三种椎间融合术治疗峡部裂致椎体轻度滑移的比较研究

Comparative study of three surgical procedures of lumbar interbody fusion for adult low-grade isthmic spondylolisthe

目的比较前路腰椎椎体间融合术（anteriorlumbarinterbodyfusion，ALIF）、后路椎体间融合术（posteriorlumbarinterbodyfusion，PLIF）、经椎间孔椎体间融合术（transforaminallumbarinterbodyfusion，TLIF）治疗椎弓根峡部裂导致的椎体轻度滑移的临床疗效和影像学改变。方法回顾性分析2004年5月至2014年5月因腰椎椎弓根峡部裂导致的椎体轻度滑移而接受椎间融合术患者70例。根据患者术前临床症状、神经压迫情况、大血管分叉位置和椎间隙前方“血管窗”宽度采用不同的手术方式，其中采用ALIF21例[男13例，女8例；年龄29-53岁，平均（43．29±8．15）岁；MeyerdingI级10例，Ⅱ级11例；L4．5 10例，L5S111例]，采用PLIF25例[男12例，女13例；年龄25-64岁，平均（44．04±12．71）岁；MeyerdingI级15例，Ⅱ级10例；L4.5 12例，L5S1 13例]，采用TLIF24例[男12例，女12例；年龄34-62岁，平均（45．00±9．36）岁；MeyerdingI级11例，Ⅱ级13例；L4.5 12例，L5S1 12例]。结果患者随访时间24-37个月，平均（25．6±8．7）个月。ALIF、PLIF、TLIF组视觉模拟评分（visualanaloguescale，VAS）分别由术前平均（7．05±0．87）分、（6．60±1．39）分、（6．75±1．11）分降至术后24个月平均（0．90±0．70）分、（0．96±0．68）分、（1．04±0．62）分；三组Oswestry功能障碍指数（Oswestrydisabilityidex，ODI）分别由术前平均78．53％±6．25％、79．80％±6．55％、79．92％±8．10％降至术后24个月平均17．14％±3．01％、21．32％±4．40％、22．46％±3．87％。手术时间、术中出血量、术后引流量及住院天数，ALIF组与TLIF组均无统计学差异，与PLIF组比较均有统计学差异。影像学显示，ALIF组L4.5及L5S1节段术后腰椎前凸角和椎间高度分别与PLIF组比较均无统计学差异，但与TLIF组比较有统计学差异。ALIF组L4.5及L5S1节段平均节段性前凸角与PLIF组和TLIF组比较均有统计学差异。PLIF组L4.5及L5S1节段术后椎体滑移指数与ALIF组和TLIF组比较均有统计学差异，但ALIF与TLIF组比较无统计学差异。三组L1椎体中点与S1后缘铅垂线的水平距离和骶骨倾斜角比较均无统计学差异。术后6-8个月三组均骨性融合。结论三种固定方式治疗椎弓根峡部裂致轻度椎体滑移的临床疗效相近，ALIF在恢复腰椎前凸、椎间高度及节段性前凸方面较好，但手术技术要求较高；TLIF、PLIF在复位、减压方面较好。

Objective To compare the clinical and radiographic outcomes of 3 kinds of lumbar interbody fusion （ALIF, PLIF, TLIF） for adult low-grade isthmic spondylolisthesis at L4.5 and L5S1 levels. Methods Data of seventy patients with low- grade isthmie spondylolisthesis who had undergone different lumbar interbody fusion （LIF） procedures according to the assessment of the clinical manifestation, neurological symptoms, plane of the common iliae vessels and the width of ＂vascular window＂ by three-dimensional computed tomography angiography between May 2004 and May 2014 were retrospectively reviewed. 21 patients had undergone anterior LIF （ALIF）（13 males and 8 females with an average of 43.29±8.15 years old （range, 29-53 years old）; I4.5 in ten, L5S1 in 11; Meyerding grade I 10 cases, grade II 11 cases）; 25 patients had undergone posterior LIF （PLIF） （12 males and 13 females, with an average of 44.04±12.71 years old （range, 25-64 years old）; L4.5 in 12, L5S1 in 13; Meyerding grade I 15 cases, grade II 10 cases） and 24 patients had undergone transforaminal LIF （TLIF） （12 males and 12 females with an average of 45.00± 9.36 years old （range, 34-62 years old）; L4.5 in 12, L5S1 in 12; Meyerding grade I 11 cases, grade II 13 cases）. Results All pa- tients were followed up for 24-37 months （average, 25.6± 8.7 months）. The visual analogue scale （VAS） in all groups were de- creased from 7.05±0.87 （ALIF）, 6.60±1.39 （PLIF）, 6.75±1.11 （TLIF） pre-operation to 0.90±0.70, 0.96±0.68, 1.04±0.62 24 monthsafter operation. Oswestry disability index （ODI） scores were decreased from 78.53%±6.25%, 79.80%±6.55%, 79.92%±8.10% pre- operation to 17.14%±3.01%, 21.32%±4.40%, 22.46%±3.87%. Perioperative data including operation time, blood loss, postopera- tive blood drainage, length of stay showed no significant difference between ALIF group and TLIF group, but showing significant difference comparing with PL1F group. The imageological results showed that ALIF procedure increased whole lumbar lordosis （WL） and disc height （DH）, showing no significant difference comparing with PLIF group, but showing significant difference com- paring with TLIF group. The ALIF procedure increased segmental lordosis angle （SL）, showing significant difference comparing with PLIF group and TLIF group. The PLIF procedure decreased spondylolisthesis index （SI）, showing significant difference com- paring with A/TLIF group, but showing no significant difference between ALIF group and TLIF group. There was no significant dif- ference showed comparing the L4.5 axis S1 distance （LASD） and sacral slope （SS）, in three groups. The graft fusion was achieved in all patients after 6-8 months postoperatively without instrument failure or displacement. Conclusion Three surgical procedures of lumbar interbody fusion for adult w-grade isthmic spondylolisthesis showed silimar clinical efficacy. The ALIF procedure is su- perior in its capacity to restore WL, DH, and SL, and the P/TLIF procedure are superior in correcting the vertebral slippage and spinal cord decompression.