后路復位技術在重度腰椎滑脫癥治療中的應用_《中國修復重建外科雜志》

作者：

龔全 , 孔清泉 , 李濤 , 曾建成 , 劉立岷 , 劉浩 , 宋躍明

四川大學華西醫院骨科（成都，610041）;

關鍵詞：

重度腰椎滑脫癥后路復位神經根牽張損傷

DOI：

10.7507/1002-1892.20130093

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目的總結分析經后路復位治療重度腰椎滑脫癥的復位技巧，并探討神經牽張損傷預防方法。方法回顧性分析2007年7月－2011年4月收治且隨訪資料完整的17例重度腰椎滑脫癥患者臨床資料。其中男2例，女15例；年齡8～67歲，中位年齡15歲。病程5個月～16年4個月，中位病程18個月。重度腰椎滑脫部位：L4 1例，L5 16例。滑脫Meyerding分度為Ⅲ度12例，Ⅳ度5例。16例為發育性滑脫，其中高度發育不良型9例，低度發育不良型7例；1例為L5創傷性滑脫。16例L5椎體滑脫根據腰骶椎滑脫國際脊柱畸形學會（SDSG）標準分型，4型6例，5型9例，6型1例。患者均行后路椎管減壓、雙向Schanz釘固定并復位滑脫椎體、椎間及后外側聯合植骨融合，以及糾正腰骶部畸形。根據出行神經根張力調整復位幅度，原則上復位要糾正至MeyerdingⅡ度以內。手術前后攝站立位全脊柱正側位X線片（包括雙側股骨頭）分析手術前后椎體滑脫幅度和腰骶角糾正情況；疼痛視覺模擬評分（VAS）評估術后神經根減壓情況；CT三維重建評價植骨融合情況。結果術后除1例出現L5神經根麻痹癥狀，4周后自行緩解外，其余患者均無神經損害加重。術后切口均Ⅰ期愈合。17例均獲隨訪，隨訪時間12～48個月，平均25個月。椎體滑移百分比、腰骶角、下肢疼痛VAS評分分別由術前的72% ± 10%、（18.2 ± 3.5）°、（7.0 ± 1.5）分改善至術后12個月的12% ± 6%、（— 7.3 ± 2.9）°、（1.5 ± 1.3）分，差異均有統計學意義（P lt; 0.05）。術后12個月CT三維重建均可見植骨區成熟骨橋生長，未發現斷釘、斷棒和復位丟失情況。結論采用后路椎管減壓、雙向Schanz釘固定復位滑脫椎體、椎間及后外側聯合植骨融合治療重度腰椎滑脫臨床結果滿意。通過降低復位后椎間高度、術中根據神經根張力情況調整滑脫椎體復位幅度、糾正腰骶后凸畸形等措施，可預防神經根牽張損傷。

引用本文： 龔全,孔清泉,李濤,曾建成,劉立岷,劉浩,宋躍明. 后路復位技術在重度腰椎滑脫癥治療中的應用. 中國修復重建外科雜志, 2013, 27(4): 393-398. doi: 10.7507/1002-1892.20130093 復制

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2.	Molinari RW, Bridwell KH, Lenke LG, et al. Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches. Spine (Phila Pa 1976), 1999, 24(16): 1701-1711.
3.	Schoenecker PL, Cole HO, Herring JA, et al. Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction. J Bone Joint Surg (Am), 1990, 72(3): 369-377.
4.	Seitsalo S, Osterman K, Hyvarinen H, et al. Severe spondylolisthesis in children and adolescents. A long-term review of fusion in situ. J Bone Joint Surg (Br), 1990, 72(2): 259-265.
5.	Albrecht S, Kleihues H, Gill C, et al. Repositioning injuries of nerve root L5 after surgical treatment of high degree spondylolistheses and spondyloptosis—in vitro studies. Z Orthop Ihre Grenzgeb, 1998, 136(2): 182-191.
6.	Lamartina C, Zavatsky JM, Petruzzi M, et al. Novel concepts in the evaluation and treatment of high-dysplastic spondylolisthesis. Eur Spine J, 2009, 18 Suppl 1: 133-142.
7.	Petraco DM, Spivak JM, Cappadona JG, et al. An anatomic evaluation of L5 nerve stretch in spondylolisthesis reduction. Spine (Phila Pa 1976), 1996, 21(10): 1133-1139.
8.	Poussa M, Remes V, Lamberg T, et al. Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ: long-term clinical, radiologic, and functional outcome. Spine (Phila Pa 1976), 2006, 31(5): 583-592.
9.	Martiniani M, Lamartina C, Specchia N. “In situ” fusion or reduction in high-grade high dysplastic developmental spondylolisthesis (HDSS). Eur Spine J, 2012, 21 Suppl 1: S134-140.
10.	Bourghli A, Aunoble S, Reebye O, et al. Correlation of clinical outcome and spinopelvic sagittal alignment after surgical treatment of low-grade isthmic spondylolisthesis. Eur Spine J, 2011, 20 Suppl 5: 663-668.
11.	Harroud A, Labelle H, Joncas J, et al. Global sagittal alignment and health-related quality of life in lumbosacral spondylolisthesis. Eur Spine J, 2012. [Epub ahead of print].
12.	Schuller S, Charles YP, Steib JP. Sagittal spinopelvic alignment and body mass index in patients with degenerative spondylolisthesis. Eur Spine J, 2011, 20(5): 713-719.
13.	Labelle H, Mac-Thiong JM, Roussouly P. Spino-pelvic sagittal balance of spondylolisthesis: a review and classification. Eur Spine J, 2011, 20 Suppl 5: 641-646.
14.	Lamartina C, Berjano P, Petruzzi M, et al. Criteria to restore the sagittal balance in deformity and degenerative spondylolisthesis. Eur Spine J, 2012, 21 Suppl 1: S27-31.
15.	Shufflebarger HL, Geck MJ. High-grade isthmic dysplastic spondylolisthesis: monosegmental surgical treatment. Spine (Phila Pa 1976), 2005, 30(6 Suppl): S42-48.
16.	Karampalis C, Grevitt M, Shafafy M, et al. High-grade spondylolisthesis: gradual reduction using Magerl’s external fixator followed by circumferential fusion technique and long-term results. Eur Spine J, 2012, 21 Suppl 2: S200-206.
17.	Lonner BS, Song EW, Scharf CL, et al. Reduction of high-grade isthmic and dysplastic spondylolisthesis in 5 adolescents. Am J Orthop (Belle Mead NJ), 2007, 36(7): 367-373.
18.	Kawakami M, Tamaki T, Ando M, et al. Lumbar sagittal balance influences the clinical outcome after decompression and posterolateral spinal fusion for degenerative lumbar spondylolisthesis. Spine (Phila Pa 1976), 2002, 27(1): 59-64.
19.	Min K, Liebscher T, Rothenfluh D. Sacral dome resection and single-stage posterior reduction in the treatment of high-grade high dysplastic spondylolisthesis in adolescents and young adults. Eur Spine J, 2012, 21 Suppl 6: S785-791.
20.	Ruf M, Koch H, Melcher RP, et al. Anatomic reduction and monosegmental fusion in high-grade developmental spondylolisthesis. Spine (Phila Pa 1976), 2006, 31(3): 269-274.
21.	Labelle H, Roussouly P, Berthonnaud E, et al. Spondylolisthesis, pelvic incidence, and spinopelvic balance: a correlation study. Spine (Phila Pa 1976), 2004, 29(18): 2049-2054.
22.	Mac-Thiong JM, Wang Z, de Guise JA, et al. Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis. Spine (Phila Pa 1976), 2008, 33(21): 2316-2325.
23.	王宇, 彭雄奇. 腰椎椎間植骨融合有限元分析. 力學學報, 2011, 43(2): 381-389.
24.	Vialle R, Dauzac C, Khouri N, et al. Sacral and lumbar-pelvic morphology in high-grade spondylolisthesis. Orthopedics, 2007, 30(8): 642-649.

1. Kasliwal MK, Smith JS, Shaffrey CI, et al. Short-term complications associated with surgery for high-grade spondylolisthesis in adults and pediatric patients: a report from the scoliosis research society morbidity and mortality database. Neurosurgery, 2012, 71(1): 109-116.
2. Molinari RW, Bridwell KH, Lenke LG, et al. Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches. Spine (Phila Pa 1976), 1999, 24(16): 1701-1711.
3. Schoenecker PL, Cole HO, Herring JA, et al. Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction. J Bone Joint Surg (Am), 1990, 72(3): 369-377.
4. Seitsalo S, Osterman K, Hyvarinen H, et al. Severe spondylolisthesis in children and adolescents. A long-term review of fusion in situ. J Bone Joint Surg (Br), 1990, 72(2): 259-265.
5. Albrecht S, Kleihues H, Gill C, et al. Repositioning injuries of nerve root L5 after surgical treatment of high degree spondylolistheses and spondyloptosis—in vitro studies. Z Orthop Ihre Grenzgeb, 1998, 136(2): 182-191.
6. Lamartina C, Zavatsky JM, Petruzzi M, et al. Novel concepts in the evaluation and treatment of high-dysplastic spondylolisthesis. Eur Spine J, 2009, 18 Suppl 1: 133-142.
7. Petraco DM, Spivak JM, Cappadona JG, et al. An anatomic evaluation of L5 nerve stretch in spondylolisthesis reduction. Spine (Phila Pa 1976), 1996, 21(10): 1133-1139.
8. Poussa M, Remes V, Lamberg T, et al. Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ: long-term clinical, radiologic, and functional outcome. Spine (Phila Pa 1976), 2006, 31(5): 583-592.
9. Martiniani M, Lamartina C, Specchia N. “In situ” fusion or reduction in high-grade high dysplastic developmental spondylolisthesis (HDSS). Eur Spine J, 2012, 21 Suppl 1: S134-140.
10. Bourghli A, Aunoble S, Reebye O, et al. Correlation of clinical outcome and spinopelvic sagittal alignment after surgical treatment of low-grade isthmic spondylolisthesis. Eur Spine J, 2011, 20 Suppl 5: 663-668.
11. Harroud A, Labelle H, Joncas J, et al. Global sagittal alignment and health-related quality of life in lumbosacral spondylolisthesis. Eur Spine J, 2012. [Epub ahead of print].
12. Schuller S, Charles YP, Steib JP. Sagittal spinopelvic alignment and body mass index in patients with degenerative spondylolisthesis. Eur Spine J, 2011, 20(5): 713-719.
13. Labelle H, Mac-Thiong JM, Roussouly P. Spino-pelvic sagittal balance of spondylolisthesis: a review and classification. Eur Spine J, 2011, 20 Suppl 5: 641-646.
14. Lamartina C, Berjano P, Petruzzi M, et al. Criteria to restore the sagittal balance in deformity and degenerative spondylolisthesis. Eur Spine J, 2012, 21 Suppl 1: S27-31.
15. Shufflebarger HL, Geck MJ. High-grade isthmic dysplastic spondylolisthesis: monosegmental surgical treatment. Spine (Phila Pa 1976), 2005, 30(6 Suppl): S42-48.
16. Karampalis C, Grevitt M, Shafafy M, et al. High-grade spondylolisthesis: gradual reduction using Magerl’s external fixator followed by circumferential fusion technique and long-term results. Eur Spine J, 2012, 21 Suppl 2: S200-206.
17. Lonner BS, Song EW, Scharf CL, et al. Reduction of high-grade isthmic and dysplastic spondylolisthesis in 5 adolescents. Am J Orthop (Belle Mead NJ), 2007, 36(7): 367-373.
18. Kawakami M, Tamaki T, Ando M, et al. Lumbar sagittal balance influences the clinical outcome after decompression and posterolateral spinal fusion for degenerative lumbar spondylolisthesis. Spine (Phila Pa 1976), 2002, 27(1): 59-64.
19. Min K, Liebscher T, Rothenfluh D. Sacral dome resection and single-stage posterior reduction in the treatment of high-grade high dysplastic spondylolisthesis in adolescents and young adults. Eur Spine J, 2012, 21 Suppl 6: S785-791.
20. Ruf M, Koch H, Melcher RP, et al. Anatomic reduction and monosegmental fusion in high-grade developmental spondylolisthesis. Spine (Phila Pa 1976), 2006, 31(3): 269-274.
21. Labelle H, Roussouly P, Berthonnaud E, et al. Spondylolisthesis, pelvic incidence, and spinopelvic balance: a correlation study. Spine (Phila Pa 1976), 2004, 29(18): 2049-2054.
22. Mac-Thiong JM, Wang Z, de Guise JA, et al. Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis. Spine (Phila Pa 1976), 2008, 33(21): 2316-2325.
23. 王宇, 彭雄奇. 腰椎椎間植骨融合有限元分析. 力學學報, 2011, 43(2): 381-389.
24. Vialle R, Dauzac C, Khouri N, et al. Sacral and lumbar-pelvic morphology in high-grade spondylolisthesis. Orthopedics, 2007, 30(8): 642-649.

《中國修復重建外科雜志》

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《中國修復重建外科雜志》

后路復位技術在重度腰椎滑脫癥治療中的應用

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