峡部延长型腰椎滑脱症的手术技巧

Surgical Skills For Spondylolisthesis of Elongation Of Pars Without Separation

目的：探讨峡部延长型腰椎滑脱症的手术技巧。方法单节段峡部延长型腰椎滑脱22例,L 32例,L 411例,L 59例。采用Wiltse入路置钉、切除双侧延长的下关节突、常规椎板间开窗减压、上连接棒、复位后行椎间融合,采用术后5d、3个月、6个月、12个月、24个月X线片进行影像学评价。采用腰椎JOA（29分法）评分评估患者腰椎活动功能。结果所有患者顺利完成手术,术中一次性复位15例（68%）,需要进一步切除关节突获得复位4例（18%）,调整螺钉深度获得复位3例（13%）。下关节突的大部分切除没有损伤关节突关节完整性19例,因关节突切除过多致关节突骨折和椎间孔后壁开放3例。行单侧椎板间开窗椎管扩大成形神经根减压椎间融合＋对侧下关节突切除20例,行双侧下关节突切除椎板间开窗椎管扩大成形神经根减压＋单侧入路椎间融合2例。采用下关节突骨块两枚行椎间支撑融合13例, Cage支撑融合9例。手术时间90~140 min,平均110 min。出血量300~670mL,平均470mL。术中无马尾、神经根损伤,术后脑脊液漏1例。所有患者均获随访,随访时间1年5月~9年8个月,平均3．6年。术后滑脱椎体复位率为92%,术后椎间隙高度为10．1mm,较术前增加3．4mm,植骨融合率100%,平均融合时间术后6个月,末次随访时滑脱复位程度及椎间隙高度无明显丢失。术前平均JOA评分14分,末次随访25分。结论①狭部延长型腰椎滑脱患者,Wiltse入路可获得椎弓根螺钉置入,下关节突切除,椎板间开窗,神经根减压,滑脱复位及椎间融合的良好手术视野和操作空间,并保留后方韧带复合体完整；②增生肥大的下关节突切除是确保滑脱复位的关键；③下关节突切除可获得足够的自体骨完成椎间融合,并可提供结构性支撑植骨。

Objective To study the surgical skills for spondylolisthesis of elongation of pars without separation. Methods There were 22 consecutive patients who all were single-level spondylolisthesis of elongation of pars,included 11 in level L4,9 in L5 and 2 in L3. The Wiltse approach was used to achieve fixation,resection of bilateral elongation inferior articular process,inter-laminal fenestration to decompress as routine,rod implantation,reduction and then fusion. Radiographic evaluation was made by X-ray at 5 days,3month,6m,12m and 24m after surgery. JOA score was adopted to assess the condition of lumbar spine. Results Each operation of all patients was finished successfully,15 （ 68%） cases were reduced satisfyingly for the first time,4 （ 18%） were forced to adopt further resection of inferior articularis process to achieve reduction and 3（13%） needed to adjust the depth of the insertion of pedicle screws to achieve reduction. There were 19 cases who underwent major resection of inferior articularis process without damage of the integrity of the facet joint,3 who underwent excessive resection of inferior articularis process and then resulted in the opening of posterior wall of the foramen, 20 who underwent interlaminal fenestration and nuero-elements decompres-sion and fusion monolaterally combined with resection of inferior articularis process at opposite side,2 who underwent interlaminal fenestration and nuero-elements decompression bilaterally combined with interbody fusion monolaterally. There were 13 cases who underwent interbody fusion with strut atuo-graft by two bone bulk which harvested by inferior articularis process,9 underwent fusion with cage insertion. There was 1 case with CSF leak after surgery. All patients were underwent follow-up of 3. 6 years. The mean reduction rate of slip was 92%,mean height of disc space was 10. 1 millimeter and 3. 4 mm higher than the height before opera-tion. All patients were achieved solid fusion at the last follow-up. Mean JOA score was 14 preoperatively,and 25 at the last fol-low-up. Conclusion ①For spondylolisthesis of elongation of pars,better vision and larger space for pedicle screw insertion,re-section of inferior articular process, interlaminal fenestration, root decompression, proper reduction and interbody fusion with the preserve of the intact posterior ligament complex could be achieved by using the Wiltse approach.②The resection of the hyperpla-sia inferior articular process is the key to achieve reduction.③resection of inferior articular process can provide enough strut bone graft and morselized bone graft.