腰椎滑脱症外科治疗策略选择

The study on the surgical management of lumbar spondylolisthesis

目的探讨不同类型腰椎滑脱症及合并症的手术治疗方式、疗效及优缺点.方法2000年2月～2004年4月应用后路椎弓根螺钉复位内固定后,分别采用后外侧植骨融合术、后路椎体间植骨融合术及前路椎体间植骨融合术治疗不同类型腰椎滑脱症及合并症的患者78例,比较术后及随访时疗效、滑脱椎体复位率、椎间隙高度恢复率、植骨融合率以及复位丢失率.结果术后28例Ⅰ度滑脱及37例Ⅱ度腰椎滑脱患者获得解剖复位,9例Ⅱ度滑脱及4例Ⅲ度腰椎滑脱患者矫正至Ⅰ度滑脱.随访时总体优良率为89.72%,42例椎体间植骨患者植骨融合良好,滑脱椎体复位无丢失,椎间隙高度维持良好;36例后外侧植骨者有12例复位丢失,2例椎弓根螺钉松动,2枚椎弓根螺钉断裂.结论对小于Ⅱ度退变性腰椎滑脱合并腰椎管狭窄者宜选用后路椎弓根钉复位固定加后外侧植骨融合术;对峡部裂性腰椎滑脱合并腰椎管狭窄者宜选用后路椎弓根钉固定加椎体间植骨融合术;对Ⅱ度以上峡部裂性单纯腰椎滑脱者以及腰椎滑脱翻修者宜选用后路椎弓根钉固定加前路椎体间植骨融合术.

Objective To investigate the ideal surgical methods for the treatment of different types of lumbar spondylolisthesis and complications, and compare their therapeutical effects and indications. Methods 78 cases with different types of lumbar spondylolisthesis and complications were treated with posterior pedicle screw fixation combined with posterolateral bone graft fusion, posterior lumbar interbody fusion and anterior lumbar interbody fusion from February 2000 to April 2004. The therapeutical effect and the rates of lumbar spondylolithesis reduction, height recovery of disc space, bone graft fusion and loss of reduction were observed after operation and during the follow-up. Results 28 cases with one-degree lumbar spondylolisthesis and 37 cases with two-degree lumbar spondylolisthesis were reduced anatomically, and 9 cases with two-degree lumbar spondylolisthesis and 4 cases with three-degree lumbar spondylolisthesis were reduced to one-degree spondylolisthesis. During the follow-up, the total success rate was 89.72%. 42 cases with lumbar interbody fusion had good bone graft fusion, normal disc space and no loss of spondylolisthesis reduction. 12 cases with posterolateral bone graft fusion had loss of spondylolisthesis reduction to a certain extent, 2 cases had pedicle screws loosened and 2 cases had pedicle screws broken.Conclusion The patient with slight degenerative lumbar spondylolisthesis combined with spinal stenosis should be treated with posterior pedicle screw fixation and posterolateral bone graft fusion. The patient with severe lumbar broken isthmus spondylolisthesis combined with spinal stenosis should be treated with posterior pedicle screw fixation and lumbar interbody fusion. The patient with over two-degree lumbar broken isthmus spondylolisthesis and the revision should be treated with posterior pedicle screw fixation and anterior lumbar interbody fusion.