tan Junming 2. Surgical Treatment of Rheumatoid Arthritis in Cervical Spine. sygkzz, 2017, 23(12): 1057-1061.

链接本文:

http://www.sygkzz.com/CN/ 或 http://www.sygkzz.com/CN/Y2017/V23/I12/1057

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