椎问隙狭窄型峡部裂性腰椎滑脱的手术治疗

目的探讨椎间隙狭窄型峡部裂性腰椎滑脱的手术方法及临床疗效。方法对30例椎间隙狭窄型峡部裂性腰椎滑脱患者采用钉棒系统内固定加经椎间孔椎体间融合器结合打压植骨融合（TLIF）术进行治疗。结果随访12—18个月,所有患者腰腿痛症状均消失,植骨融合率100％,4例患者残留部分下肢麻木症状。结论钉棒系统内固定加经椎间孔椎体间融合器结合打压植骨融合（TLIF）术可达到恢复椎间隙高度、神经根孔间接减压、椎管减压、重建脊柱的生理曲度和脊柱的稳定性的效果,是一种可靠、有效的方法。     

腰椎滑脱症外科治疗策略选择

目的探讨不同类型腰椎滑脱症及合并症的手术治疗方式、疗效及优缺点。方法2000年2月～2004年4月应用后路椎弓根螺钉复位内固定后，分别采用后外侧植骨融合术、后路椎体间植骨融合术及前路椎体问植骨融合术治疗不同类型腰椎滑脱症及合并症的患者78例，比较术后及随访时疗效、滑脱椎体复位率、椎间隙高度恢复率、植骨融合率以及复位丢失率。结果术后28例Ⅰ度滑脱及37例Ⅱ度腰椎滑脱患者获得解剖复位．9例Ⅱ度滑脱及4例Ⅲ度腰椎滑脱患者矫正至Ⅰ度滑脱。随访时总体优良率为89．72％，42例椎体间植骨患者植骨融合良好，滑脱椎体复位无丢失，椎间隙高度维持良好；36例后外侧植骨者有12例复位丢失，2例椎弓根螺钉松动，2枚椎弓根螺钉断裂：结论对小于Ⅱ度退变性腰椎滑脱合并腰椎管狭窄者宜选用后路椎弓根钉复位固定加后外侧植骨融合术；对峡部裂性腰椎滑脱合并腰椎管狭窄者宜选用后路椎弓根钉固定加椎体间植骨融合术；对Ⅱ度以上峡部裂性单纯腰椎滑脱者以及腰椎滑脱翻修者宜选用后路椎弓根钉固定加前路椎体间植骨融合术。     

不同手术方式治疗腰椎滑脱症的比较

目的：比较采用不同内固定及植骨融合方式治疗腰椎滑脱症的手术疗效及适应证。方法：应用后路椎弓根螺钉复位内固定后．分别采用后外侧植骨融合术、后路椎体间植骨融合术及前路椎体间植骨融合术治疗不同类型及合并症的腰椎滑脱症患者67例，比较不同术式的手术时间与出血量、手术疗效与并发症、滑脱椎体复位率与复位丢失率以及椎间隙高度。结果：后路椎弓根钉固定加椎体间植骨融合术手术时间最长、出血量最多。手术总体优良率为88．71％，三种术式间无差异。所有椎体间植骨组植骨融合良好，椎间隙高度维持良好，滑脱椎体复位无丢失；12例后外侧植骨者平均复位丢失率为11．24％，2例椎弓根螺钉松动，2枚椎弓根螺钉断裂。结论：退变性腰椎滑脱者宜选用后路椎弓根钉固定加后外侧植骨融合术；峡部裂性腰椎滑脱者宜选用后路椎弓根钉固定加椎体间植骨融合术；腰椎滑脱翻修者宜选用后路椎弓根钉固定加前路椎体间植骨融合术     

成人轻度峡部裂型腰椎滑脱的治疗分析

目的比较后外侧融合与后外侧融合加椎间植骨融合治疗成人轻度峡部裂型腰椎滑脱的临床及放射学疗效。方法回顾性分析52例成人轻度峡部裂型腰椎滑脱,分别行后外侧植骨融合固定32例(A组),后外侧植骨融合加椎间融合固定20例(B组)。结果患者获随访1~7年,两组术后JOA评分较术前有显著改善,两组融合率比较差别无统计学意义。B组手术时间长、出血量大、并发症多。结论对成人轻度峡部裂型腰椎滑脱采用单纯后外侧植骨融合固定和后外侧融合加椎间融合固定均为有效的治疗方式,两者在临床及影像学有效率方面疗效相当。     

GSS-Ⅲ系统治疗腰椎峡部裂性腰椎滑脱

目的探讨GSS-Ⅲ内吲定治疗腰椎椎弓峡部裂合并腰椎滑脱症的手术疗效。方法 采用腰椎后路减压．GSS-Ⅲ系统固定加后外侧植骨融合治疗45例。结果45例经6-28个月随访，平均18个月。依据13本JOA评分法：优38例．良4例，呵3例，差0例，优良率93．3％，结论 CSS-Ⅲ系统内同定结合后外侧植骨融合可满足腰椎滑脱短节段崮定和复位要求，复位、融合率高，可取得良好的临床效果。     

三种后路融合方式治疗腰椎滑脱的外科疗效评价

目的比较后外侧融合、后路椎间融合与后路环形融合治疗腰椎滑脱的手术疗效，探讨其适应证。方法分别应用3种术式治疗不同类型及合并症的腰椎滑脱患者58例，比较手术时间、并发症、椎体滑脱矫正与复位丢失率、椎间隙高度以及下腰痛症状改善情况。结果三者均可以明显改善下腰痛；后外侧融合减少了术后一过性下肢麻痛的发生率但易出现植骨不融合及内固定失败；后路椎间融合及后路环形融合明显提高了植骨融合率，降低了假关节发生率和滑脱矫正度的丢失。结论3种后路融合术都是治疗腰椎滑脱的有效术式，退变性腰椎滑脱宜选用后外侧融合；峡部裂性腰椎滑脱宜选用后路椎间融合技术；Ⅱ度以上严重峡部裂性腰椎滑脱症或合并腰椎管狭窄需行广泛减压者宜选用后路环形融合。     

无内固定异体骨圈嵌植治疗腰椎滑脱症

目的探讨无内固定异体骨圈前路腰椎椎间融合治疗腰椎峡部裂滑脱症的可行性和安全性。方法用深低温异体骨圈加自体骨嵌植峡部裂腰椎滑脱症15例,不加任何内固定,腰围外固定3个月以上,术后复查X线片观察融合情况、测量椎间隙高度和滑脱椎位移距离差。结果平均随访28个月,融合时间最短8个月,最长13个月;椎间隙高度减低3mm1例,2mm4例;滑椎前移2mm和3mm各1例。按Macnab法评定,优10例,良4例,优良率93.3%。结论齿状异体骨圈加自体松质骨嵌植,无需内固定,治疗腰椎峡部裂Ⅰ°～Ⅱ°滑脱安全可靠,达到复位、稳定、融合的效果。     

延长固定节段结合短节段融合在中重度腰椎滑脱治疗中的应用

目的探讨延长固定节段结合短节段融合在中重度峡部裂型腰椎滑脱治疗中的手术技巧及疗效。方法对36例中重度峡部裂型腰椎滑脱患者行后路减压复位、椎间植骨融合,并包括滑脱椎近端相邻椎的延长节段钉棒系统固定术。通过影像学资料评估复位及植骨融合情况;采用JOA及VAS评分评价治疗效果。结果患者均获得随访,时间16~39个月。滑脱复位率91.8%~95.2%;椎间隙高度由术前4.7 mm±2.1 mm恢复至术后10.5 mm±2.4 mm;植骨融合率100%;JOA评分:术前7.9分±2.1分,术后3个月17.3分±3.9分,末次随访时24.5分±2.0分;VAS评分:术前7.5分±2.0分,术后3个月3.1分±1.4分,末次随访时1.8分±0.9分。参照JOA和VAS评分评价疗效,优20例,良13例,可2例,差1例,优良率91.7%。随访期间滑脱复位率及椎间隙高度无明显丢失。均无滑脱畸形加重,内固定松动,断钉断棒,感染及神经损害加重等现象。结论延长节段固定结合短节段融合治疗中重度峡部裂型腰椎滑脱症,可以达到理想的复位固定效果和可靠的骨性融合,临床疗效满意。     

椎弓根钉复位固定及两种融合方式治疗腰椎滑脱疗效比较

目的比较椎弓根钉后路固定联合椎体间植骨融合或椎间cage加后外侧植骨融合两种融合方式治疗腰椎滑脱的疗效差异。方法对腰椎滑脱51例行椎弓根钉后路固定联合椎体间植骨融合治疗27例(A组),行椎弓根钉后路固定联合椎间cage加后外侧植骨融合治疗24例(B组)。结果两组术后JOA评分、滑脱角、滑移率较术前差异有统计学意义(P<0.05),两组之间差异无统计学意义(P>0.05)。两组术中出血量、手术时间、术后椎间隙高度、术后融合率比较差异有统计学意义(P<0.05)。结论椎弓根钉后路固定联合椎间cage加后外侧植骨融合治疗腰椎滑脱在术后椎间隙高度维持、融合率较椎体间植骨融合有一定优势。     

短节段椎弓根螺钉后路椎间植骨治疗重症峡部裂型腰椎滑脱症

[目的]探讨应用短节段椎弓根螺钉系统内固定并后路椎间植骨融合治疗重症峡部裂型腰椎滑脱症的疗效和手术技巧.[方法]2005年1月～2007年1月,对51例重症峡部裂型腰椎滑脱患者行短节段椎弓根螺钉后路椎间植骨融合术,年龄25～67岁,平均41岁;术前滑脱程度按Meyerding分级标准均大于33%,平均为42%,均有不同程度的神经根受损症状.通过术前、术后脊柱正、侧位X线片和Beaujon functional score(BFS)评分,分析临床疗效,评价治疗效果.[结果]51例患者均获随访,随访时间为2～3年10个月,平均2年8个月.术后平均滑脱复位率92%;椎间隙高度由术前平均4.9 mm恢复至术后的10.3 mm;植骨融合率100%,平均融合时间4个月;BFS评分由术前平均8.1分升至术后2年的17.9分,疗效优良率为91%.随访期间滑脱复位率、椎间隙高度无明显丢失.[结论]短节段椎弓根螺钉系统内固定后路椎间植骨融合术可以用于治疗重症峡部裂型腰椎滑脱症,能保留更多的腰椎运动单元.     

游离椎弓根峡部嵌入植骨术治疗合并椎间盘突出的腰椎弓峡部裂

目的：介绍一种治疗合并有椎间盘突出的腰椎椎弓峡部裂的手术方法。方法：先将患椎的后半部分游离取下并修整,待椎间盘切除、植骨床修整后,取髂骨块嵌入,再将后半部分回植,用螺丝钉贯穿固定,同时行横突椎板植骨。结果：本组治疗１３例,其中１１例随访１年以上,临床症状消失,峡部裂均融合,患椎滑脱无继续加重。结论：该术式操作简单,确实可靠,疗效理想。     

Uninstrumented in situ fusion for high-grade childhood and adolescent isthmic spondylolisthesis: long-term outcome

BACKGROUND: Intermediate-term radiographic studies have shown that anterior and circumferential techniques result in high fusion rates in patients with high-grade spondylolisthesis, whereas posterolateral fusion is less successful. We are not aware of any long-term comparative studies in which these three methods have been evaluated with regard to functional outcome, including systematic spinal mobility and trunk strength measurements. METHODS: Sixty-nine of eighty-three consecutive patients with high-grade isthmic spondylolisthesis who underwent posterolateral (twenty-one), anterior (twenty-three), or circumferential (twenty-five) uninstrumented spondylodesis between 1977 and 1991 participated in the study. The average duration of follow-up was 17.2 years. Radiographs that were made preoperatively and at the time of the most recent follow-up were assessed with regard to fusion quality and degenerative changes. Outcome was assessed at the time of the most recent follow-up by independent observers on the basis of a physical examination, spinal mobility and nondynamometric trunk strength measurements, and Oswestry Disability Index scores. RESULTS: The mean preoperative vertebral slip was 61% in the posterolateral fusion group, 63% in the anterior fusion group, and 71% in the circumferential fusion group. The final fusion rate was 86% (eighteen of twenty-one) in the posterolateral fusion group, 100% (twenty-three of twenty-three) in the anterior fusion group, and 96% (twenty-four of twenty-five) in the circumferential fusion group. A decrease in lumbar intervertebral disc height at the first mobile level superior to the fusion was noted in five patients in the posterolateral fusion group, seven patients in the anterior fusion group, and one patient in the circumferential fusion group (p = 0.037). The mean Oswestry Disability Index score was 9.7 for the posterolateral fusion group, 8.9 for the anterior fusion group, and 3.0 for the circumferential fusion group (p = 0.035). Nondynamometric trunk strength measurements corresponded with referential values. Abnormally low lumbar flexion affected the posterolateral and circumferential fusion groups more often than the anterior fusion group (p = 0.0015). The percentage of slip showed inverse correlations with lumbar flexion, lumbar extension, and trunk side-bending. CONCLUSIONS: As assessed on the basis of patient-based outcomes, circumferential in situ fusion provided slightly better long-term results than did posterolateral or anterior in situ fusion. When the radiographic and functional results were combined with the patient-based outcomes, the overall differences between the three groups were small.     

采用临时短节段椎弓根螺钉固定联合髂骨植骨治疗青少年腰椎椎弓崩裂症的临床观察

目的观察并评价临时短节段椎弓根螺钉固定联合髂骨植骨治疗青少年腰椎椎弓崩裂症的临床疗效。方法回顾性分析2016年8月至2018年12月因腰椎峡部崩裂症42例患者,对30例平均年龄为24.4岁符合标准的患者采取本手术方法。采用全椎弓根螺钉固定联合横连装置进行崩裂的峡部椎体和下位椎体进行坚强固定。对崩裂的峡部进行瘢痕清理和硬化骨处理;最后取自体髂骨进行峡部修补。术后定期随访,待峡部植骨融合后再次给予内固定取出,恢复固定节段活动度。行X线及CT检查,确定其峡部骨性愈合。待峡部融合后再次取出内固定装置,恢复固定节段活动,进行腰椎动力位片检查评估,测量固定节段的活动度,与术前同节段活动度进行对比。同时分别在手术前、手术固定1年时及内固定取出后1年行腰椎MRI检查,并采用modic分级及pfirrmann分级标准来观察固定节段椎间盘及椎体终板的变化,观察固定节段相应椎体的终板及椎间盘的变化。结果完整随访30例,平均随访时间24(18~36)个月;平均手术时间为107 min;平均出血量为126 ml;平均融合时间为13个月;融合率为100%。所有患者原有下腰痛症状消失,所有患者X线及CT片均提示峡部融合。内固定装置取出后,对患者进行腰椎过伸过屈位X线片检查,动力位片显示固定阶段活动度保存良好,活动度保留率为88.5%。腰椎MRI显示,16例患者固定阶段终板modic改变呈正变化,14例患者无变化,固定阶段椎间盘组织无明显退变变化。结论临时短节段椎弓根螺钉联合横连装置固定是一种治疗腰椎峡部裂简便、有效的方法,固定坚强、融合率高;且临时短节段坚强固定并不会加速固定节段椎间盘退变及临近节段的退变。     

腰椎间盘突出与脊椎滑脱的力学关系和手术选择

目的：用力学原理解释腰椎间盘同症和脊椎滑脱的病理关系,以指导手术方法。方法：自１９９０年１月～１９９７年１２月共３４例腰椎间盘突出和脊椎滑脱鹗２经后路行椎管探查减压,椎间盘摘除,横突间隔合,其中２６例行ＲＰ或Ｓｔｅｆｆｅｅ椎弓根螺钉复位内固定术,８例采用自体腓骨纵截移植脊椎融合内固字术,对术式选择、手术原则和治疗结果进行了临床分析。结果：３４例手术患者按Ｓｔａｕｆｆｅｒ疗效标准,自体腓骨移植治疗组     

Geometry of the vertebral bodies and the intervertebral discs in lumbar segments adjacent to spondylolysis and spondylolisthesis: pilot study

The objective is to evaluate the geometric parameters of vertebral bodies and intervertebral discs in spinal segments adjacent to spondylolysis and spondylolisthesis. This pilot cross-sectional study was an ancillary project to the Framingham Heart Study. The presence of spondylolysis and spondylolisthesis as well as measurements of spinal geometry were identified on CT imaging of 188 individuals. Spinal geometry measurements included lordosis angle, wedging of each lumbar vertebra and intervertebral disc. Last measurements were used to calculate ΣB, the sum of the lumbar L1–L5 body wedge angles; and ΣD, the sum of the lumbar L1–L5 intervertebral disc angles. Using Wilcoxon–Mann–Whitney test we compared the geometric parameters between individuals with no pathology and ones with spondylolysis (with no listhesis) at L5 vertebra, ones with isthmic spondylolisthesis at L5–S1 level, and ones with degenerative spondylolisthesis at L5–S1 level. Spinal geometry in individuals with spondylolysis or listhesis at L5 shows three major patterns: In spondylolysis without listhesis, spinal morphology is similar to that of healthy individuals; In isthmic spondylolisthesis there is high lordosis angle, high L5 vertebral body wedging and very high L4–5 disc wedging; In degenerative spondylolisthesis, spinal morphology shows more lordotic wedging of the L5 vertebral body, and less lordotic wedging of intervertebral discs. In conclusion, there are unique geometrical features of the vertebrae and discs in spondylolysis or listhesis. These findings need to be reproduced in larger scale study.     

腰5椎体Ⅱ度以上峡部裂性滑脱的手术策略

目的探讨腰5椎体Ⅱ度以上峡部裂性滑脱的手术治疗策略。方法 2003年8月～2008年10月,应用经椎间孔腰椎间融合（transforaminal lumbar interbody fusion,TLIF）技术,以小关节突为中心椎管减压、椎间隙松解撑开复位、椎弓根钉棒系统补充复位固定、椎间隙打压植骨联合椎间融合器技术治疗腰5椎体Ⅱ度以上峡部裂性滑脱26例。结果经18～36个月（平均30个月）随访,滑脱椎体复位无丢失,椎间隙高度维持良好,下腰椎生理弧度恢复正常,椎弓根螺钉无断裂、松动,融合器无移位、沉降。25例获骨性融合。根据NaKai评分标准,优良率为84.6%。结论采用TLIF技术治疗腰5椎体Ⅱ度以上滑脱,神经根管减压是影响疗效的关键因素,滑脱椎体复位有利于神经根减压以及椎间融合率的提高,椎体间融合是维持长期疗效的基础。     

Progression of lumbosacral isthmic spondylolisthesis in adults

STUDY DESIGN: A retrospective clinical and radiographic review of adult patients with progressive isthmic lumbosacral spondylolisthesis. OBJECTIVES: To describe the clinical presentation of adult-onset progression of isthmic spondylolisthesis and to analyze its causes. SUMMARY OF BACKGROUND DATA: Until recently, progression of lumbosacral spondylolisthesis in adults was rarely reported. On the contrary, although slip progression before skeletal maturity has been widely recorded, its occurrence in adults has been doubted. Only sporadic case reports of adult slip progression and only brief notes on the subject in clinical studies describing other aspects of spondylolisthesis have been published. METHODS: Patients with isthmic lumbosacral spondylolisthesis who had serial radiographs of the lumbar spine on which slip progression during adult life was noted were evaluated. The amount of vertebral slip was calculated in millimeters from decubitus lateral spinal radiographs. The calculation was expressed as the percentage of slipped vertebral body length. RESULTS: From 1989 to 1995, 18 patients (9 women and 9 men), ages 32 to 55 years, with documented adult isthmic slip progression were identified at the Spinal Surgery Unit of the Hadassah University Hospital. All patients reported incapacitating low back pain, accompanied in most by significant sciatica. Documented slip progression ranged from 9% to 30% (average, 14.6%), and occurred during a period of 2 to 20 years (average duration, 6.8 years). Slip progression started after the third decade of life and coincided with marked disc degeneration at the olisthetic level. Slip progression associated with disc degeneration (i.e., intervertebral space narrowing and the formation of spondylophytes and vacuum phenomenon) brought about severe clinical symptomatology related to segmental instability and spinal stenosis. Of the 18 patients in this study, 14 were treated with surgery. All these patients except 1 underwent decompression, pedicle screw fixation, and bilateral lateral fusion. One patient underwent posterolateral fusion without instrumentation. Immediate postoperative complications were observed in three patients, including two superficial wound infections and one transient foot drop. Solid fusion was obtained in 11 of the 14 patients who underwent surgery. CONCLUSIONS: The concurrent occurrence of disc degeneration at the slip level and adult slip progression explains how an asymptomatic developmental lesion, present for at least two to three decades, may become symptomatic.     

成人峡部裂型腰椎滑脱症的手术治疗

目的 总结手术治疗成人峡部裂型腰椎滑脱症的临床疗效.方法 回顾总结自2004年1月～2008年5月收治的采用腰椎椎间隙撑开复位、椎间融合内固定术治疗的45例成人峡部裂型腰椎滑脱症的临床资料.术后应用Oswestry功能障碍指数、JOA评分及影像学检查对临床疗效进行评价.结果 平均手术时间130min,术中出血量平均410 ml.随访时间24～60个月,平均38个月.末次随访0DI为(25.4±4.2)％、JOA评分为(25.8±1.2)分,与术前相比差异有统计学意义(P＜0.001),临床疗效满意率为86.7％.滑移程度末次随访为(9.8±3.9)％,滑脱复位率为743％,2年融合率为97.7％.结论 应用椎间隙撑开复位、椎间融合内固定治疗成人峡部裂型腰椎滑脱症,疗效确切,操作简单、安全,并发症少.     

腰椎滑脱手术复位问题的探讨

目的探讨腰椎滑脱手术的复位问题。方法66例腰椎滑脱患者,其中36例(治疗组)采用椎弓根螺钉内固定加椎体间、后外侧植骨及Cage应用治疗,30例(对照组)采用后外侧原位植骨融合手术治疗。对两组术前、术后和最终随访时的X线片测量结果、融合率、断钉率、JOA评分等进行综合评价。结果①治疗组能明显增加椎间隙高度、相对椎间隙高度,提高复位率,降低滑脱率;②治疗组能明显提高术后1年、2年骨性融合率,降低断钉率;③治疗组能明显提高术后JOA评分。结论①腰椎滑脱症手术时滑脱椎体应尽可能复位;②不能过分强调解剖复位,主张部分复位比较安全;③滑脱复位后,术后常出现复位的丢失,如何减少复位的丢失,是需值得重视的问题;④在此基础上彻底的减压是基础,坚强的骨性融合是关键。