重度腰椎滑脱的治疗

Treatment of Severe Lumbar Spondylolisthesis

作者报告２６例Ⅲ度以上腰椎滑脱患者的手术治疗，其中Ⅲ度１４例，Ⅳ度１０例，Ⅴ度２例。病理分型为退行性及峡部裂滑脱。滑脱平面为Ｌ４，５及Ｌ５Ｓ１。病史２～７年，平均３．５年。手术指征以临床症状体征为主，影像学检查均证实为Ⅲ度以上滑脱。２４例患者采取后路双侧小关节及椎板切除彻底减压，ＲＦ－Ⅱ型椎弓根螺钉系统复位固定，其中４例加ＢＡＫ椎间植骨融合器，２４例后路一次手术完成减压复位、椎间植骨融合内固定。２例（Ｖ度）行前后路联合手术，先期前路手术切除坠落于骶骨前的滑椎，二期手术将滑椎的上位椎体与骶骨相连接，恢复脊柱序列，ＲＦ－Ⅱ型内固定，椎间植骨融合。术后本组２６例全部达到解剖复位，无感染。除１例Ⅴ度滑脱术后出现暂时性Ｌ４，５、Ｌ５Ｓ１神经根牵拉症状外，余患者无神经系统功能恶化。所有病人原有症状均获得不同程度改善，其中优６例，良１８例，可２例。本组随访１２～３８个月，平均１８个月，随访中椎体间植骨融合良好，无复位丢失，患者情况稳定。Ｘ线片显示椎间植骨融合良好，螺钉无折断，无其它远期并发症。因此，在重度滑脱的治疗中，走出传统减压仅行椎板切除的误区，以小关节为中心进行彻底减压，是椎弓根螺钉系统复位后不产生新的症状的关键。?

Twenty-six patients with severe lumbar spondylolisthesis were studied. The duration of follow-up ranged from 12 to 38 months, with an average of 18 months. The mean age of the patients at surgery was 46.2 years(range, 22 to 56 years). Fourteen patients were classified as degree Ⅲ lesion, 10 as degree IV lesion and 2 as degree Vlesion. Degenerative spondylolisthesis was found in 16,is thmic in 8 and post traumatic in 2. L4,5 involvement occurred in 16and L5S1 in 10. All of the cases had neurological deficit preoperatively. The surgery included laminectomy and facectomy in both sides for complete decompression of the dural and nerve roots associated with RF-Ⅱ pedicle screw system for reduction and fixation. The interbody fusion was also performed before pedicle screw fixation by use of autografting. BAK cage was added in 4 of the patients for fusion. For the 2 cases with degreeⅤ lesion,the surgery was divided into two stages.The vertebral body of L5。was removed firstly through anterior approach, and then the reduction of L4 on the top of S1, pedicle screw fixation and interbody fusion were performed one week later. At the latest follow up, there was no lost of correction in all patients. Twenty four patients had satisfactory pain relief and there were no complications of neurological deterioration andpse udoarthroses in this series.The authors considered that bilateral facectomy with laminectomy was very important for complete decompression, anatomic reduction and interbody fusion.