ObjectiveTo explore the effectiveness of posterior lumbar interbody fusion in the treatment of double-segmental bilateral isthmic lumbar spondylolisthesis. MethodsBetween February 2008 and December 2013, 17 patients with double-segmental bilateral isthmic lumbar spondylolisthesis were treated with posterior lumbar interbody fusion. There were 12 males and 5 females, with an age ranged 48-69 years (mean, 55.4 years). The disease duration ranged from 11 months to 17 years (median, 22 months). According to the Meyerding classification, 30 vertebrea were rated as degree I, 3 as degree Ⅱ, and 1 as degree Ⅲ. L4, 5 was involved in 14 cases and L3, 4 in 3 cases. The preoperative visual analogue scale (VAS) score was 8.6±3.2. ResultsCerebrospinal fluid leakage occurred in 2 cases because of intraoperative dural tear; primary healing of incision was obtained, with no operation related complication in the other patients. The patients were followed up 1-6 years (mean, 3.4 years). At last follow-up, VAS score was decreased significantly to 1.1±0.4, showing significant difference when compared with preoperative score (t=7.652, P=0.008). X-ray films showed that slippage vertebral body obtained different degree of reduction, with a complete reduction rate of 85% (29/34) at 1 week after operation. All patients achieved bony union at 6-12 months (mean, 7.4 months). According to the Lenke classification, 13 cases were rated as grade A and 4 cases as grade B. No internal fixation loosening and fracture were observed during the follow-up. Intervertebral disc height was maintained, no loss of spondylolisthesis reduction was found. ConclusionIt can obtain satisfactory clinical result to use spinal canal decompression by posterior approach, and screw fixation for posterior fusion in treatment of double-segmental bilateral isthmic lumbar spondylolisthesis. The key points to successful operation include accurate insertion of screw, effective decompression, distraction before reduction, rational use of pulling screws, and interbody fusion.
目的:探讨使用Moss Miami系统经骶棘肌肌间隙入路在APERTURE工具的引导下微创治疗腰椎滑脱症的疗效。方法:20例腰椎滑脱症患者(男11例,女9例),年龄30～65岁(平均40岁)。其中退变性14例、峡部裂5例、腰椎间盘突出合并钙化1例;Ⅰ度滑脱15例,Ⅱ度滑脱5例。滑脱部位:L4滑脱14例,L5滑脱6例,采用全麻俯卧位下经下腰部正中小切口(5cm),经双侧骶棘肌肌间隙入路在APERTURE工具的引导下放置Moss Miami系统进行复位固定和椎体间及后外侧植骨融合。结果:本组患者术中在C臂X光机监视,经骶棘间隙放置Moss Miami固定系统简单易行,切口较小、显露好、出血少,对骶棘肌等软组织造成的损伤轻,复位固定效果满意。术后经6月随访表明:本组患者腰腿痛等临床症状缓解,X线片显示滑脱复位无丢失、植骨融合良好、内固定器械无松动及断裂。结论:在C臂X光机监视下,采用Moss Miami经骶棘肌肌间隙入路在APERTURE工具的引导下治疗腰椎滑脱症具有切口小、肌肉软组织损伤轻、出血少、固定器械放置简单易行等优点,有利于患者术后康复。
Objective To evaluate the therapeutic effects of expandable pedicle screw (EPS) combined with interbody fusion cage on lumbar spondylolisthesis. Methods From June 2004 to March 2008, 23 patients with lumbar spondylolisthesiswere treated, including 9 males and 14 females aged 24-72 years old (average 48.7 years old). The course of the disease varied from 6 months to 6 years (average 30.4 months). There were 18 cases of degenerative spondylol isthesis and 5 of isthmic spondylolisthesis, including 1 case at L3,4 level, 14 at L4,5 level, and 8 at L5 and S1 levels. There were 17 cases of grade I, 4 of grade II, and 2 of grade III (including 1 case of recurrent L5 spondylolysis) according to Meyerding classification system. Posterior lumbar interbody fusion was performed using 48 PLIVIOS interbody fusion cages, and spondylolisthesis reduction and internal fixation were conducted using 84 pieces of EPS. The indications for use of EPS were initial operation with bone mass reduction or osteoporosis, reoperation of previous pedicle instrumentation, intraoperative screw relocation, sacral anchoring, and construct reinforcement. Cl inical outcomes, radiographic reduction of spondylol isthesis and bone fusion of lumbar interbody were evaluated based on JOA score, Boxall index, and Cook criteria. Results The incision healed by first intension in all cases except for one revision case that suffered from postoperative cerebrospinal fluid leakage and obtained delayed-healing without infection 23 days after operation using conservative treatment. No operative compl ications such as nerve and organ injuries were found.All cases were followed up for 12-39 months (average 17.8 months). X-ray exams of spine AP, lateral, fully extended position and fully flexed position view showed all 84 EPS were fully expanded within vertebral body. The improvement rate of JOA at the final follow-up visit was markedly effective in 14 cases, and effective in 5 cases, and noneffective in 4 cases, with a total effective rate of 82.61%. Anatomic reduction was achieved in 14 cases, improvement was obtained in 6 cases, no improvement was observed in 3 cases, and the reduction rate was 86.69%. Lumber interbody fusion was achieved in 20 cases, fixation was achieved in 2 cases, failure was observed in 1 cases, and the fusion rate was 86.69%. Conclusion EPS in complex with interbody fusion cage provides effective reduction, internal fixation and interbody fusion for the reconstruction of lumbar spondylolisthesis.
ObjectiveTo investigate the effectiveness of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) assisted with microscope in treatment of lumbar spondylolisthesis. MethodsBetween January 2011 and June 2012, 52 patients with lumbar spondylolisthesis underwent MI-TLIF assisted with microscope. There were 29 males and 23 females with an average age of 46 years (range, 32-67 years). The median disease duration was 3.2 years (range, 3 months to 6 years). There were 38 cases of lumbar isthmic spondylolisthesis and 14 cases of degenerative spondylolisthesis; 12 cases had stenosis secondary to lumbar spondylolisthesis. The affected segments were L4, 5 (29 cases) and L5, S1 (23 cases). According to the Meyerding evaluating system, 24 cases were classified as degree I and 28 cases as degree Ⅱ. The visual analogue scale (VAS) score and Oswestry disability index (ODI)were used for clinical assessment, and the clinical effects were also analyzed by Macnab criterion at last follow-up. The radiographic data were used to evaluate reduction of spondylolisthesis, including slipping degree, slipping angle, and intervertebral space height. The fusion rate was assessed by Suk criterion. ResultsThe operations were performed successfully in all patients. No dural tear or cerebrospinal fluid leakage occurred during operation. The average operation time was 105 minutes; the average intraoperative blood loss was 225 mL; the average postoperative drainage volume was 75 mL; and the average hospitalization days were 5.5 days. Superficial infection of incision occurred in 1 case and was cured after change dressing, and primary healing of incision was obtained in the others. All patients were followed up 12-26 months (mean, 18 months). No loosening, breakage, and displacement of pedicle screw and no Cage dislocation occurred by X-ray films after operation. The lumbar spondylolisthesis all got good correction. The three-dimensional CT showed continuous bone trabecula between centrums. The VAS score, ODI, and the slipping degree, slipping angle, and intervertebral space height were significantly improved at last follow-up when compared with preoperative ones (P<0.05). According to Macnab criterion at last follow-up, the results were excellent in 20 cases, good in 29 cases, and fair in 3 cases; the excellent and good rate was 94.2%. According to Suk criterion for fusion, 49 cases obtained complete fusion and 3 cases got possible fusion. ConclusionAs long as indications are seized, MI-TLIF assisted with microscope is safe and reliable for treatment of lumbar spondylolisthesis (Meyerding dergee I or Ⅱ), and it has the advantage of less injury, less blood loss, less complications, and definite short-term effectiveness.
ObjectiveTo explore a better segment of fixation and fusion for high-grade spondylolisthesis. MethodsA total of 21 patients with high-grade spondylolisthesis who had undergone reduction and posterior instrumented fusion between July 2007 and March 2012, were retrospectively reviewed. All cases underwent posterior spinal canal decompression, Schanz screws fixation and reduction, and intervertebral and posterolateral fusion. The concept of "unstable zone" and the feature of spinal deformity helped us to identify the most appropriate segment to fuse. The pre/post-operative differences on slip percentage, pelvic incidence (PI) and lumbosacral angle were compared and analyzed. The nerve function was evaluated by physical examination and neurological Frankel grade. The Visual Analogue Scale (VAS) and Oswestry Disability Index were used to assess clinical and functional outcomes of lower limbs. Bone fusion was assessed using CT reconstruction. ResultsAll patients were followed up between 12 and 48 months. The clinical and radiological outcomes such as VAS scores and PI angle were all improved compared with that of preoperative, and the differences were all statistically significant (P<0.05). ConclusionFor children with severe spondylolisthesis, if not combined with structural scoliosis, the fixation and fusion level should be up to the upper vertebra which PI angle>60°, and try to protect the posterior longitudinal ligament complex in case adjacent segments become instability or even slip. For adults with severe spondylolisthesis, if not combined with other spinal disorders such as severe osteoporosis, only mono-segmental fusion is recommended after reduction. If the slipped vertebrae could not be reduced to Meyerding gradeⅠ, two or more segments would need to be fixed and fused.
Objective To investigate the effect of the sagittal alignment of the spine and pelvis after surgical posterior intervertebral fusion combined with pedicle screw fixation for low-grade isthmic lumbar spondylolisthesis, and to assess the effectiveness. Methods Between October 2009 and October 2011, 30 patients with low-grade isthmic spondylolisthesis underwent surgical posterior intervertebral fusion combined with pedicle screw fixation, and the clinical data were retrospectively reviewed. There were 14 males and 16 females with an average age of 56.7 years (range, 48-67 years). The pre- and post-operative radiographic parameters, such as percentage of slipping (PS), intervertebral space height, angle of slip (AS), thoracic kyphosis (TK), thoracolumbar junction angle (TLJ), sagittal vertical axis (SVA), lumbar lordosis (LL), spino-sacral angle (SSA), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI) were measured. The functional evaluation was made using the Oswestry Disability Index (ODI). Pearson correlation were used to investigate the association between all parameters and ODI score. Results PS, intervertebral space height, AS, and ODI were improved significantly compared with properative ones (P lt; 0.05). Significant differences were found in the other parameters between pre- and post-operation (P lt; 0.05) except TLJ and TK. The alteration of SVA showed significant correlation with the changes of PS, PI, PT, LL, SS, AS, SSA, and ODI. The alteration of SSA showed significant correlation with the changes of PS, PI, LL, SS, AS, PT, and ODI. Conclusion Surgical posterior intervertebral fusion combined with pedicle screw fixation for low-grade isthmic spondylolisthesis can effectively improve and maintain the spinal sagittal parameters. SVA and SSA are adequate to evaluate pre-and post-operative balance. The good clinical outcome is closely related with the improved of SVA and SSA.