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收稿日期:2011-08-11 修回日期:2011-09-20 编辑:伊姗

枢椎齿状突骨折的诊疗进展

刘越1※(综述),赵艳梅2,张晓林1(审校)

(1.天津医院脊柱三科,天津300211;2.武警后勤学院部队防护医学教研室,天津300162)

中图分类号:R683 文献标识码:A 文章编号:1006-2084(2012)02-0258-04

摘要:枢椎齿状突骨折是影响寰枢椎稳定性的严重损伤,骨折不愈合会造成寰枢关节不稳,甚至脱位,产生高位颈髓压迫,严重者危及生命。然而齿状突骨折在诊断上容易漏诊,分型治疗方法多样,但目前并没有达成一致性的意见。齿状突骨折在治疗上主要分为保守与手术两种方式,具体选择哪种治疗方式取决于多种因素,如骨折类型、寰枢关节稳定性、并发损伤、年龄、解剖变异等。现从解剖特点、诊断分型与治疗三个方面详细介绍临床上齿状突骨折的诊治进展情况,同时就诊治过程中存在的争议进行讨论,旨在为临床枢椎齿状突骨折的诊治提供参考。

关键词:齿状突;骨折;诊断;治疗

Progress on Diagnos is and Tre atment o f Odonto id Pro ces s Fract ure of Axis LIU Yue1,ZH AO Yan-m ei2,ZH ANG Xiao-lin1.(1.Department Three of S pine,Tianjin H ospital,Tianjin300211,China;2.Depart-ment of Military Pr otective Medicine,Logistics College of the Chinese People′s Ar med Police Forces,Tianjin 300162,C hina)

Abst rac t:Odontoid process fracture of axis is a serious trauma,which affects the stability of atlantoaxial joint.Nonunion of odontoid process fr actur e w ill cause atlantoaxial joint instability,dislocation,upper cer vical cord compr ession,or even threaten life in ser ious cases.Odontoid pr ocess fra cture is easily misdiagnosed and there are var ious methods for fracture categorizing and treatment,though no consistent opinion ha s been r eached yet.Conser vative ther apy a nd oper ation a re the two main methods.Selection of the tr eatments de-pends on m any factors such as fracture patter n,atlantoaxial stability,concur rent injury,patient′s age and a na-tomic var iation etc..Here is to introduce the progr ess in odontoid fra ctur e in thr ee aspects including anatomic feature,diagnosis classifica tion and treatment;a nd discuss the existing controver sial points in odontoid fr ac-ture diagnosis and tr eatment in order to provide the clinical reference.

Key words:Odontoid process;Fr actur e;Diagnosis;Tr eatment

由车祸、高处坠落等引起的枢椎齿状突骨折,是

影响寰枢椎稳定性的严重损伤,其发生率占整个颈

椎骨折的10%～14%,而在枢椎骨折中则占半数以

上。随着现代工业及交通运输业的发展,齿状突骨

折的发生率呈上升趋势。未经治疗或治疗不当造成

的齿状突骨折不愈合率为41.7%～72.0%。骨折不

愈合造成寰枢关节不稳,甚至脱位,对高位颈髓构成

压迫,严重者危及生命。故对枢椎齿状突骨折的患

者应积极治疗。近年来,随着解剖学不断研究及新

型材料学的进展,新的治疗方法和技术不断应用于

临床,目前在齿状突骨折的诊断与治疗方面已经取

得突破,现就其进展情况予以综述。1 解剖特点

齿状突是位于枢椎椎体上的圆柱状突起。尖部有尖韧带附着于枕骨大孔前正中缘,两侧有附向枕髁内侧缘的翼状韧带。齿状突前后各有椭圆形前、后关节面,前者与寰椎前弓的齿状突关节面构成寰齿前关节,后者与寰椎横韧带构成寰齿后关节。在颈椎完成旋转活动时,齿状突成为寰枢椎旋转的轴。即寰椎前弓绕着齿状突前方的关节面旋转。在维持寰椎稳定方面,齿状突限制寰椎向后方移动,而寰椎横韧带、

翼状韧带和齿突尖韧带则限制寰椎向前及侧方移动。在受到异常外力时,上述结构的损伤常导致寰枢椎不稳。组织形态学三维分析结果表明,齿状突基底部的骨小梁结构量少,仅为枢椎和齿状突的55%,且其皮质厚度为齿状突的1/3,因而齿状突基底为骨折好发区[1]。解剖学上寰椎横韧带不能完全覆盖齿状突,约69%位于齿状突的中下部,因此,多数齿状突的腰部有比较明显的狭窄带,这可能是齿状突骨折易发在腰部的原因之一。此外,齿突的血供主要来自中央动脉与经齿突尖韧带、翼状韧带及副韧带进入的动脉。上述解剖特点导致发生在齿状突腰部的Ⅱ型骨折多因血运不佳而影响愈合。