退行性腰椎滑脱症的矢状面形态分型及其临床意义

Sagittal morphological classification of degenerative lumbar spondylolisthesis and its clinical significance

中文关键词:  退行性腰椎滑脱症  侧前方腰椎椎间融合术  矢状位形态分型  脊柱-骨盆参数

英文关键词:Lumbar degenerative spondylolisthesis  Anterolateral lumbar interbody fusion  Sagittal morphology classification  Spinopelvic parameters

中文摘要:

  【摘要】 目的：基于矢状面形态特点对退行性腰椎滑脱症（degenerative spondylolisthesis，DS）进行分型，评价其在腰椎侧前方入路手术治疗DS中的指导价值。方法：回顾性分析2015年1月～2016年12月我院收治的37例L4 DS患者的临床资料，其中男15例，女22例；年龄50～67岁（58.5±9.5岁）。由3名观察者分别根据DS患者术前L4/5节段矢状面形态分为3型：（1）开口型，腰椎滑脱角（slip angle，SA）>5°；（2）平行型，0°≤SA≤5°；（3）闭口型，SA<0°。所有患者均采用侧前方腰椎椎间融合术（anterolateral lumbar interbody fusion，ALLIF）治疗，术中参照患者矢状位形态分型调整手术体位摆放、cage置入位置和固定等。测量术前及术后腰椎前凸角 （lumbar lordosis，LL）、骨盆入射角（pelvic incidence，PI）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（sacral slope，SS）和脊柱矢状面平衡（sagittal vertical axis，SVA）；评估术前及术后末次随访时的腰痛和下肢痛疼痛视觉模拟评分（visual analogue scale，VAS）、腰椎Oswestry功能障碍指数（Oswestry disability index，ODI）和健康调查简表（the MOS item short from health survey，SF-36）评分。对3名观察者的分型结果进行Kappa一致性检验，并对各组患者临床资料进行统计学分析。结果：3名观察者之间分型的一致性Kappa值为0.826～0.894，观察者自身的一致性 Kappa值为0.875～0.916，均高度一致。37例DS患者中开口型12例（A组），平行型17例（B组），闭口型8例（C组），术前各组间LL、PT、SS具有统计学差异（P<0.05），C组LL、SS显著性低于其余两组（P<0.05），各组间PI、SVA无统计学差异（P>0.05）；术后A、B组脊柱-骨盆矢状面参数均较术前无显著性变化（P>0.05），而C组 PT较术前显著性降低，SS、LL显著性增加（P<0.05）。术前C组患者腰痛VAS显著大于其余两组（P<0.05），术后各组腰痛、腿痛VAS，ODI及SF-36评分均较术前显著性改善（P<0.05），其中C组腰痛VAS、ODI和SF-36心理健康评分改善幅度均大于其余两组（P<0.05）。结论：基于DS矢状面形态特点分型简单、方便且可信度高，根据DS不同分型制定相应的ALLIF治疗策略可以获得满意的临床疗效。

英文摘要:

  【Abstract】 Objectives: To investigate a new classification of lumbar degenerative spondylolisthesis(DS) based on the features of sagittal morphology, and evaluate its value in anterolateral approach surgery for DS. Methods: From January 2015 to December 2016, 37 cases with L4 DS were analyzed retrospectively, including 15 males and 22 females. The age ranged from 50 to 67 years(58.5±9.5 years). According to sagittal morphology, the patients were divided into three groups by 3 observers: opened type with SA(sagittal slipping angle)>5°, parallel type with 0°≤SA≤5°, and closed type with SA<0°. All patients were treated with anterolateral lumbar interbody fusion(ALLIF). In the surgical procedure, operative position, cage placement and fixation were adjusted according to sagittal morphology type. The followings were recorded: the pre- and postoperative spino-pelvic parameters including lumbar lordosis(LL), pelvic incidence(PI), pelvic tilt(PT), sacral slope(SS), sagittal vertical axis(SVA), and clinical scores including VAS for low-back and leg pain, ODI for functional disability, SF-36 for quality of life. The Kappa consistency test was performed on the classification results from the three observers, and the clinical data of each group was also statistically analyzed. Results: The Kappa of intra-observer agreement was 0.826-0.894, and the Kappa of intra-observer was 0.875-0.916, both of which were highly consistent. Of the 37 patients, 12 cases were open type(group A), 17 cases were parallel type(group B), and 8 cases were closed type(group C). There were significant differences of preoperative PT, SS and LL among the groups(P<0.05), and closed type had the lowest LL and SS in all subtypes(P<0.05), but no difference was found in PI and SVA(P>0.05). There was no significant change in spino-pelvic parameters of group A and B before and after surgery(P>0.05). While in group C, PT decreased, and SS, LL increased significantly(P<0.05). The preoperative VAS for low back pain in group C was significantly higher than those in the other two groups(P<0.05). The postoperative VAS for low back pain and leg pain, ODI, SF-36 scores were significantly improved(P<0.05). The improvement of VAS for low back pain, ODI and SF-36 mental component summary(MCS) scores in group C were greater than those in the other two groups(P<0.05). Conclusions: This new sagittal morphological classification system is a simple and reliable method for classifying DS cases, based on which the ALLIF treatment can achieve satisfactory clinical outcomes.