后路S1截骨复位融合术治疗青少年L5重度滑脱患者的远期疗效

Long-term outcome of posterior S1 osteotomy and reduction surgery on adolescent high-grade spondylolisthesis

目的:评估后路S1截骨复位融合术治疗青少年L5重度滑脱患者的远期疗效及影像学参数变化。方法:回顾性分析2008年1月~2015年1月于我院行后路S1截骨复位融合术治疗的青少年L5重度滑脱患者21例,其中男性13例,女性8例;年龄14.4±5.2岁(9~21岁),体质指数(body mass index,BMI)23.4±6.5kg/m2,随访时间73.7±11.3个月(60~96个月),术前滑脱Meyerding分度Ⅲ度13例,Ⅳ度5例,Ⅴ度3例。记录所有患者术前、术后6个月及终末随访时的滑移率、矢状面轴向垂直距离(sagittal vertical axis,SVA)、胸椎后凸角(thoracic kyphosis,TK)、腰椎前凸角(lumbar lordosis,LL)、骨盆投射角(pelvic incidence,PI)、骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)、腰骶后凸角(lumbaosacral angle,LSA)及腰痛视觉模拟评分(lumbar visual analogue scale,lumbar-VAS)、腿痛视觉模拟评分(leg visual analogue scale,leg-VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)、日本骨科协会(Japanese Orthopaedic Association,JOA)评分,并采用JOA评分评价临床治疗改善率,改善率≥50%者评定为优良。采用脊柱侧凸研究学会22项问卷表(scoliosis research society questionnaire-22,SRS-22),评估各组术前、术后6个月及终末随访时疼痛、自我形象、活动度、精神、治疗满意度评分。应用卡方检验、Fisher精确检验、独立样本t检验统计分析青少年重度腰椎滑脱经后路S1截骨复位融合术后的远期疗效。结果:末次随访JOA评分总优良率为80.95%,融合率95.23%,滑脱复位率(71.22±6.7)%,内固定断裂并假关节形成1例,予翻修手术。滑脱复位术后6个月较术前PT(24.7°±7.6°vs 34.3°±10.7°)、SS(48.2°±6.7°vs 38.4°±16.4°)、LL(-42.3°±9.4°vs-63.4°±12.4°)、LSA(-7.3°±5.4°vs18.3°±6.4°)、TK(18.6°±12.7°vs 9.4°±22.6°)、SVA(1.4±2.7cm vs 3.1±2.7cm)均显著改善(P<0.05),PI(73.2°±10.8°vs 73.6°±11.3°)较术前无明显变化(P<0.05)。终末随访较术后6个月PI(81.6°±13.7°vs 73.2°±10.8°)、PT(28.3°±8.6°vs 24.7°±7.6°)、SS(52.2°±13.3°vs 48.2°±6.7°)、LL(-56.4°±15.3°vs-42.3°±9.4°)改变有统计学意义(P<0.05),LSA(-7.1°±5.8°vs-7.3°±5.4°)、TK(15.4°±12.4°vs 18.6°±12.7°)、SVA(1.2±3.1cm vs 1.4±2.7cm)较术后6个月无统计学意义(P>0.05)。术后6个月腰痛VAS(1.8±1.4分vs 6.8±2.1分)、腿痛VAS(1.5±1.1分vs 5.4±1.3分)、JOA评分(22.5±5.7分vs 8.5±3.4分)、ODI[(15.2±5.5)%vs(42.6±7.5)%]、SRS-22疼痛(4.2±0.8分vs 2.8±0.8分)、自我形象(4.6±0.5分vs 3.1±0.6分)、活动度(4.3±0.6分vs 3.4±0.6分)、精神(4.2±0.6分vs 3.3±0.7分)、总评分(4.3±0.5分vs 3.2±0.4分)较术前均显著改善有统计学意义(P<0.05)。终末随访时,腰痛VAS(3.6±1.2分vs 1.8±1.4分)、SRS-22疼痛评分(3.7±0.6分vs 4.2±0.8分)较术后6个月增加并有统计学意义(P<0.05),余各项无明显变化(P>0.05)。结论:青少年L5重度滑脱患者行后路S1截骨复位融合术可有效改善临床症状及影像学矢状面序列。

Objectives:To analyze the long-term outcome and radiographic parameter changes of posterior S1 osteotomy and reduction surgery on adolescent high-grade L5 spondylolisthesis.Methods:21 cases of adolescent high-grade L5 spondylolisthesis who received posterior S1 osteotomy and reduction surgery between January 2008 and January 2015 in our medical center were retrospectively analyzed.There were a total of 13 males and 8 females with an average age of 14.4±5.2 years old and average BMI of 23.4±6.5 kg/m^2.The average follow up period was 73.7±11.3 months.The Meyerding classification status were as follows:13 cases of gradeⅢ,5 cases of gradeⅣ,and 3 cases of gradeⅤ.General epidemiological data includinglumbar-VAS,leg-VAS,ODI,JOA score,SRS-22 score and radiologic parameters of slippage rate,SVA,TK,LL,PI,PT,SS,and LSA at preoperation,6 months postoperatively and final follow-up were collected.Chi square test and independent sample T-test were used for statistical analysis of imaging parameters and SRS-22 questionnaire scores.Results:At final follow-up,the superior rate of JOA was 80.95%,the fusion rate was 95.23%.Amelioration of lumbar spondylolisthesis was 71.22%.One case developed screw breakage and received revision surgery.Comparing between parameters at 6 months follow-up and before surgery:PT(24.7°±7.6°vs 34.3°±10.7°),SS(48.2°±6.7°vs 38.4°±16.4°),LL(-42.3°±9.4°vs-63.4°±12.4°),LSA(-7.3°±5.4°vs 18.3°±6.4°),TK(18.6°±12.7°vs 9.4°±22.6°)and SVA(1.4±2.7 cm vs 3.1±2.7 cm)improved significantly(P<0.05);while PI(73.2°±10.8°vs 73.6°±11.3°,P>0.05)presented no significant change.Comparing between parameters at final followup and at 6 months follow-up:PI(81.6°±13.7°vs 73.2°±10.8°),PT(28.3°±8.6°vs 24.7°±7.6°),SS(52.2°±13.3°vs 48.2°±6.7°)and LL(-56.4°±15.3°vs-42.3°±9.4°)improved significantly(P<0.05):whiles LSA(-7.1°±5.8°vs-7.3°±5.4°),TK(15.4°±12.4°vs 18.6°±12.7°)and SVA(1.2±3.1 cm vs 1.4±2.7 cm)presented no significant change.Lumbar-VAS(1.8±1.4 vs 6.8±2.1),leg-VAS(1.5±1.1 vs 5.4±1.3),JOA(22.5±5.7 vs 8.5±3.4),ODI[(15.2±5.5)%vs(42.6±7.5)%],SRS-22 pain score(4.2±0.8 vs 2.8±0.8),self-image score(4.6±0.5 vs 3.1±0.6),activity score(4.3±0.6 vs 3.4±0.6),mental score(4.2±0.6 vs 3.3±0.7)and total score(4.3±0.5 vs 3.2±0.4)at the 6 months follow-up showed various dimensions changes compared with that preoperatively(P<0.05).Lumbar-VAS(3.6±1.2 vs 1.8±1.4)and SRS-22 pain score(3.7±0.6 vs 4.2±0.8)deteriorated at final follow-up(P<0.05).Conclusions:Posterior S1 osteotomy and reduction surgeryon adolescent high-grade spondylolisthesis could achieve satisfying clinical symptoms and sagittal alignment improvement at more than five years follow-up.