前路椎弓根螺钉（ATPS）重建技术治疗下颈椎疾病

颈椎病和创伤治疗的主要目的是对神经根和脊髓进行减压，然后重建其稳定性。ACDF（颈椎前路减压植骨融合内固定术）能针对来自椎管前方的致压物直接进行减压，是治疗各种原因的颈椎疾病和创伤的有效方法。ACDF多采用单皮质椎体螺钉固定，对于单节段手术患者固定的强度较好，但对于老年性骨质疏松患者、颈椎多节段减压后、下颈椎严重“三柱”损伤的患者，运用单皮质椎体螺钉不足以重建多节段椎体切除后的稳定性，术后容易发生内固定的松动失败^[7-9]。文献报道，多节段ACDF的患者内固定松动失败的概率高达20～50%，而由于内固定失败需要翻修手术的比例为10%～20%^{[7, 10-11]}。

自1994年Abumi等^[12]首次报道采用颈椎后路椎弓根螺钉固定技术治疗中、下颈椎创伤不稳，已被公认为是生物力学稳定性最强的内固定方法并在临床上广泛应用。该方法使螺钉穿过了颈椎最坚固部分, 是一种即刻、安全、有效的内固定方法。单纯后路手术虽然具有较好的稳定性，但对于来自椎管前方的压迫从后路很难达到彻底的减压效果。另外，ACDF后补充后路椎弓根螺钉固定的二次手术，增加了手术风险和并发症的发生。在这些情况下颈椎前路椎弓根螺钉可以做为一种新的前路固定方法使用。

2008年,Aramomi等^[7]第一次描述了下颈椎前路椎弓根螺钉作为一种新的固定方法在多节段椎体次/全切除后稳定性重建中的应用。前路椎弓根螺钉的进钉方式与传统的前路和后路椎弓根螺钉固定的方法不一致，为了达到一次前路手术解决减压和重建这两个问题的目的，采用了与前路椎体螺钉和后路椎弓根螺钉不同的钉道。尽管下颈椎前路椎弓根螺钉固定有其优点，但至今仍没有得到广泛的应用。

下面附件是我2015年2月刚发表在Eru Spine J上的一篇文章，将详细介绍这项技术并会附上相关的经典病例

Anterior transpedicular screws in conjunction with plate fixation and fusion for the treatment of subaxial cervical spine diseases

Abstract

Objective This study aimed at exploring the clinical application of anterior transpedicular screw (ATPS) and plate in the reconstruction of subaxial cervical spine.

Methods 8 cases were reconstructed by ATPS and plate in the subaxial cervical spine from Jan 2009 to Dec 2011.

X-rays and computed tomography images were collected to evaluate the position of ATPS. Magnetic resonance imaging was also included to evaluate the result of decompression, the existence of epidural hematoma and the morphology of the cervical spinal cord. Japanese Orthopaedic Association scores were observed before and after operation as a functional estimation.

Results All of the eight cases were followed up from 3 to 36 months with the average of 15.5 months. A total of 16 ATPS were implanted in the subaxial cervical spine in the

eight patients. All the screws were inserted smoothly. Bone fusion was found in all the subjects 4.5 months after operation on average. No loosening or breakage of the internal fixation was observed in our study. Hoarseness was

observed in one case due to distraction injury of the recurrent laryngeal nerve, which disappeared after 3 weeks’conservative treatment. Dysphagia was complained by two patients after surgery, which was alleviated 3 months later.There were four screws deviating less than 1 mm (Grade

1), two medially and two laterally. All the anterior compressions were removed completely in this group. Only a

small amount of epidural hematoma was found in four cases on MRI images before discharge. The average JOAscores were significantly improved from 5.6 ± 1.4 beforesurgery to 14.5 ± 0.8 at discharge (P \0.01), which decreased to 13.2 ± 1.2 at 3 months after operation, but improved again to 15.2 ± 0.8 at 1 year after operation.

Conclusion Although there are some complications,ATPS with plate is an effective and safe technique for anterior reconstruction in the subaxial cervical spine. Only those spine centers with sufficient experience in complex

cervical spine reconstruction surgery can conduct this technique according to strict indications.