Pedicle fixation combined with intervertebral fusion for lumbar spondylolithesis: whether restoring disc height affects the biomechanics and spinal function

doi:10.3969/j.issn.2095-4344.2017.35.010

Abstract

Abstract:

BACKGROUND: According to the current most prevailed posterior pedicle screw reduction and Cage fusion for spondylolisthesis, the previous focus is to restore the vertebral sagittal displacement, and whether restoring disc height is needed and the degree of recovery remain unclear. Moreover, there is still a lack of better quantitative indicators to restore the disc height.

OBEJCTIVE: By comparing the surgery of lifting reduction, to study the clinical effect of distraction and lifting reduction combined with posterior intervertebral fusion in the treatment of lumbar spondylolisthesis.

METHODS: Sixty patients with L₅spondylolisthesis located in L₅/S₁ were selected, and were divided into two groups based on the surgery methods (n=30 per group): group A (single lifting reduction group) and group B (lifting and distracting reduction group). The patients in the group B were given distracting reduction amid insertion of 12 mm-height Cage; while the patients in the group A were subjected to lifting reduction, and intervertebral fusion with 8 mm-height Cage. The general information and the Visual Analogue Scale, Japanese Orthopaedic Association and Oswestry Disability Index scores at baseline, postoperative 1 month and last follow-up, as well as the postoperative correction and bone fusion were recorded. Additionally, the clinical effectiveness was assessed by Macnab score.

RESULTS AND CONCLUSION: (1) At postoperative 1 month and last follow-up, the disc height, disc height/vertebral height, neuroforamen height and clinical effectiveness in the group B were superior to those in the group A (P < 0.05). (2) To conclude, the pedicle screw system combined with posterior intervertebral cage fusion for spondylolisthesis, can rapidly restore the disc height, contribute to restructure better biomechanics of spine. Furthermore, it significantly improves clinical systems, is easy to operate, and achieves better efficacy; therefore, it is recommended firstly.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Lumbar Vertebrae, Spinal Fusion, Spondylolisthesis, Tissue Engineering

CLC Number:

R318

Wang Li, Qiu Nan-hai, Yu Ming. Pedicle fixation combined with intervertebral fusion for lumbar spondylolithesis: whether restoring disc height affects the biomechanics and spinal function[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(35): 5636-5643.

Figures/Tables 4

2.2 一般手术数据撑开组和单纯提拉组在手术完成时间、术中出血量、术后引流量及住院时间方面比较，差异均无显著性意义(P > 0.05)，见表2。撑开组在上述4组数据方面略显优势，但与单纯提拉组差异无显著性意义。 2.3 不良反应及并发症术后无患者出现伤口感染。撑开组1例患者伤口内积血，拆除少许缝线后换药二期愈合。1例患者术中出现硬脊膜撕裂、术后脑脊液漏，延长术后放置引流管时间至术后10 d，待引流液清亮，量少于50 mL后拔管并深部缝扎。随访患者未出现明显发热及低颅压头痛症状。1例病例术后出现左侧L5神经根支配区酸胀痛症状，术后对症2周症状逐渐消失。单纯提拉组1例患者末次随访时L5左侧椎弓根钉可见 1 mm硬化边缘，考虑松动，但因无其他钉棒松动迹象及明显退钉表现，亦无神经根及脊髓压迫等相关症状，故暂未处理，仅嘱患者定期随访。1例患者术后20个月再次出现L5左侧神经根酸胀痛症状，症状反复2次，均经保守输液治疗后症状好转，无下肢肌力改变及括约肌功能障碍，复查影像学检查未见明显内植物断裂现象，可见神经根肩部瘢痕组织轻度压迫，植骨可疑融合，仍在定期随访观察。 2.4 临床评分组内比较，2组患者术后目测类比评分、JOA评分、ODI均较术前明显改善，差异有显著性意义。组间比较，术后1个月随访时，JOA评分方面撑开组明显优于单纯提拉组，差异有显著性意义。末次随访提示目测类比评分、JOA评分、ODI撑开组均明显占优，差异有显著性意义(表3-5)。 2.5 临床疗效采用Macnab标准评价临床疗效，单纯提拉组总优良率为93%(28/30)，而撑开组为80%(24/30)，2组相比差异有显著性意义(P < 0.01)，见表6。 2.6 影像学指标滑脱率方面，组内比较，2组患者术后均较术前明显改善，差异有显著性意义。组间比较，术后1个月及末次随访显示撑开组滑脱率平均值更低，但差异无显著性意义(表7)。椎间隙高度方面，组内比较，单纯提拉组与撑开组术后1个月及末次随访均较术前明显改善，末次随访2组椎间隙高度均有少许丢失，但差异无显著性意义。组间比较，术后1个月及末次随访提示撑开组椎间隙高度明显高于单纯提拉组，差异有显著性意义(表8)。椎间孔高度方面，组内比较，单纯提拉组术后较术前改善差异无显著性意义；撑开组术后1个月及末次随访均较术前明显改善，末次随访2组椎间孔高度亦均较术后1个月时有少许丢失，但差异无显著性意义。组间比较，术后1个月及末次随访时撑开组椎间孔高度明显高于提拉组，差异有显著性意义(表9)。椎间隙角度方面，组内比较，单纯提拉组术后较术前少许增加，差异无显著性意义；撑开组术后1个月及末次随访椎间隙角度均较术前明显增加，差异有显著性意义。组间比较，术后1个月及末次随访提示撑开组椎间隙角度明显高于提拉组，差异有显著性意义(表10)。椎间隙(L5/S1)高度/椎体(L5)高度比，组内比较，单纯提拉组术后较术前增加差异无显著性意义；撑开组术后1个月及末次随访均较术前明显改善(差异有显著性意义)，分别达到(43.8±3.8)%及(42.1±2.1)%，且接近正常成人生理水平的(46±11)%[4]。组间比较，术后1个月及末次随访提示撑开组椎间隙高度/椎体高度比值明显高于提拉组，差异有显著性意义(表11)。末次随访时，X射线片/CT检查示单纯提拉组2例Cage椎间融合器轻度移位，分别为2 mm及3 mm，移位Cage未对椎管及周围其他重要组织造成压迫，患者亦无相关临床症状，嘱其避免腰部过大扭力，仍在定期随访观察。椎间融合情况，根据Suk标准评价，撑开组完全融合30例；单纯提拉组完全融合28例，可能融合2例，差异无显著性意义(P > 0.05)。 2.7 典型病例撑开组典型病例见图2，单纯提拉组典型病例见图3。 "

References

[1] 叶握球,杨艳琴,郑建河,等．经椎旁间隙与正中入路单纯椎弓根钉内固定术治疗轻度峡部裂型腰椎滑脱症的疗效比较[J].广东医学,2014,35(6):900-902.

[2] 杨利斌,宗海斌,董玉珍,等.cage联合椎弓根螺钉在不稳定性腰椎管狭窄症中的应用[J]. 中国实用医药,2010,5(5):38-40.

[3] Lian XF, Hou TS, Xu JG, et al. Single segment of posterior lumbar interbody fusion for adult isthmic spondylolisthesis: reduction or fusion in situ. Eur Spine J. 2014;23 :172–179.

[4] 焦根龙,李志忠,赵明杰,等. 115例20-30岁正常国人腰椎数据测量与其临床意义[D]. 暨南大学, 2008.

[5] 乔风雷,朱斌,马军,等. 腰椎正中矢状面椎间隙的CT测量及临床意义[J]. 中国中西医结合影像学杂志,2015,13(4):382-384.

[6] 黄鑫鹏. 第五腰椎椎弓根螺钉改良置入技术的研究[D].南京医科大学,2016.

[7] 田胜兰,谭伟,冯丹,等. 经皮椎间孔镜下髓核摘除术治疗腰椎间盘突出症的临床观察[J]. 华中科技大学学报(医学版), 2015, 44(4):472-475.

[8] 孙国荣,吴成如,蒋传海,等. 腰椎滑脱的手术治疗进展[J]. 安徽医学,2016,41(10):1311-1313.

[9] 李军,王洁艳.椎弓根螺钉内固定及后路植骨融合术治疗腰椎滑脱症疗效观察[J].实用临床医药杂志,2014,18(16):93-95.

[10] Pollintine P, Dolan P, Tobias JH, et al. Intervertebral disc degeneration can lead to “stress-shielding” of the anterior vertebral body: a cause of osteoporotic vertebral fracture. Spine. 2004;29(7):774-782.

[11] Asano S, Kanrda K, Umehara S. The mechanical properties of the human L4-5 functional spinal unit during cyclic loading. The structural effects of the posterior elements. Spine. 1992; 17:1343-1352.

[12] 刘恩志.撑开型融合器治疗腰椎疾患长期随访及疗效评价[D].南方医科大学,2014.

[13] Umehara S, Zindrick MR, Patwardhan AG, et al. The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adjacent spinal segments. Spine. 2000;25(13)：1617-1624.

[14] 王晓东,马丽,王德洪,等. 60-69岁老年人腰椎椎间隙高度与慢性腰痛的相关性研究[J]. 中国运动医学杂志,2013,32(6):540-544.

[15] Fu MC,Nemani VM,Albert TJ. Operative treatment of thoracolumbar burst fractures: is fusion necessary? HSS J. 2015;11(2):187-189.