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     

腰椎滑脱症手术治疗体会

目的 提高腰椎滑脱症手术复位和后路一次椎体间植骨融合率。方法 对行Ｓｔｅｆｆｅｅ椎弓根螺钉系统、ＲＦ系统、ＳＦ内固定装置复位内固定加植骨融合术治疗的腰椎滑脱２０例进行观察,对比分析术前和术后症状、体征和影像学改变。结果 ２０例均获满意复位,椎间植骨融合。结论 应用具有提拉作用的椎弓根螺钉系统固定滑脱腰椎＋滑脱椎椎间植骨融合是较理想的治疗方法。     

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。     

腰椎滑脱症翻修手术(附21例报告)

目的探讨腰椎滑脱症初次手术失败原因、翻修手术方式及疗效。方法回顾分析2003年4月～2006年10月21例腰椎滑脱症翻修手术病例,针对初次手术失败的原因,分别应用后路椎弓根螺钉复位内固定加椎体间植骨融合术、后路椎弓根螺钉复位内固定加前路椎体间植骨融合术以及后路椎弓根螺钉复位内固定加前路游离腓骨移植椎体间植骨融合术进行再次手术,比较术后疗效、滑脱椎体复位率以及植骨融合率。结果本组全部患者翻修手术后均获随访,时间为4～48个月,平均32.6个月,总体优良率为90.48%,所有翻修手术病例植骨融合良好,植骨融合最短时间为3.8个月,最长时间为6.4个月,滑脱椎体再次复位后矫正度无丢失,椎弓根螺钉无松动及断裂。结论腰椎滑脱症初次手术失败原因主要与手术方式选择不当、忽视植骨融合的质与量以及手术操作不当有关,只要翻修手术方式得当、术中仔细操作、合理应用内固定及植骨融合材料,仍能取得满意疗效。     

后路椎间植骨椎弓根钉系统内固定治疗腰椎滑脱症

目的 报道后路椎体间植骨融合椎弓根钉系统内固定术治疗腰椎滑脱的疗效。方法 应用后路椎体间自体髂骨植骨融合椎弓根钉系统内固定治疗腰椎滑脱36例，I度滑脱18例，Ⅱ度滑脱15例，Ⅲ度滑脱3例；峡部裂型30例，退变性5例，外伤性1例，结果 随访6个月1～2年，术后6个月植骨处均骨性愈合，无内固定物松动、脱出或断裂现象。临床疗效综合评价：优14例，良20例，可2例。结论 后路腰椎椎体间植骨融合加椎弓根钉系统复位固定治疗腰椎滑脱可以取得良好复位、坚强内固定、彻底减压、融合率高等效果。     

PLIF加椎弓根内固定治疗腰椎滑脱症

目的探讨后路腰椎间植骨融合加椎弓根螺钉复位内固定治疗腰椎滑脱的临床应用。方法自2004年11月至2008年3月对31例腰椎滑脱采用后路腰椎间融合加椎弓根螺钉复位内固定治疗,分析手术疗效、滑脱椎体复位率及椎体间植骨融合率。结果后路腰椎间融合加椎弓根螺钉内固定确切,复位率为96.8%,椎体间植骨融合率为96.8%,椎间隙高度维持良好,滑脱椎体复位无丢失,总体疗效优良率为90.3%。结论腰椎间融合加椎弓根螺钉复位内固定治疗腰椎滑脱症具有复位满意、固定牢靠、植骨融合率高、减压彻底、临床疗效满意等优点。     

前后路联合手术治疗腰椎滑脱症

目的探讨应用后路椎弓根内固定系统联合前路椎体间植骨治疗重度腰椎滑脱症的临床疗效.方法应用后路SOCON提拉复位内固定系统复位并固定滑脱椎体,结合前路经腹膜外途径椎体间髂骨植骨治疗重度腰椎滑脱症20例.结果术后18例Ⅱ度椎体滑脱获得解剖复位,2例Ⅲ度脱位复位至Ⅰ度滑脱.经4～18个月随访,滑脱椎体复位无丢失,椎弓根螺钉无松动,椎体间骨融合牢固,椎间隙高度维持良好.结论SOCON提拉复位内固定系统可提供滑脱椎体满意的复位内固定作用,前路椎体间植骨融合率高,术后复位丢失率低.     

经前后路联合手术治疗L5S1椎体结核

目的 探讨一期经前路病灶清除后路植骨内固定治疗L5S1椎体结核的临床疗效.方法 对40例L5S1椎体结核患者,采用一期经前路病灶清除椎体间植骨加后路椎弓根螺钉内固定植骨融合治疗.结果 所有患者随访6～24个月,35例植骨融合良好,5例融合欠佳;有1例出现尿路感染.结论 一期经前路病灶清除椎体间植骨加后路椎弓根螺钉内固定椎板植骨治疗L5S1椎体结核能在彻底清除病灶的前提下保证脊柱的稳定性,提高植骨块的融合率和缩短患者卧床时间.     

后路复位植骨内固定治疗腰椎滑脱的临床观察

目的探讨后路椎弓根内固定加椎间植骨融合及椎弓根植骨术在治疗腰椎滑脱中的应用及其临床效果。方法腰椎滑脱者28例,男8例,女20例,采用提拉型RF或G SS椎弓根内固定器械行后路复位内固定加后路椎体间植骨及椎弓根植骨治疗。结果术后随访6~36个月,平均21个月,滑脱的复位率为86%,融合率为90.9%,无再滑脱现象。结论椎弓根内固定加后路椎间植骨融合及椎弓根植骨治疗腰椎滑脱,能提供稳定的生物力学环境,内固定可靠,椎体间融合良好,经济适用。     

椎弓根螺钉内固定加椎体间融合器治疗腰椎滑脱症

目的：探讨后路椎弓根螺钉内固定加椎体间Cage融合术治疗腰椎滑脱症的疗效。方法：手术治疗62例腰椎滑脱患者，其中行椎弓根螺钉内固定加Cage(21例)或植骨(3例)椎体间融合共24例：峡部裂型16例，退变性8例；腰4椎体滑脱13例，腰5椎体滑脱11例。按Meyerding分度：I度滑脱18例，Ⅱ度滑脱6例。2例先作后路椎弓切除减压椎弓根螺钉复位内固定，再作前路Cage植入，一期完成手术；其余22例均作后路切口行椎弓切除或椎板切除神经减压，椎弓根螺钉复位内固定，后路椎体间融合，其中19例加用单枚Cage后外侧斜向植入行椎体间融合，另3例行椎体问植骨融合，而使用Cage病例中有6例在其前方加用骨碎块植骨。结果：24例均获得3～48个月的随访，平均随访时间为18个月。根据Asher的疗效观察项目：优12例、良10例、可1例、差1例，优良率达91．7％。结论：腰椎滑脱的治疗减压后的融合是关键；为了达到融合的目的，复位内固定是必要的；减压后椎弓根螺钉内固定加后路腰椎椎体间融合是一个值得推荐的治疗腰椎滑脱的手术方法；而后外侧斜向放置单个Cage是一种安全有效的后路椎体间融合的方法。     

Clinical outcome of trans-sacral interbody fusion after partial reduction for high-grade l5-s1 spondylolisthesis

STUDY DESIGN: A clinical retrospective study was conducted. OBJECTIVE: To evaluate the clinical and radiographic outcome of reduction followed by trans-sacral interbody fusion for high-grade spondylolisthesis. SUMMARY OF BACKGROUND DATA: In situ posterior interbody fusion with fibula allograft has improved the fusion rates for patients with high-grade spondylolisthesis. The use of this technique in conjunction with partial reduction has not been reported. METHODS: Nine consecutive patients underwent treatment of high-grade (Grade 3 or 4) spondylolisthesis with partial reduction followed by posterior interbody fusion using cortical allograft. The average age at the time of surgery was 27 years (range, 8-51 years), and the average follow-up period was 43 months (range, 24-72 months). Before surgery, eight patients had low back pain, seven patients had radiating leg pain, and five patients had hamstring tightness. The average grade of spondylolisthesis by Meyerding grading was 3.9 (range, 3-5). Charts and radiographs were evaluated, and outcomes were collected by use of the modified SRS outcomes instrument. RESULTS: Radiographic indexes demonstrated significant improvement with partial reduction and fusion. The slip angle, as measured from the inferior endplate of L5, improved from 41.2 degrees (range, 24-82 degrees ) before surgery to 21 degrees (range, 5-40 degrees ) after surgery. All the patients were extremely or somewhat satisfied with surgery. The two patients who underwent this operation without initial instrumentation experienced fractures of their interbody grafts. Both of these patients underwent repair of the pseudarthrosis with placement of trans-sacral pedicle screw instrumentation and subsequent fusion. CONCLUSIONS: Partial reduction followed by posterior interbody fusion is an effective technique for the management of high-grade spondylolisthesis in pediatric and adult patient populations, as assessed by radiographic and clinical criteria. Pedicle screw instrumentation with the sacral screws capturing L5 is recommended when this technique is used for the treatment of high-grade spondylolisthesis. According to the clinical and radiographic results from this study, partial reduction and posterior fibula interbody fusion supplemented with pedicle screw instrumentation is an effective technique for select patients with high-grade spondylolisthesis at L5-S1.     

Primary lumbosacral stability after open posterior and endoscopic anterior fusion with interbody implants: a roentgen stereophotogrammetric analysis

STUDY DESIGN: After posterior stabilization of the spondylolytic lumbosacral level, mobility of the fused vertebrae could be studied before and after an additional anterior endoscopic interbody fusion using roentgen stereophotogrammetric analysis. OBJECTIVE: To determine the in vivo primary lumbosacral stability of additional anterior interbody fusion after transpedicular screw fixation. SUMMARY OF BACKGROUND DATA: In vitro studies indicate a significant decrease in segmental motion after pedicle screw fixation and additional anterior fusion. Roentgen stereophotogrammetric studies demonstrate the adequacy of transpedicular lumbar instrumentation in posterolateral fusions. There are no studies examining the effect of additional anterior interbody fusion after posterior instrumentation in vivo. METHODS: In this study, 15 patients with low-grade spondylolisthesis at L5-S1 underwent a two-stage open posterior and endoscopic anterior lumbar fusion using carbon fiber (Brantigan I/F) cages. At surgery, tantalum markers were implanted into the fifth lumbar (L5) and the first sacral (S1) vertebra. All the patients were examined by roentgen stereophotogrammetric analysis after the first and second surgical procedures. RESULTS: After implantation of the posterior pedicle system only, the mean intervertebral mobility determined by roentgen stereophotogrammetric analysis was 0.23 mm in the transverse (x), 0.54 mm in the vertical (y), and 1.2 mm in the sagittal (z) axes. After additional anterior endoscopic fusion with carbon cages, the remaining translation between the fused segment L5/S1 decreased to 0.17 mm in the x, 0.16 mm in the y, and 0.44 mm in the z axes. CONCLUSION: Anterior endoscopic lumbosacral fusion significantly increases the primary stability of the posterior fusion with a pedicle system in two axes of motion.     

腰椎滑脱的减压、内固定与融合术

目的观察采用腰椎管减压、横突间植骨、Cage椎间融合器和SOCON内固定治疗腰椎滑脱合并腰椎管狭窄的早期疗效。方法从1997年12月～1999年12月,对38例腰椎滑脱患者采用腰椎管减压,横突间植骨和SOCON内固定手术进行治疗。术前X线检查按Meyerding分度,Ⅰ度滑脱32例,Ⅱ度滑脱6例;L4,5滑脱29例,L5S1滑脱9例。结果术后平均随访18.2个月(14～26个月),比较手术前后临床症状和X线片滑脱复位程度,38例患者中,31例症状完全消失,优良率为81.6%。32例Ⅰ度滑脱完全复位,4例Ⅱ度滑脱完全复位,2例Ⅱ度滑脱复位达90%,解剖复位率达94.7%。结论应用SOCON内固定治疗腰椎滑脱,效果良好,复位满意。     

Posterior lumbar interbody fusion using titanium cylindrical threaded cages: is optimal interbody fusion possible without other instrumentation?

 This study evaluated the bony union obtained through posterior lumbar interbody fusion (PLIF) using Ray's threaded fusion cage (TFC) without other instrumentation. We assessed 25 consecutive patients who underwent treatment using this method. A bone graft was placed in the cages only. No additional instrumentation, such as a pedicle screw system, was used. The study group consisted of 12 men and 13 women. The mean age at the time of operation was 48.6 years, and the mean follow-up period was 44 months. The extent of facet joint destruction, bony union, and correction loss of spondylolisthesis were assessed. Union was assessed radiologically. Solid union was defined as the point at which complete superimposition of the fused vertebrae was detected in the flexion-extension lateral radiograph and the angle of sagittal rotaion was zero. Total facetectomy was performed in 20 of the 25 cases. Solid fusion of the operative intervertebral level was achieved in 7 cases (28%), and nonunion was detected in 18 cases (72%). There was no loss of correction of the anterolisthesis in 14 patients with spondylolisthesis. Received: February 18, 2002 / Accepted: October 25, 2002 Offprint requests to: T. Fuji, Department of Orthopaedic Surgery, Osaka Koseinenkin Hospital, 4-2-78 Fukushima, Fukushima-ku, Osaka 553-0003, Japan     

Transforaminale lumbale interkorporelle Fusion zur Versorgung der degenerativen Spondylolisthese

Introduction

Degenerative spondylolisthesis (DS) is a common cause of lumbal and lumbosacral pain as well as radicular pain. Retention and fusion is a good treatment option. Some patients have a symptomatic adjacent degenerative disc disease (DDD) in addition to DS. In these cases the adjacent segments should be fused as well. There are different techniques of fusion available, such as posterior with instrumentation or additional anterior support. This study evaluated results of transforaminal lumbar interbody fusion (TLIF) in patients with monosegmental DS and adjacent DDD.

Material and methods

A total of 28?patients with monosegmental DS and adjacent DDD were included into the study (all patients with bisegmental posterior instrumentation and fusion, 14?patients 1 level TLIF, 14?patients 2 level TLIF). Before surgery and 12?months after surgery the following measurements were made: pain (visual analog scale VAS), Oswestry disability index (ODI) and plain radiographs with radiometric analysis. In a sub-analysis patients with 1 and 2 level TLIF were compared.

Results

Pain reduction (average VAS from 8.7?C3.1) and ODI (63% to 28%) showed significant improvements. Radiometric analysis showed a significant disc height reconstruction and a significant reduction of spondylolisthesis (TLIF level with spondylolisthesis). Bisegmental anterior support showed a significantly better relordosation compared to monosegmental anterior support. The complication rate was 21.4% including hemorrhages, dura leakage, wound infection and adjacent segment degeneration. There were no fatal complications.

Discussion

The TLIF procedure is a safe and effective treatment for monosegmental DS with adjacent symptomatic DDD. Clinical results (pain, function) show no difference between both kinds of fusion (dorsal fusion and instrumentation versus dorsal fusion with instrumentation and TLIF) for the adjacent DDD. However, additional anterior support is more effective for relordosation of the segment. This could have impact on the mid-term and long-term outcome or in cases of adjacent segment fusion.     

Radiographic analysis of transforaminal lumbar interbody fusion for the treatment of adult isthmic spondylolisthesis

The radiographs of 35 consecutive adult patients with isthmic spondylolisthesis who underwent a transforaminal lumbar interbody fusion (TLIF) with one or two Brantigan carbon fiber cages and pedicle screw instrumentation were evaluated. Anterolisthesis, disk space height, and slip angle were measured in preoperative and postoperative standing neutral radiographs. Anterolisthesis was reduced and disk space height was increased with the TLIF procedure. Average slip angle, however, was not significantly altered. The restoration of lordosis across the listhetic disk space correlated with a more anterior placement of the interbody cage within the disk space. The TLIF technique, performed with the Brantigan cage and pedicle screw instrumentation, appears to be able to restore disk height and reduce forward translation in patients with isthmic spondylolisthesis, but improvement in sagittal alignment is dependent upon anterior placement of the interbody device.     

Percutaneous axial lumbar interbody fusion (AxiaLIF) of the L5-S1 segment: initial clinical and radiographic experience

INTRODUCTION: Anterior access to the L5-S1 disc space for interbody fusion can be technically challenging, frequently requiring the use of an approach surgeon for adequate exposure. We reviewed our experience with a novel minimally invasive technique for L5-S1 interbody fusion that exploits the presacral space and its relative dearth of critical structures. METHODS: 35 patients (20 F:15 M, mean age 54 years) were included in this analysis. Average follow-up was 17.5 months. Back pain was secondary to lumbar degenerative disc disease (DDD), degenerative lumbar scoliosis, or lytic spondylolisthesis. All patients had radiographic evidence of L5-S1 degeneration and underwent percutaneous paracoccygeal axial fluoroscopically-guided interbody fusion (axiaLIF) with cage, local bone autograft, and rhBMP. RESULTS: Mean operative time for the L5-S1 axiaLIF procedure was 42 minutes. Twenty-one patients underwent axiaLIF followed by percutaneous L5-S1 pedicle screw-rod fixation. Two patients underwent axiaLIF followed by percutaneous L4-L5 extreme lateral interbody fusion (XLIF) and posterior instrumentation. Ten patients had a stand-alone procedure. Unfavorable anatomy precluded access to the L5-S1 disc space during open lumbar interbody fusion in 2 patients who subsequently underwent axiaLIF at this level as part of a large construct. Thirty-two patients (91%) had radiographic evidence of stable L5-S1 interbody cage placement and fusion at the last follow-up. CONCLUSIONS: The percutaneous paracoccygeal approach to the L5-S1 interspace provides a minimally invasive corridor through which discectomy and interbody fusion can safely be performed. It can be used alone or in combination with minimally invasive or traditional open fusion procedures. It may provide an alternative route of access to the L5-S1 interspace in those patients who may have unfavorable anatomy for or contraindications to the traditional open anterior approach to this level.     

后路减压植骨融合RF内固定治疗腰椎滑脱症

目的：探讨后路应用RF椎弓根螺钉复位固定、减压、椎体间及后外侧植骨融合治疗腰椎滑脱症的疗效。方法：对87例腰椎滑脱症患者行后路椎管减压，应用RF椎弓根螺钉系统对滑脱椎体进行复位固定，椎体间和后外侧植骨融合。结果：随访9—48个月，临床优良率89．7％，腰椎滑脱复位率96．7％，6-12个月复查X线片均显示椎体间骨性融合，椎体间高度较术前明显增大。结论：RF椎弓根螺钉系统能有效撑开提拉滑脱椎体，复位满意，固定力强，并为彻底减压提供有效空间。采用椎体间联合后外侧植骨能有效提高植骨融合率。     

后路椎间融合术治疗成人腰椎滑脱的前瞻性研究

目的前瞻性比较采用自体髂骨块和椎间融合器治疗成人腰椎滑脱的效果。方法自1998年2月～2002年2月治疗78例腰椎滑脱患者,所有患者均行椎弓根螺钉固定、后路椎间融合术,根据椎间融合材料的不同,前瞻性将患者随机分为融合器组36例(采用后方斜向单枚椎间融合器)和自体骨组42例(采用自体髂骨块)。男33例,女45例;年龄35～59岁,平均43岁。其中Ⅰ度滑脱29例,Ⅱ度滑脱39例,Ⅲ度滑脱10例。比较两组患者的基本情况、临床效果和影像学结果(融合率和手术节段椎间隙高度的变化)。结果术后随访2年～3年7个月,平均35个月。两组在性别、年龄、滑脱程度、手术时间、失血量以及住院时间上差异无显著性,两组患者均无严重并发症。融合器组优良率为88.8%,自体骨组为83.2%(P=0.99)。术后1年融合器组的融合率为86.1%,自体骨组为83.3%,两组间差异无显著性意义(P=0.87);最终随访时椎间隙高度融合器组平均减少1.7 mm,自体骨组平均减少2.6 mm,两组间差异有非常显著性意义(t=1.38,P< 0.005)。结论采用自体骨为植骨材料者术后椎间隙高度丢失明显增加,但两组之间融合率和临床优良率差异无显著性。椎间融合器和自体髂骨块均可以作为腰椎滑脱后路椎间融合的植骨材料,临床疗效好。     

Posterolateral versus interbody fusion in isthmic spondylolisthesis: functional results in 52 cases with a minimum follow-up of 6 years

Posterolateral fusion has long been considered the "gold standard" technique for surgical treatment of adult spondylolisthesis. Superior results have subsequently been reported with interbody fusion with cages and posterior instrumentation. The goal of this prospective study was to compare the two techniques regarding their clinical outcomes and fusion rates. Fifty-two patients with isthmic spondylolisthesis were operated by the same surgeon. One group (25 patients) had decompression and posterolateral fusion (PLF) with a pedicle screw system ; patients in the other group were treated by decompression, posterior interbody fusion (PLIF) and a pedicle screw system. The two groups were similar with respect to grade of slipping, age, and activity. Seventy-seven percent of the patients had a good or very good result with PLIF and 68% with posterolateral fusion. However, there was no statistical difference in cases with low grade slipping, whereas the difference was significant for cases with high grade slipping. The fusion rate was 93% with PLIF and 68% with PLF, but without any significant incidence on the functional outcome. Based on these findings, we now use posterior interbody fusion for high grade spondylolisthesis which requires reduction or if the disc space is still high. When the slip grade is low, or the disc space is narrow, we prefer posterolateral fusion.