CARDS分型D型和非D型退变性腰椎滑脱临床特点及经椎间孔椎体间融合手术疗效的对比分析

Comparison of patient characteristics and surgical outcomes following transforaminal lumbar interbody fusion between CARDS classification type D and non-type D spondylolisthesis

目的对比分析退变性腰椎滑脱临床和影像学分型(CARDS分型) D型和非D型患者的临床特点及椎间孔椎体间融合术(transforaminal lumbar interbody fusion,TLIF)疗效。方法回顾性分析2010年1月至2016年7月,我院行TLIF治疗的119例L4~5退变性滑脱患者的临床资料,其中男24例、女95例;年龄43~72岁,平均54.9岁。根据在站立或动力位X线片上滑脱节段椎间隙是否向后成角分为D型滑脱组和非D型滑脱组。术前、术后和随访时测量滑脱率(slip percentage,SP)、滑脱角(slip angle,SA)、椎间隙高度(disc height,DH)、腰椎前凸角(lumbar lordosis,LL)、下腰椎前凸角(low lumbar lordosis,Lower LL)和L1椎体中心至骶骨垂线间距离(L1 axis S1 distance,LASD)。同时采用Oswestry功能障碍指数(oswestry disability index,ODI)和腰部疼痛视觉模拟评分(visual analogue scale,VAS)对患者生活质量进行评估。结果本组D型滑脱23例(19.3%),两组患者一般资料差异无统计学意义。术前D型滑脱组和非D型滑脱组SA分别为(1.9±1.6)°和(8.0±2.2)°,差异有统计学意义(P<0.05),D型滑脱组LL和Lower LL分别为(42.8±10.4)°和(29.1±7.7)°,显著低于非D型滑脱组的(52.3±14.7)°和(37.4±9.6)°(P<0.05);而LASD为(25.1±11.4) mm,显著高于非D型滑脱组的(17.3±9.6) mm (P<0.05),DH和SP组间比较差异无统计学意义。经TLIF术后,两组患者术后及末次随访时各影像学指标较术前均明显改善,两组患者术后和末次随访时SA、DH、LL和Lower LL组间比较差异无统计学意义(P>0.05),但D组滑脱组复位率显著高于非D型滑脱组(89.7%vs. 76.5%,P<0.01)。术前D型滑脱组ODI和VAS分别为(45.7±11.3)和(7.9±2.1),显著高于非D型滑脱组的(40.6±10.1)和(6.2±1.8),差异有统计学意义(P<0.05),术后ODI和VAS评分均较术前明显改善,但两组间评分在术后和随访时差异无统计学意义(P>0.05)。结论 CARDS分型D型滑脱术前腰椎前凸丢失、生活质量评分低,TLIF术式是治疗D型滑脱的有效术式,术后可以获得的腰椎前凸重建和生活质量的改善。

Objective To compare patient characteristics between CARDS classification type D and non-type D spondylolisthesis, as well as the surgical outcomes following transforaminal lumbar interbody fusion. Methods This study reviewed 119 patients( 24 males and 95 females) who received TLIF for L4/5 DS between 2010 and 2016, with a mean age of 54.9 years( range: 43 to 72 years). Enrolled patients were divided into two groups based on preoperative slip angle on the preoperative lateral radiographs: type D group and non-type D group. Slip angle( SA), disc height( DH), slip percentage( SP), lumbar lordosis( LL), lower lumbar lordosis( Lower LL) and L1 axis S1 distance( LASD)were measured. Oswestry disability index( ODI) and visual analogue scale( VAS) in back pain were collected to evaluate the quality of life. Results Type D spondylolisthesis were noticed in 23( 19.3%) patients, and no differences were detected between the two groups in demographic parameters. Preoperative SA in type D group and non-type D were( 1.9 ± 1.6)° and( 8.0 ± 2.2)°, respectively( P < 0.05);preoperative LL [( 42.8 ± 10.4)° vs.( 52.3 ± 14.7)°,P < 0.05 ] and Lower LL [( 29.1 ± 7.7)° vs.( 37.4 ± 9.6)°, P < 0.05 ] were significantly lower in the type D group than that in the non-type D group;LASD [( 25.1 ± 11.4) mm vs.( 17.3 ± 9.6) mm, P < 0.05 ] was significantly higher in the type D group;no differences were noticed in DH and SP between the two groups. After TLIF surgery,radiographic results showed that patients of both groups had significant improvement with no between-group differences in SA, DH, LL, Lower LL and LASD postoperatively and at the last follow-up. Reduction rates were significantly higher in type D group than non-type D group( 89.7% vs. 76.5%, P < 0.01). Preoperative ODI [( 45.7 ±11.3) vs.( 40.6 ± 10.1), P < 0.05 ] and VAS [( 7.9 ± 2.1) vs.( 6.2 ± 1.8), P < 0.05 ] scores were significant higher in the type D group than non-type D group( P < 0.05) with no between-group differences after surgery and at the last follow up( P > 0.05). Conclusions CARDS classification type D spondylolisthesis was characterized by loss of lumbar lordosis and poor life quality;Reconstruction of lumbar sagittal profile and improvement of life quality can be achieved in type D spondylolisthesis after TLIF surgery.