青少年发育不良性腰椎滑脱症合并脊柱侧凸的临床分析

Clinical analysis of adolescent dysplastic lumbar spondylolisthesis associated with scoliosis

目的:对青少年发育不良性腰椎滑脱症患者合并脊柱侧凸的情况进行调查并对侧凸情况做术后随访。方法:回顾性分析2007年3月~2017年10月于我院行滑脱复位固定融合手术治疗的28例青少年发育不良性腰椎滑脱症患者,滑脱节段均为L5,依据Meyerding滑脱分度将其分为重度滑脱(Ⅲ、Ⅳ、Ⅴ度)组与轻度滑脱(Ⅰ、Ⅱ度)组。以术前全脊柱正侧位X线片评估两组患者有无脊柱侧凸(Cobb角≥10°诊断为脊柱侧凸)、滑脱情况(滑脱程度、Dubousset腰骶角)以及脊柱-骨盆矢状位参数(骨盆入射角、骶骨倾斜角、骨盆倾斜角)。青少年腰椎滑脱合并的脊柱侧凸分为特发性侧凸和痉挛/疼痛性侧凸两大类,其中痉挛/疼痛性侧凸又分为单纯痉挛性侧凸和"滑脱性"侧凸两种,"滑脱性"侧凸主要由滑脱椎体的旋转造成。对有侧凸的患者测量其末次随访时的侧凸角度以了解侧凸改善情况。结果:发育不良性重度腰椎滑脱15例,年龄12.5±2.6岁,男2例,女13例;轻度滑脱者13例,年龄14.5±2.6岁,男6例,女7例,两组年龄、性别比例及各脊柱-骨盆矢状位参数均无统计学差异(P>0.05)。重度滑脱组的Dubousset腰骶角明显小于轻度滑脱组(55.6°±17.0°vs.83.3°±18.4°,P<0.05)。28例患者中合并脊柱侧凸者14例,其中重度滑脱组合并脊柱侧凸13例,轻度滑脱组中仅1例符合脊柱侧凸诊断,两组合并侧凸比例有统计学差异(86.7%vs.7.7%,P<0.001)。重度滑脱患者术前冠状位平均Cobb角明显大于轻度滑脱患者(18.1°±13.0°vs.4.6°±3.7°,P=0.001)。重度滑脱组中脊柱侧凸的构成情况:特发性侧凸5例,Cobb角11.6°~52.6°,平均30.2°±17.0°;痉挛/疼痛性侧凸8例,其中单纯痉挛性侧凸4例(Cobb角12.5°~17.5°,平均14.8°±2.1°),"滑脱性"侧凸4例(Cobb角11.2°~12.6°,平均11.9°±0.6°)。对13例重度滑脱伴侧凸患者进行术后随访,其中12例获得随访,随访时间为1~100个月(23.8±28.7个月),末次随访时单纯痉挛性侧凸的平均矫正率为92%,特发性脊柱侧凸的平均矫正率为7.5%,"滑脱性"脊柱侧凸的平均矫正率为4%。结论:青少年发育不良性腰椎滑脱症患者中,重度滑脱患者合并脊柱侧凸的比例高于轻度滑脱者,发育不良性重度腰椎滑脱与脊柱侧凸可能具有相关性,其中单纯痉挛性侧凸在滑脱复位固定融合术后可大部分自发矫正。

Objectives： To investigate adolescent dysplastic lumbar spondylolisthesis associated with scoliosis, and to make a follow-up of scoliosis after reduction and fusion surgery of spondylolisthesis. Methods： Twenty-eight young patients of L5 dysplastic spondylolisthesis undergoing spinal surgery, including reduction of the olisthetic vertebra with fixation and fusion between March 2007 and October 2017 in our hospital were studied retrospectively. The patients were divided into severe spondylolisthesis group（n=15, Meyerding grade Ⅲ, Ⅳ and Ⅴ） and mild spondylolisthesis group（n=13, Meyerding grade Ⅰ and Ⅱ）. The pre-op whole-spine X-ray of the patients were analyzed to find out the scoliosis cases（Cobb angle ≥10°）. The sagittal parameters（pelvic incidence, sacral slope, pelvic tilt） and slip parameters（slippage grade, Dubousset′s lumbar-sacral-angle） were also compared between the two groups. Scoliosis in adolescent spondylolisthesis was divided into two types： idiopathic scoliosis and spasm/antalgic scoliosis. The latter group was further divided into pure spasm scoliosis and spasm scoliosis combined to olisthetic scoliosis, mainly caused by the rotation of the olisthetic vertebra. The scoliosis angle of the patients was measured at the last follow-up to evaluate the correction of the scoliosis after the reduction and fusion of the olisthetic vertebra. Results： There were 15 severe spondylolisthesis patients （age, 12.5±2.6y; 2 males, 13 females） and 13 mild spondylolisthesis patients （age,14.5±2.6y; 6 males, 7 females）. No significant difference was found of age, sex ratio or sagittal parameter between groups（P〉0.05）. Dubousset′s LSA was different significantly between severe group and mild group（55.6°±17.0° vs. 83.3°±18.4°, P〈0.05）. 14 of 28 dysplastic lumbar spondylolisthesis patients were associated with scoliosis. The ratio of scoliosis[86.7%（13/15） vs. 7.7%（1/13）, Fisher Test, P〈0.001] and the coronal Cobb angle（18.1°±13.0° vs. 4.6°±3.7°, t=3.619, P=0.001） of the severe spondylolisthesis group were significantly higher than those of the mild group. Scoliosis in severe group included 5 idiopathic scoliosis（Cobb angle 30.2°±17°, 11.6°-52.6°）, 8 spasm/antalgic scoliosis with 4 pure spasm scoliosis（Cobb angle 12.5°-17.5°, 14.8°±2.1°） and 4 olisthetic scoliosis （Cobb angle 11.2°-12.6°, 11.9°±0.6°）. 12 of 13 dysplastic severe lumbar spondylolisthesis patients were followed up, with an average of 23.8±28.7 months follow-up（range, 1-100 months）. Correction rates at last follow-up were 7.5% of idiopathic scoliosis, 92% of pure spasm scoliosis and 4% of olisthetic scoliosis. Conclusions： In adolescent dysplastic lumbar spondylolisthesis patients, the severe olisthetic ones have a higher ratio of scoliosis than the mild ones. Adolescent dysplastic severe lumbar spondylolisthesis may be related to scoliosis. Pure spasm scoliosis can be mostly spontaneously corrected after reduction and fusion of the olisthetic vertebra.