腰椎后路减压内固定术后远端交界性峡部裂滑脱的危险因素分析及治疗选择

Risk factors and management of distal junctional isthmic spondylolisthesis after posterior lumbar decompression with instrumented fusion

中文关键词:  腰椎减压固定融合术  机械性并发症  远端交界性失败  峡部裂滑脱  翻修手术

英文关键词:Lumbar decompression and fusion  Mechanical complications  Distal junctional failure  Spondylolysis spondylolisthesis  Revision operation

中文摘要:

  【摘要】 目的：探讨腰椎后路减压内固定术后远端交界性峡部裂滑脱（distal junctional isthmic spondylolisthesis，DJIS）发生的危险因素及治疗方式。方法：回顾性分析2015年1月~2022年1月在我院接受治疗的10例后路减压内固定术后发生DJIS的患者，男7例，女3例；年龄45~75岁（63.4±10.3岁），纳入DJIS组。按照年龄、性别、术前诊断、手术节段及手术方式匹配，以1∶2比例选取同期因腰椎退变性疾病在我院接受后路减压内固定术但未出现DJIS的患者作为对照组（20例）。比较两组患者的一般资料[体重指数（body mass index，BMI）、L1椎体CT值、骨质疏松患者比例]、下端椎椎板切除范围（下端椎椎板横向减压百分比、棘突切除百分比）、初次手术后骨盆入射角（pelvic incidence，PI）、腰椎前凸角（lumbar lordosis，LL）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（sacral slope，SS）等，分析腰椎后路减压内固定术后DJIS发生的危险因素，总结腰椎后路减压内固定术后DJIS的治疗方法。结果：DJIS组患者的BMI显著性高于对照组（27.4±4.1kg/m2 vs. 23.7±3.4kg/m2，P<0.001），L1椎体CT值显著性低于对照组（105.2±43.9HU vs. 133.5±23.5HU，P=0.028），骨质疏松患者比例高于对照组（70% vs. 10%，P=0.003）。DJIS组患者的PI（52.5±8.8° vs. 45.8±7.4°，P<0.05）和初次术后LL（47.4±14.3° vs. 36.5±10.6°，P<0.05）均显著性高于对照组，PT和SS两组无显著性差异（P>0.05）；下端椎椎板横向减压百分比[（89.3±9.0）% vs. （78.0±3.2）%，P<0.05]和下端椎棘突切除百分比[（51.1±16.1）% vs. （39.3±9.1）%，P<0.05]显著性高于对照组。8例DJIS患者行远端减压、滑脱复位固定融合术，翻修术后生活质量评分显著性改善；2例临床症状不重，采取保守治疗，随访过程未诉症状加重。结论：高BMI、骨质疏松、高PI以及术中远端椎椎板切除范围过广是腰椎后路减压内固定术后发生DJIS的可能危险因素。

英文摘要:

  【Abstract】 Objectives: To investigate the risk factors and treatment methods for distal junctional isthmic spondylolisthesis(DJIS) following posterior lumbar decompression and fixation surgery. Methods: The 10 patients who were treated at our hospital for DJIS following posterior decompression and fixation between January 2015 and January 2022 were retrospectively analyzed. The patients were included in the DJIS group, including 7 males and 3 females, aged 63.4±10.3(45-75) years old. And according to age, gender, preoperative diagnosis, operative stage, and operative method, the patients were matched in a ratio of 1∶2 with some other patients who didn′t develop DJIS after underwent posterior decompression and fixation at our hospital due to lumbar degenerative diseases during the same period as control(20 cases). The general data[body mass index(BMI), L1 CT value, proportion of patients with osteoporosis)], laminectomy range of the lower vertebra(transverse decompression percentage of lamina, spinous process resection percentage), pelvic incidence(PI), and postoperative lumbar lordosis(LL), pelvic tilt(PT), sacral slope(SS), etc. of the two groups were compared to explore the risk factors for DJIS after posterior lumbar decompression and fixation. The treatment methods for DJIS were also summarized. Results: The BMI of patients in the DJIS group was significantly higher than that of the control group(27.4±4.1kg/m2 vs. 23.7±3.4kg/m2, P<0.001). The L1 vertebral CT value of the DJIS group was significantly lower than that of the control group(105.2±43.9HU vs. 133.5±23.5HU, P=0.028), and the proportion of patients with osteoporosis of the DJIS group was higher(70% vs. 10%, P=0.003). The DJIS group was greater in PI(52.5°±8.8° vs. 45.8°±7.4°, P<0.05) and postoperative LL(47.4°±14.3° vs. 36.5°±10.6°, P<0.05) significantly than the control group, PT and SS were not significantly different between the two groups(P>0.05). Additionally, the transverse decompression percentage of lamina of the lower vertebra[(89.3±9.0)% vs. (78.0±3.2)%, P<0.05] and the spinous process resection percentage of the distal vertebra[(51.1±16.1)% vs. (39.3±9.1)%, P<0.05] in the DJIS group were also significantly higher than those in the control group. Eight DJIS patients underwent distal decompression, reduction, fixation, and fusion surgery, and their quality of life scores significantly improved after revision surgery. Two DJIS cases with mild clinical manifestations were treated conservatively, no symptom exacerbation was reported during follow-up. Conclusions: High BMI, osteoporosis, high PI, and excessive distal vertebral lamina resection during surgery are potential risk factors for DJIS after posterior lumbar decompression and fixation.