经后路S1截骨短节段固定联合360°环形融合治疗青少年重度峡部发育不良性滑脱

S1 osteotomy L5-S1 monosegmental instrumented reduction and 360 degrees circumferential fusion for severe adolescent isthmic dysplastic spondylolisthesis

目的 ：探讨经后路S1截骨L5-S1短节段内固定复位及360°环形融合术治疗青少年重度峡部发育不良性滑脱的优缺点及安全性。方法：2007年9月~2014年9月湘雅二医院共收治10例青少年重度L5峡部发育不良性滑脱患者,年龄15.8±2.6岁（12.5~18.0岁）,均行后路S1截骨L5-S1短节段内固定复位,通过后外侧植骨和前路小切口椎间植骨完成360°环形植骨融合。分析手术前后Oswestry功能障碍指数（ODI）、VAS疼痛评分,脊柱全长X线片上测量脊柱-骨盆参数,包括滑脱百分比、骨盆入射角（PI）、骶骨倾斜角（SS）、骨盆倾斜角（PT）、腰椎前凸角（LL）、胸椎后凸角（TK）、髋关节-S1后角距离（SFD）、C7铅垂线骶骨后角距离（SC7D）、T9倾斜角、腰骶角（Dub-LSA）及腰骶关节角（LSJA）,观察矫正效果。结果：术后随访时间为38±6个月,脊柱-骨盆参数手术前及末次随访时变化如下：滑脱百分比由（78±17.5）%减至（4.5±4.2）%。PI值术前术后无明显变化,均为74.5±9.6°。SS由45.1°±8.5°增至49.2°±9.1°,PT由29.4°±8.4°减至25.3°±6.3°,LL由65.0°±10.3°减至50.2°±8.8°,TK由24.8°±7.1°增至37.2°±7.6°,SFD由58.1±12.4mm减至54.2±11.9mm,SC7D由51.6±37.8mm减至18.7±30.2mm,T9倾斜角由8.2°±4.8°减至1.5°±4.5°,Dub-LSA由76.6°±11.3°增至110.3°±12.4°,LSJA由32.1°±19.4°减至1.7°±12.3°。术后半年患者ODI由（60±7.4）%降为（9.5±2.1）%,VAS疼痛评分由7.2±1.1降为1.8±0.5。所有患者均无永久性神经损害、肌肉萎缩、假关节形成及内固定失败等并发症。1例患者术后发生脑脊液漏,延长引流管放置时间至1周,伤口愈合可,无继发感染。2例患者出现下肢暂时性放射痛,经过理疗后逐渐消失。结论：经后路S1截骨L5-S1短节段内固定复位及360°环形融合术治疗青少年重度滑脱安全、有效,减少术后神经系统并发症的发生,并且可恢复脊柱-骨盆矢状位平衡。

Objectives： Discuss the advantages, disadvantages and security of S1 osteotomy L5-S1 monoseg-mental instrumented reduction and 360 degrees circumferential fusion for severe adolescent isthmic spondy-lolisthesis. Methods： Ten adolescent patients with severe isthmic spondylolisthesis treated between September2007 and September 2014 in the second Xiangya hospital of Central South University. All patients were av-erage 15.8±2.6 years（12.5-18.0 years） and were treated by S1 osteotomy L5-S1 monosegmental instrumented reduction and 360 degrees circumferential fusion. The preoperative and postoperative Oswestry disability index（ODI）, visual analog scale（VAS） pain score and spino-pelvic parameters measured using full-spine radiographs were retrospectively analyzed. Including the mean degree of slip, pelvic incidence（PI）, sacral slope（SS）, pelvic tilt（PT）, lumbar lordosis（LL）, thoracic kyphosis（TK）, sacro-femoral distance（SFD）, the horizontal distance be-tween C7 plumb line and the posterior corner of the sacrum（SC7D）, T9 tile angle, dubousser lumbosacral an-gle（Dub-LSA）, lumbosacral joint angle（LSJA）. Results： The average follow-up time was 38 ±6 months. The mean degree of slip was reduced from（78±17.5）% preoperative to（4.5±4.2）% postoperative. PI didn′t had obvious change, remained 74.5°±9.6°. SS increased from 45.1°±8.5° to 49.2°±9.1° and PT decreased from29.4°±8.4° to 25.3°±6.3°. LL decreased from 65.0°±10.3° to 50.2°±8.8°, TK increased from 24.8°±7.1° to37.2°±7.6°, SFD decreased from 58.1±12.4mm to 54.2±11.9mm, SC7 D decreased from 51.6±37.8mm to 18.7±30.2mm, T9 tilting angle decreased from 8.2°±4.8° to 1.5°±4.5°, Dub-LSA increased from 76.6°±11.3° to110.3°±12.4°, LSJA decreased from 32.1°±19.4° to 1.7°±12.3°. At the half year follow-up, the ODI decreased from（60±7.4）% to（9.5 ±2.1）%, and the VAS pain score decreased from 7.2 ±1.1 to 1.8 ±0.5. There were no permanent neurological injury, pseudarthrosis, muscular atrophy and no implant failures. One case appeard postoperative cerebrospinal fluid leakage, prolong drainage tube standing time to a week, wounds were healing well, without secondary infection. Only two patient had radicular pain in hip to back of the thighs postoperative a half year, which recovered fully with physical therapy. Conclusions： S1 osteotomy L5-S1 monosegmental instrumented reduction and 360 degrees circumferential fusion is a safe and effective surgical technique.This surgical technique can decrease neurological complications during reduction and restore sagittal profile of the spine.