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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。
Objective: To investigate the advantages and disadvantages and safety of posterior S1 osteotomy L5-S1 short segment internal fixation and 360 ° circumferential fusion in the treatment of adolescent severe isthmic spondylolisthesis. Methods: From September 2007 to September 2014, 10 cases of dysplastic spondylolisthesis of severe young L5 isthmus in the Second Xiangya Hospital were treated, aged 15.8 ± 2.6 (12.5 ~ 18.0 years). All patients underwent L5- S1 short segment of the internal fixation reset, through the posterolateral bone graft and anterior small incision intervertebral bone graft to complete 360 ° circumferential bone fusion. The preoperative and postoperative Oswestry Disability Index (ODI), VAS pain score, spine-pelvis parameters including spondylolisthesis, pelvis incidence angle (PI), sacral tilt angle (SS), and pelvic tilt angle , Lumbar lordosis (TK), thoracic kyphosis (TK), hip-S1 posterior angle (SFD), C7 plumb line SC7D, T9 tilt angle, lumbosacral angle (Dub -LSA) and lumbosacral joint angle (LSJA), to observe the effect of correction. Results: The follow-up time was 38 ± 6 months. The changes of spine-pelvic parameters before and at the last follow-up were as follows: The percentage of slippage decreased from (78 ± 17.5)% to (4.5 ± 4.2)%. There was no significant change in PI before and after operation, both of which were 74.5 ± 9.6 °. SS increased from 45.1 ° ± 8.5 ° to 49.2 ° ± 9.1 °, PT decreased from 29.4 ° ± 8.4 ° to 25.3 ° ± 6.3 °, LL decreased from 65.0 ° ± 10.3 ° to 50.2 ° ± 8.8 °, and TK increased from 24.8 ° ± 7.1 ° to 37.2 ° ± 7.6 °, SFD decreased from 58.1 ± 12.4 mm to 54.2 ± 11.9 mm, SC7D decreased from 51.6 ± 37.8 mm to 18.7 ± 30.2 mm, T9 tilt angle decreased from 8.2 ° ± 4.8 ° to 1.5 ° ± 4.5 °, Dub-LSA increased from 76.6 ° ± 11.3 ° to 110.3 ° ± 12.4 °, and LSJA decreased from 32.1 ° ± 19.4 ° to 1.7 ° ± 12.3 °. After 6 months, 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. All patients had no permanent nerve damage, muscle atrophy, pseudarthrosis and other complications of internal fixation failure. One patient had cerebrospinal fluid leakage after operation, extended drainage tube placement time to 1 week, wound healing, no secondary infection. Two patients had transient lower limb radiating pain and gradually disappeared after treatment. Conclusion: The posterior S1 osteotomy L5-S1 short segment internal fixation and 360 ° circumferential fusion are safe and effective in treating severe adolescent spondylolisthesis, reducing the occurrence of postoperative neurological complications and restoring the spinal-pelvic sagittal balance.