滑脱复位后路腰椎椎体间融合术治疗椎间隙完全塌陷型Ⅱ~Ⅲ度L5峡部裂性滑脱的疗效

Clinical effect of surgical reduction and posterior lumbar interbody fusion in treating grade Ⅱ-Ⅲ L5 isthmic spondylolisthesis with completely collapsed disc space

中文关键词:  腰椎滑脱  峡部裂  椎间隙塌陷  复位  椎间融合  矢状面参数

英文关键词:Lumbar spondylolisthesis  Sondylolysis  Collapsed disc space  Reduction  Interbody fusion  Sagittal parameters

中文摘要:

  【摘要】 目的：观察滑脱复位后路腰椎椎体间融合术（posterior lumbar interbody fusion，PLIF）治疗椎间隙完全塌陷型Ⅱ~Ⅲ度L5峡部裂性滑脱的疗效。方法：回顾性分析在我院接受滑脱复位PLIF治疗的49例椎间隙完全塌陷型Ⅱ~Ⅲ度L5滑脱患者的临床和影像学资料，男性22例，女性27例，年龄58.0±9.8岁。术后随访31.2±6.9个月，记录并比较患者手术并发症，术前、术后1个月和术后2年腰部和腿部视觉模拟评分（visual analog scale，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI），在站立位脊柱侧位X线片上测量滑移程度、骨盆入射角（PI）、骨盆倾斜角（PT）、骶骨倾斜角（SS）、腰椎前凸角（LL）、L1-L5前凸角（L1-5 L）和L5-S1前凸角（L5-S1 L）等参数。术前和术后2年以Hresko线Y=（0.844835X）＋25.021为界评估骨盆平衡状态。以SS为纵坐标Y，PT为横坐标X，每一个病例对应一个散点，49个病例构成散点图。散点位于Hresko线上方，对应的病例为骨盆平衡状态，位于Hresko线下方，则对应的病例为骨盆失衡状态。结果：49例患者均手术顺利，4例患者在术后出现暂时性腿痛，对症处理后均明显好转，1例患者在术后18个月时出现骶骨螺钉断裂，查CT示L5/S1节段已骨性融合，取出内固定，取出内固定后3个月复查时患者无明显腰腿痛。术后1个月及术后2年的VAS评分和ODI较术前均有显著下降（P<0.05）。术前和术后PI无明显差异（P>0.05）。SS从术前的41.6°±4.1°增加到术后2年的43.7°±4.5°（P<0.05），LL从术前的45.1°±9.8°增加到术后2年的52.2°±7.8°（P<0.05），L5-S1 L从术前的8.7°±2.6°增加到术后2年的21.8°±4.3°（P<0.05）。SP从术前54.3°±8.4°下降到术后2年的9.4°±3.1°（P<0.05），PT从术前18.3°±3.7°下降到术后2年的16.7°±4.0°（P<0.05）；L1-5 L从术前36.5°±8.3°下降到术后2年的31.4°±6.7°（P<0.05）。术前骨盆平衡31例，骨盆失衡18例；术后2年骨盆平衡42例，骨盆失衡7例，具有统计学差异（P<0.05）。结论：对于椎间隙完全塌陷型Ⅱ~Ⅲ度L5滑脱患者，复位联合PLIF可改善骨盆失衡状态，减少脊柱-骨盆代偿，获得满意的临床疗效。

英文摘要:

  【Abstract】 Objectives: To observe the effect of surgical reduction and posterior lumbar interbody fusion(PLIF) in treating grade Ⅱ-Ⅲ L5 isthmic spondylolisthesis(IS) with completely collapsed disc space. Methods: The imaging and clinical data of 49 patients with grade Ⅱ-Ⅲ L5 IS with completely collapsed disc space treated with surgical reduction and PLIF were reviewed. There were 22 males and 27 females, aged 58.0±9.8 years old, with a follow-up period of 31.2±6.9 months. The operational complications were recorded, and low back and leg pain visual analog scale(VAS) score, Oswestry disability index(ODI) preoperatively, 1 month and 2 years postoperatively were recorded and compared. The radiographic outcomes, including slippage percentage, pelvic incidence(PI), pelvic tilt(PT), sacral slope(SS), lumbar lordosis(LL), L1-L5 lordosis(L1-5L) and L5-S1 lordosis(L5-S1 L) were measured on standing lateral spinal X-rays preoperatively, 1 month and 2 years postoperatively. Before operation and at 2 years after operation the balance conditions of pelvis were evaluated according to Hresko line Y=（0.844835×X）+25.021. With SS as the Y-axis and PT as the X-axis, each case corresponded to a scatter point, and 49 cases constituted the scatter plot. When the scatter point was above the Hresko line, the corresponding case had a balanced pelvis, and when it was below the Hresko line, the corresponding case had an unbalanced pelvis. Results: The operation went smoothly in all the patients. Four patients experienced temporary leg pain after surgery, which improved significantly after symptomatic treatment. One patient experienced sacral screw fracture 18 months after surgery, and CT scan showed bone fusion in the L5/S1 segment. And the internal fixation was removed, and there was no significant low back or leg pain observed during the 3-month follow-up after removal of internal fixation. The VAS score and ODI at 1 month and 2 years after operation reduced significantly compared with those values before operation(P<0.05). No significant difference was observed between the preoperative and postoperative PIs(P>0.05). SS increased from 41.6°±4.1° before surgery to 43.7°±4.5° 2 years after surgery(P<0.05), LL increased from 45.1°±9.8° before surgery to 52.2°±7.8° 2 years after surgery(P<0.05), and L5-S1 L increased from 8.7°±2.6° before surgery to 21.8°±4.3° 2 years after surgery(P<0.05). SP decreased from 54.3°±8.4° preoperatively to 9.4°±3.1° 2 years postoperatively(P<0.05), PT decreased from 18.3°±3.7° preoperatively to 16.7°±4.0° 2 years postoperatively(P<0.05); L1-5 L decreased from 36.5°±8.3° before surgery to 31.4°±6.7° 2 years after surgery(P<0.05). There were 31 cases with balanced pelvis and 18 cases with imbalanced pelvis before operation, while there were 42 cases with balanced pelvis and 7 cases with imbalanced pelvis after operation, and the difference was statistically significant(P<0.05). Conclusions: In treating patients of grade Ⅱ-Ⅲ L5 IS with collapsed disc space, surgical reduction and PLIF can improve the imbalance conditions of pelvis, which can reduce spino-pelvic compensation and achieve satisfactory clinical results.