青年战士腰椎峡部裂的分型与治疗

Classification and treatmentof lumbar spondylolysisin young soldiers

中文关键词:  腰椎峡部裂  分型  青年战士  峡部修复

英文关键词:Lumbar pondylolysis  Direct repair  Young soldier  Classification

中文摘要:

  【摘要】 目的：根据青年战士腰椎峡部裂临床特点及影像学表现进行分型，根据不同分型采用不同手术方式，评价治疗效果及并发症。方法：回顾性分析2010年3月~2016年12月期间，我科收治的青年战士腰椎峡部裂患者326例。均为男性，年龄18~36岁，平均22.4±5.1岁。根据临床特点和影像学表现将所有病例分为3型，A型为单纯型峡部裂，无椎间盘突出及腰椎滑脱；B型为峡部裂伴有轻度椎间盘突出或Ⅰ度滑脱，无神经压迫症状及体征；C型为峡部裂合并Ⅰ度或Ⅱ度滑脱并椎间盘突出同时有神经压迫症状及体征。影像学检查：术前均进行腰椎正侧位、左右斜位、站立位全长正侧位X线片，腰椎CT及矢状位重建，腰椎MRI检查。腰椎X线片观察腰椎峡部裂位置及滑脱情况，腰椎CT明确峡部裂的程度及位置。腰椎MRI观察腰椎间盘突出及神经压迫情况。手术方法：A型或B型病例采用椎弓根钉固定，有滑脱进行复位，清理峡部，取髂骨峡部原位植骨。C型病例采用后路椎板减压，椎间盘切除，椎间植骨融合椎弓根螺钉内固定术。术后半年、1年、1年半门诊随访，采用视觉模拟评分（VAS）评价腰痛情况，Oswestry功能障碍指数（ODI）评价功能改善情况。术后半年，1年，1年半，2年及以后进行CT及矢状位重建判断峡部愈合情况。结果：A型和B型病例共305例，C型21例。283例得到随访，通过平均20.0±7.8个月的随访，VAS由术前的平均5.6±1.1分降至终末随访的1.1±0.3分，ODI由术前的平均25.2±3.2分降至末次随访的5.3±1.7分。术后半年复查CT发现，A和B型病例峡部裂愈合252例，愈合率91%（252/278），平均愈合时间12个月，愈合后再次手术取出内固定。椎间植骨病例无需取出内固定。结论：青年战士A、B型腰椎峡部裂病例采用椎弓根螺钉固定，峡部自体髂骨原位植骨融合率高，效果好，C型战士峡部裂则宜采用后路椎间植骨融合椎弓根螺钉内固定术。

英文摘要:

  【Abstract】 Objectives: To classify lumbar spondylolysisin young soldiers according to the clinical features and imaging findings, and evaluate the therapeutic outcome and complications of different surgical methods. Methods: From March 2010 to December 2016, 326 cases of young soldiers with lumbar spondylolysis were admitted into our department. All were male, with an average age of 22.4±5.1 years(18-36 years). All patients were divided into three types according to clinical features and imaging findings as follows: Type A, simplex spondylolysis, no disc herniation or slippage; type B, spondylolysis with mild intervertebral disc herniation or degree Ⅰ slippage, without nerve compression symptoms and signs; type C, spondylolysis with degree Ⅰ or Ⅱ slippage and intervertebral disc herniation and accompanied with nerve compression symptoms and signs. Preoperative lumbar spine AP and lateral radiographs, left and right oblique radiographs, full-length standing AP and lateral radiographs, lumbar CT scan and sagittal reconstruction, and lumbar MRI were performed. The position of spondylolysis were evaluated using lumbar X-ray, and the diagnosis and position of spondylolysis were determined based on lumbar CT. Lumbar disc herniation and nerve compression status were assessed using MRI. Operation method: type A or type B cases were treated with pedicle screw fixation, slip reduction and in situ bone graft fusion. Type C cases were treated with posterior decompression and intervertebral disc excision, intervertebral bone graft fusion with pedicle screw fixation. Patients were followed up at 6 months, 1 year, 18 months and then every year after the operation. VAS was adopted to evaluate back pain. Lumbar disability function was evaluated with ODI. CT and sagittal reconstruction were performed at 6 months, one year, 18 months, and 2 years after the operation. Results: Type A and type B include 305 cases, type C 21 cases. A total of 283 cases were followed up. At an average follow-up of 20.0±7.8 months, the average VAS was decreased from 5.6±1.1 points before surgery to 1.1±0.3 points at the last follow-up, and the average ODI was decreased from 25.2±3.2 points before surgery to 5.3±1.7 points. Six months after operation, we found isthmus union on CT scan in 252 type A and type B cases with the healing rate of 91%(252/278), the average healing time was 12 months, and internal fixation were removed after healing. No removal of internal fixation was required in the cases of intervertebral bone grafting. Conclusions: Type A and type B cases of lumbar spondylolysis in young soldiers can be treated using pedicle screw fixation, and iliac crest autograft in isthmus may achieve satisfying fusion rate. For type C patients, posterior intervertebral bone grafting and pedicle screw fixation were appropriate.