齿突骨折与迟发性寰枢椎脱位.ppt

齿突骨折与迟发性寰枢齿突骨折与迟发性寰枢椎脱位椎脱位现在学习的是第1页，共34页PrefacelDens axis Atlantoaxial stability Most important axial bone structurelOdontoid fracture Atlantoaxial instability Secondary SCI现在学习的是第2页，共34页Odontoid fracture 710%of cervical spine fracturecause SCI instantly Respiratory dysfunction Even deathSpecial structures and functionHigh ununion rate after fracture现在学习的是第3页，共34页Odontoid fracturel lLack of effective treatmentl lNot treated Unstable factors exist Atlas lost the restriction of Dens axis and ligamentsDelayed atlantoaxial dislocation现在学习的是第4页，共34页Clinical informationMale 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现在学习的是第5页，共34页Injury causesAccidental 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现在学习的是第6页，共34页Course of diseasesTime 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现在学习的是第7页，共34页Treatment coursenot treated after injury 12 casesno diagnosis when admitted 7 casesskull traction 23W stabilized by collars 16 casesonly collars stabilization 21 cases现在学习的是第8页，共34页Local featuresUncomfortable and pain of neck and nape 37 cases Middle or bilateral area of the occipitocervical Middle or bilateral area of the occipitocervical Possible feeling of hyperesthesia or pain at fields Possible feeling of hyperesthesia or pain at fields dominated by great occipital or great auricular nerve dominated by great occipital or great auricular nerveSkull and neck motor limitation 21 casesTilt stiffness of head and neck 14 cases现在学习的是第9页，共34页Motor functionNormal 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现在学习的是第10页，共34页Neurologic examinationnormal 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 casespain,anaesthesia of GAN and GON 15 casestendon hyperreflex,muscle hypertension muscle force decrease 23 grades 32 casesHoffmanHoffman抯抯抯抯 sign positive 19 casessign positive 19 casesBabinski抯抯抯抯 sign positive 8 cases Both 6 casessign positive 8 cases Both 6 cases现在学习的是第11页，共34页Radiological examinationRoutine X-ray programhead-neck AP lateraldynamic lateral filmsopen mouth viewAll case showed odontoid fractureAccording to Anderson-D扐扐lonzo classificatonType 47 cases Type 9 cases现在学习的是第12页，共34页Dislocation statusno displacement 8 casesForeward displacement 4mm 14cases 57mm 20 cases 810mm 8 cases 1112mm 3 casesDorsal displacement 3 casesDynamic reducible dislocation 14casesflexiondislocation extensionreduction现在学习的是第13页，共34页MRI examination 41 casesNo significant abnormal 8 casesSpinal cord compression 33 casesl l SC signals increasing 5cases现在学习的是第14页，共34页Treatment All received operationBefore operation Skull traction routinely1W later X rays observe reduction trend possible reductionkeep traction until restored impossible reductiongive up tractionl lReducible dislocation need no continuous traction receive operation directly现在学习的是第15页，共34页Atlanoaxial posterior structure bone graft and wire fixationModified Gallie method 17 cases Modified Brooks method 14 casesAutogenous iliac bone clip to be clip to be 揟揟揟揟?shape?shapeThe convex of bone graft is inserted into the gap The 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现在学习的是第16页，共34页Atlas posterior arch resection +Occipital-cervical fusionResect 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现在学习的是第17页，共34页ResultsNo death caseNo death caseAll be followed-upAll be followed-upAverage follow-up time 3yrs and 6MShortest 11M Longest 10yrs and 8M现在学习的是第18页，共34页Assessment arcording tospinal cord function and imageExcellent:no abnormal feelingNormal or near normal of limbs Bone graft unionNormal or near normal of limbs Bone graft unionNo significant difficulty of head and neck motionGood:feel goodUncomfortable on head or neck occasionallyUncomfortable on head or neck occasionallySometimes weakness of extremities,normal gait Neurologic examinationNeurologic examination hypersensitive of tendon reflex hypersensitive of tendon reflex pathologic reflex may exist现在学习的是第19页，共34页Better:symptoms and signs improved Limbs motor deficit,unstable gaitno-change:no change of symptoms and signs or feelings Bone grafts un-union 现在学习的是第20页，共34页Results of treatmentAtlantoaxial fusionAtlantoaxial fusionExcellent 14 cases Good 11 casesBetter 4 cases No change 2 cases*1 case bone graft ununion and displacedOccipitocervical fusion Occipitocervical fusion Excellent 12 cases Good 8 casesBetter 3 cases No change 2 cases*bone graft ununion and displaced现在学习的是第21页，共34页Discussion:Features of Odontoid fracture and delayed atlantoaxial dislocationOdontoid fracture Atlas-axis loss restriction of bone structure Results in instability between atlas and axisEspecially Anderson-D扐扐lozon typeor type fracture Many cases died instantly for severe cervical spinal cord injury and respiratory failure现在学习的是第22页，共34页Main causes of early mis-diagnosisSurvivals of odontoid fracture only complicated with mild dislocation or no dislocation of atlasclinical symptoms are mild not enough to take patient抯抯 attentionthe illegible radiography show overlapping of bone structure between atlas and axis现在学习的是第23页，共34页Pathological changesIntensive related factorsIntensive related factorsTraumatic force formTraumatic force strengthAnatomic structure现在学习的是第24页，共34页Anatomy about odontoidThe apical ligament and the alar ligamentThe apical ligament and the alar ligament extend from the tip and the two sides of the dens body 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 posterior part of alar ligament attaches to the anterior rim of occipital foramen magnum and the occipital the anterior rim of occipital foramen magnum and the occipital condyles condyles Odontoid jointed with the posterior side of atlas anterior arch,Odontoid jointed with the posterior side of atlas anterior arch,keeping stable with the strong transverse ligament and alar ligament keeping stable with the strong transverse ligament and alar ligament which restrict the motor range of odontoidwhich restrict the motor range of odontoid现在学习的是第25页，共34页Anatomy about odontoidSagittal diameter of C1 canal=30 mmDiameter of cord=10 mmDiameter of dens=10 mmSafe space for cord=10 mmConsiderable buffering space is available现在学习的是第26页，共34页Mechanism of odontoid fractureSkull flexion injury is one of the major causesTraumatic forces head bended suddenlyOdontoid Odontoid Anterior arch of C1 Anterior arch of C1 Transverse ligamentTransverse ligamentImpacting forward togetherImpacting forward togetherTransverse shear force Vertical compress forceTransverse shear force Vertical compress forceSeparate the connection between odontoid and C2 bodyOdontoid fractureOdontoid fractureOutside shear force Outside tear forceOutside shear force Outside tear force现在学习的是第27页，共34页Mechanism of delayed atlas dislocationUnstable status caused by odontoid fractureUnstable status caused by odontoid fractureSkull has trends of inclining forward and moving continuouslySkull has trends of inclining forward and moving continuouslyAtlas move forward progressively with dens axisAtlas move forward progressively with dens axisDelayed atlas dislocation Delayed atlas dislocation Direct operative decompression Direct operative decompression Moving forward equably or Moving forward rotatelyMoving forward equably or Moving forward rotately Potential risks of SCI Potential risks of SCI Contributed factors Contributed factors odontoid odontoid ligaments around ligaments around articular capsule articular capsule现在学习的是第28页，共34页DiscussionDiscussion Clinical features of odontoid fractureLocal symptomsneck and nape painneck and nape pain early early restricted to upper cervical spinerestricted to upper cervical spinemotor dysfunction of head and neck especially the rotation function especially the rotation functionNeurologic symptoms mild at early stage,easy to be overlookedmild at early stage,easy to be overlookeddelayed spinal cord compressiondelayed spinal cord compression paralysis,respiration failure paralysis,respiration failure Nerve root compressionNerve root compression nimbleness,pain and stiffness of occipital-cervical area nimbleness,pain and stiffness of occipital-cervical area现在学习的是第29页，共34页Diagnosis of odontoid fracture&atlas dislocationHistoryinjury,treatment courselocal and neurologic examinationimage examination routine X-rays films routine X-rays filmsSkull-neck AP films Open-mouth films Lateral flexion and extension filmsSkull-neck AP films Open-mouth films Lateral flexion and extension filmsX-ray tomography CT MRIX-ray tomography CT MRIDifferentiate with the odontoid dysplasia and its deformity complicationDifferentiate with the odontoid dysplasia and its deformity complicationFacilitate choosing the treatment plan and assessing prognosisFacilitate choosing the treatment plan and assessing prognosis现在学习的是第30页，共34页Discussion Discussion TreatmentOdontoid 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现在学习的是第31页，共34页Atlantoaxial fusion an ideal methodConditionsReduction completely or almost restored after skull tractionAtlas is not dislocated or can restore while extension现在学习的是第32页，共34页Occipital-cervical arthrodesis a common operative procedureRestricting the skull-neck motor function in some extent Indications those who needs posterior arch resection those who needs posterior arch resection obvious atlantoaxial dislocationposterior arch of atlas is the chief compressoratlas anterior dislocation is smallsevere symptoms of SCI exist现在学习的是第33页，共34页Methods of rebuilding the stabilityModified Gallie and Brooks techniqueProcedures of wire technicalRevising and placing of bone graftsl lDistance between the posterior arch Distance between the posterior arch and laminae and spinous of C2 is 8mmwhen atlas is at neutral position under normal physical conditionl lRelatively constant keeping the ligament tension between atlas and axis and the stability of joints related to dens axis现在学习的是第34页，共34页