背景:据我们所知,以前的文献中没有非创伤性被忽视的完全颈椎脱位的报道,其特征是C4脊柱前突,极端头部下垂,和不可还原的颈胸脊柱后凸。
方法:我们报告了一例33岁的白种人,有17年的严重免疫性多发性肌炎病史,并进行了常规理疗,在进行理疗后数周出现严重的颈胸交界处的非可复性脊柱后凸和进行性四联。射线照片,计算机断层扫描,磁共振成像显示C4-C5水平完全脱位,C4脊椎下垂,后凸成角,脊髓压迫,和严重的脊髓病.由于最近神经症状恶化,采用侵入性治疗策略.患者的神经状态和脊柱畸形使麻醉和手术治疗复杂化,这是经过广泛的多学科讨论后计划的,并依靠整形外科医生和麻醉师之间的密切合作。关于麻醉,由于严重的颈椎角度,预计很难进入气道,开口有限,和甲状腺距离,有困难通气和插管的高风险。患者管理因理论上的神经源性休克风险而变得更加复杂,运动和感觉恶化,手术过程中由于位置变化而导致的不稳定,术后呼吸衰竭。关于手术,精心策划了一个多阶段的方法。在闭合还原尝试失败后,进行了三阶段的外科手术以减少位移并稳定脊柱,导致正确的脊柱重新对齐和固定。观察到进行性完全恢复的神经。
结论:这个案例说明了基于放射科医师的多学科合作的危急情况的成功管理,麻醉师,和脊柱外科医生。
BACKGROUND: To our knowledge, there is no previous report in the literature of non-traumatic neglected complete cervical spine dislocation characterized by anterior spondyloptosis of C4, extreme head drop, and irreducible cervicothoracic kyphosis.
METHODS: We report the case of a 33-year-old Caucasian man with a 17-year history of severe immune polymyositis and regular physiotherapy who presented with severe non-reducible kyphosis of the cervicothoracic junction and progressive tetraparesia for several weeks after a physiotherapy session. Radiographs, computed tomography, and magnetic resonance imaging revealed a complete dislocation at the C4-C5 level, with C4 spondyloptosis, kyphotic angulation, spinal cord compression, and severe myelopathy. Due to recent worsening of neurological symptoms, an invasive treatment strategy was indicated. The patient\'s neurological status and spinal deformity greatly complicated the anesthetic and surgical management, which was planned after extensive multidisciplinary discussion and relied on close collaboration between the orthopedic surgeon and the anesthetist. Regarding anesthesia, difficult airway access was expected due to severe cervical angulation, limited mouth opening, and thyromental distance, with high risk of difficult ventilation and intubation. Patient management was further complicated by a theoretical risk of neurogenic shock, motor and sensory deterioration, instability due to position changes during surgery, and postoperative respiratory failure. Regarding surgery, a multistage approach was carefully planned. After a failed attempt at closed reduction, a three-stage surgical procedure was performed to reduce displacement and stabilize the spine, resulting in correct spinal realignment and fixation. Progressive complete neurological recovery was observed.
CONCLUSIONS: This case illustrates the successful management of a critical situation based on a multidisciplinary collaboration involving radiologists, anesthesiologists, and spine surgeons.