| Irreducible atlantoaxial dislocation(IAAD)is a kind of atlantoaxial dislocation which can not be reduced by strict skull traction(even under general anesthesia)due to the scar con-tracture of ligament,joint capsule and muscle around the atlantoaxial joint.IAAD has always been a hot and difficult point in surgical treatment.In the past,anterior odontoidectomy via Transoral approach(TOA)can directly decompress the ventral spinal cord,and it is considered to be the standard procedure for the treatment of IAAD.However,this approach is usually accompanied by serious complications such as oropharyngeal infec-tion,velopharyngeal dysfunction,dysphagia and tracheotomy.Because of the deep position of odontoid process,it is easy to cause cerebrospinal fluid leakage and spinal cord injury during decompression.Subsequently,scholars proposed to use anterior release combined with inter-nal fixation in the treatment of IAAD,with less trauma and less bleeding.After release,the atlantoaxial joint was reduced and the spinal cord compression was relieved to prevent the occurrence of gooseneck deformities.Although it reduces the occurrence of cerebrospinal fluid leakage,it still can not avoid the postoperative complications caused by TOA.Since Kassam et al first used endoscopic endonasal approach(EEA)to remove the odontoid in 2005,many scholars have shown that this method can reduce the incidence of oropharyngeal infection,reduce the risk of postoperative tracheotomy,shorten hospital stay,and speed up the recovery of oral diet after operation.However,some studies have shown that the incidence of cerebrospinal fluid leakage during and after EEA is significantly higher than that of TOA,which may be related to the long learning curve of odontoidectomy under EEA,and endoscopic dural repair is relatively difficult.We believe that it is feasible to release the atlantoaxial vertebrae through the EEA.For this reason,this study retrospectively analyzed EEA anterior release combined with posterior fusion internal fixation in the treatment of IAAD,and compared with TOA anterior release,to explore the surgical efficacy and postop-erative complications of the two methods,in order to put forward a more reasonable method of operation.Part Ⅰ A comparative study of endoscopic transnasal and transoral anterior release in the treatment of irreducible atlantoaxial dislocationPurpose:To compare transoral and endoscopic transnasal anterior release without odontoidectomy and posterior reduction and fixation to treat irreducible atlantoaxial disloca-tion.Methods:From June 2006 to January 2017,35 consecutive patients with IAAD under-went transoral(Group TOA)or endoscopic transnasal(Group EEA)release and posterior fix-ation and fusion in our department.Clinical neurological recovery(Japanese Orthopedic As-sociation(JOA)score)and radiological reduction parameters including atlantodontoid interval(ADI),space available for the cord(SAC)and cervicomedullary angle(CMA)were analyzed and compared.The operation duration,blood loss,length of intensive care unit(ICU)/hospital stay and complications were recordedResults:All 35 patients(18 and 17 patients in the TOA and EEA group,respectively)were followed up for a mean of 36.4 months(range,21-60 months).All patients achieved excellent anatomical reduction and clinical neurological recovery,with no significant differ-ences between the two groups(P>0.05).The JOA score,ADI,SAC and CMA were not significantly different between the two groups at various postoperative points(P>0.05)Although the Tr-Oral group had shorter operation time and less blood loss than the Tr-Nasal group,the Tr-Nasal group tended to have a significantly shorter hospital/ICU stay,earlier ex-tubation and earlier oral intake than the Tr-Oral group(P<0.05).Conclusion:The transoral and endoscopic transnasal approaches can achieve equivalent release and reduction effects when treating IAAD.Compared to the transoral approach,the endoscopic transnasal route is less invasive with earlier extubation and oral intake,shorter hospital/ICU stays and lower medical costs,which is conducive to enhanced recovery after surgery.Part Ⅱ Endoscopic transnasal anterior release in the treatment of irreducible at-lantoaxial dislocation,a radiological researchPurpose:To explore the feasibility of endoscopic transnasal anterior release in the treatment of irreducible atlantoaxial dislocation and compare inferior limit of the exposure under different cervical positions.Methods:From June 2015 to June 2019,30 patients with IAAD treated in China-Japan Friendship Hospital underwent three-dimensional CT reconstruction scan of cervical vertebra in neutral position,extension position and flexion position.The length of hard palate(LHP),the distance between the lowest point of nasal bone and anterior nasal spine(LNA)were measured.The distance from NPL to HPL(DNPLC),NAXL to HPL(DNAxLC),RPL to HPL(DRPLC),and DLMHP from atlantoaxial lateral mass joint to HPL were measured under three kinds of cervical positions.We also compared the lower exposure limit between patients with basilar invagination and patients without basilar invagination.Results:The lower limits of EEA exposure(DNPLC,DNAxLC,DRPLC)predicted by different cervical vertebra angles were significantly higher than those of DLMHP(P<0.05).It is considered that anterior release of EEA is feasible.There was no significant difference in DNPLC,DNAxLC,DRPLC and DLMHP among different cervical spine positions,indicating that the cervical vertebra angle had little effect on the lower limit of EEA exposure.The DLMHP values of patients in BI group were lower than those in NBI group under three cer-vical vertebra angles,and the difference was statistically significant(P<0.05).The lower ex-posure limit of EEA is affected by LNA,LHP length and the size of angle NAH,and has a negative correlation with the size of LHP and angle NAH,and a positive correlation with the size of LNA.Conclusion:According to anatomical measurement,anterior release under EEA is feasi-ble and is not affected by the cervical positions.For patients with basilar invagination,anteri-or release under EEA is easier to reach the intervertebral space of atlantoaxial mass.Part Ⅲ Meta-Analysis of Clinical efficacy of Buyang Huanwu decoction in the treatment of Spinal Cord injuryPurpose:Through the meta-analysis of Buyang Huanwu Decoction in the treatment of spinal cord injury,the effectiveness of Buyang Huanwu Decoction in the treatment of spinal cord injury was systematically evaluated from the perspective of evidence-based medicine.Methods:Databases including CNKI、VIP、Wangfang Data、CBM、Pubmed、Embase、Cochrane library and Web of Science were searched for papers comparing Buyang Huanwu decoction combined with western medicine routine treatment and simple western medicine routine treatment.The retrieval time is from the establishment of the database to January 1,2020.The retrieval object is a randomized controlled trial of Buyang Huanwu Decoction Combined with western medicine in the treatment of spinal cord injury.The Chinese retrieval terms are "spinal cord injury","spinal cord compression","spinal cord concussion","spinal fracture","Buyang Huanwu Decoction","plus and minus Buyang Huanwu Decoction","Buyang Huanwu Decoction plus and taste","Buyang Huanwu Decoction plus and taste"Huanwu Decoction addition and subtraction,Buyang Huanwu Decoction mixture,random control,random distribution,clinical observation,clinical research,etc.The English search terms are "spiral cord interventions","spiral cord trauma","Buyanguanwu decision",etc.Revman 5.3 and Stata 16.0 are used for statistical analysis of the data.Results:A total of 1266 patients were included in 19 literatures.The treatment group was treated with Buyang Huanwu Decoction plus and minus combined with western medicine,while the control group was treated with western medicine.In the total effective rate,recovery rate,JOA score,Asia sensory and motor function scores,Buyang Huanwu Decoction Com-bined with western medicine treatment group were better than western medicine treatment group,the difference was statistically significant(P<0.05)Conclusions:The therapeutic effect of Buyang Huanwu Decoction Combined with con-ventional western medicine is significantly higher than that of conventional western medicine,which can improve the symptoms of residual nerves and promote the recovery of spinal cord function. |
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