高度发育不良性腰椎滑脱复位程度与脊柱-骨盆矢状位参数变化的关系

The relationship between the extent of reduction and the change of spino-pelvic parameters in high dysplastic developmental spondylolisthesis

目的:分析高度发育不良性腰椎滑脱(high dysplastic developmental spondylolisthesis,HDDS)的手术复位程度与脊柱-骨盆矢状位参数变化的关系,以了解复位至何种程度能够显著改善术后脊柱-骨盆矢状位序列。方法:回顾性分析2007年3月~2019年4月在我院骨科接受手术治疗的35例HDDS患者,滑脱节段均为L5,年龄14.9±5.9岁(9~35岁)。均行减压、部分复位或完全复位、椎弓根螺钉内固定融合术。随访42.5±33.1个月(3~120个月)。依据术后末次随访时的Dubousset腰骶角(Dubousset lumbosacral angle,Dub-LSA)将患者分为<70°(7例)、70°~79.9°(8例)、80°~89.9°(4例)及≥90°(16例)四组,依据末次随访时滑脱的Meyerding分度将患者分为Ⅲ度及以上(5例)、Ⅱ度(6例)、Ⅰ度以内(24例)三组,分别对比各组的术前、末次随访时脊柱-骨盆参数的变化。结果:滑脱率术前为(66.7±22.5)%(35%~100%),末次随访时为(18.9±20.9)%(0%~72%);DubLSA术前为61.9°±14.7°,末次随访时82.1°±17.3°。末次随访时Dub-LSA越大、滑脱程度越低,脊柱-骨盆矢状位参数较术前改善越明显;直至Dub-LSA≥90°和滑移程度在Ⅰ度以内时,骨盆倾斜角(pelvic tilt,PT)和骶骨倾斜角(sacral slope,SS)均有显著性改善,由后倾型骨盆转变为平衡型骨盆的比例显著增加。Dub-LSA≥90°组术前与末次随访时PT分别为36.4°±6.5°与27.2°±4.9°(P<0.001)、SS分别为33.5°±9.1°与42.1°±9.3°(P<0.001)、平衡型骨盆比例分别为0%(0/16)与43.8%(7/16)(P=0.007),末次随访时与术前比较均有统计学差异。末次随访时滑脱程度在Ⅰ度以内组,术前与末次随访时PT分别为38.9°±8.6°与30.6°±7.4°(P<0.001)、SS分别为31.4°±11.5°与41.2°±8.7°(P<0.001)、平衡型骨盆比例分别为0%(0/24)与29.2%(7/24)(P=0.009),末次随访时与术前比较均有统计学差异。结论:将HDDS患者的Dub-LSA复位至≥90°和将滑移复位至Ⅰ度以内能够显著改善脊柱-骨盆矢状位参数,并且能够将部分(43.8%)后倾型骨盆改善为平衡型骨盆。

Objectives:To investigate the relationship between the extent of reduction and the change of spino-pelvic parameters in high dysplastic developmental spondylolisthesis(HDDS),so as to know about what extent of reduction could significantly improve postoperative spino-pelvic sagittal alignment.Methods:Thirtyfive young patients of HDDS,aged 9 to 35(14.9±5.9)years old and treated between March 2007 and April 2019 in our hospital were studied retrospectively,with an average follow-up time of(42.5±33.1)months(3-120 months).They were divided into four groups of<70°(7 cases),70°-79.9°(8 cases),80°-89.9°(4 cases)and≥90°(16 cases)based on the final follow-up Dubousset lumbosacral angle(Dub-LSA),and were also divided into three groups of high-grade(gradeⅢand above)(5 cases),gradeⅡ(6 cases),and gradeⅠ(24 cases)based on the final follow-up Meyerding grade.Then,the preoperative and final follow-up spino-pelvic param-eters of each group were compared to find out what extent of reduction could significantly improve these pa-rameters and pelvic balance.Results:The slip percentage was[pre-operation(66.7±22.5)%(range 35%-100%)vs.final follow-up(18.9±20.9)%(range 0%-72%)].The Dub-LSA was(pre-operation 61.9°±14.7°vs.final follow-up 82.1°±17.3°).The differences between preoperative and final follow-up parameters became more significant with the increase of Dub-LSA and the decrease of slippage.In the Dub-LSA≥90°and the gradeⅠgroup,pelvic tilt(PT)and sacral slope(SS)were improved significantly,and the ratio of retroverted pelvis changing into balanced type was increased significantly.Dub-LSA≥90°group:PT[pre-operation(36.4°±6.5°)vs.final follow-up(27.2°±4.9°),P<0.001],SS[pre-operation(33.5°±9.1°)vs.final follow-up(42.1°±9.3°),P<0.001],and the ratio of balanced pelvis[pre-operation 0%(0/16)vs.final follow-up 43.8%(7/16),P=0.007].GradeⅠgroup:PT[pre-operation(38.9°±8.6°)vs.final follow-up(30.6°±7.4°),P<0.001],SS[pre-operation(31.4°±11.5°)vs.final follow-up(41.2°±8.7°),P<0.001],and the ratio of balanced pelvis[pre-operation 0%(0/24)vs.final follow-up 29.2%(7/24),P=0.009].Conclusions:Reduction of HDDS to DubLSA≥90°and Meyerding gradeⅠcould improve the spino-pelvic alignment significantly,and could convert part(43.8%)of the retroverted pelvis to balanced pelvis.