成人腰椎峡部裂型滑脱症的微创治疗

Minimally invasive surgical management and strategies for adult isthmic spondylolisthesis

目的探讨成人腰椎峡部裂型滑脱症的微创外科治疗方法与临床效果。方法成人峡部裂型腰椎滑脱症患者21例，男12例，女9例；年龄29-73岁，平均51．7岁；L4、5滑脱7例，L5S1滑脱14例；双侧峡部裂19例，单侧2例。根据Meyerding分级：Ⅰ度滑脱13例，Ⅱ度滑脱7例，Ⅲ度滑脱1例。患者全麻，经后路双侧旁中央26mm切口，在内镜辅助下行单侧或双侧椎管减压、椎间植骨cage融合、新型Sextant—R经皮椎弓根螺钉系统复位与内固定。结果平均手术时间170min，平均出血量160ml，平均卧床时间7．5d，平均住院时间19d。20例患者获得随访，随访时间4-32个月，平均12．5个月。术后1年随访17例，患者VAS腰痛评分从术前平均（6．0±2．6）分降至（2．9±2．5）分；VAS腿痛评分从术前平均（6．7±3．3）分降至（2．8±1．6）分；Oswestry功能指数从术前平均44.3％降至27．1％；Nakai分级优良率90％。矢状面X线片腰椎滑脱率从术前35．5％±2．5％降至8．3％±7．5％，滑脱椎的腰前凸角从术前平均11．50±1．7。增至16．8°±9．5°，椎间隙平均高度从术前（5．4±2．5）mm增至（9．1±3．0）mm。根据Lenke动态X线片评估标准：13例（76％）椎间骨性融合、2例（12％）椎间部分骨性融合、2例（12％）椎间无明显骨性融合。3例发生并发症。结论内镜辅助下后路腰椎管减压、椎间植骨cage融合及经皮椎弓根螺钉系统复位与内固定治疗成人峡部裂型腰椎滑脱症手术创伤小，近期临床疗效好。

Objective To investigate the clinical experiences and technical skills of adult isthmic spondylolisthesis. Methods Twenty-one patients with adult isthmic spondylofisthesis underwent minimally invasive surgery. There were 12 men and 9 women, with the mean age of 51.7 years. Isthmic spondylolisthesis occurred at the L 4.5 in 7 patients, and at the L5S1 in 14 patients. According to Meyerding classification, 13 cases were of Grade Ⅰ , 7 of Grade Ⅱ, 1 of Grade Ⅲ. Under general anesthesia, guiding by fluoroscopy, the surgeries performed minimally invasive microendoscopic（METRx） techniques for posterior decompression, interbody cage fusion and novel Sextant-R percutaneous pedicle screw techniques for deformity reduction and fixation. Results Seventeen cases were followed up I year postoperatively. The average low back pain VAS reduced from preoperative 6.0±2.6 to postoperative 2.9±2.5. The average leg pain VAS decreased from preoperative 6.7±3.3 to postoperative 2.8±1.6. The average ODI decreased from preoperative 44.3% to postoperative 27.1%. The Nakai good and excellent rate was 90%. The mean operative time 170 min, blood loss 160 ml, and postoperative stay in bed 7.5 d. The sagittal spondylolisthesis rate significantly decreased from preoperative 35.5%±2.5% to postoperative 8.3%±7.5%. The lordotic angle from preoperative 11.5°±1.7° increased to postoperative 16.8°±9.5°; the intervertebral disc height from preoperative （5.4±2.5） mm increased to postoperative （9.1±3.0）mm. According to Lenke judgement for fusion, complete fusion rate was 76%, incomplete fusion rate was 12%, nonfusion rate was 12%. Conclusion The minimally invasive microendoscopic （METRx） assisted with a novel Sextant-R percutaneous pediele screw systems for deformity reduction and fixation to treat adult isthmie spondylolisthesis, is not only a minimally invasive and safe surgical technique, also an effective treatment for deformity reduction and fixation.