Helenius Ilkka, Remes Ville, Poussa Mikko
Children's Hospital, Helsinki University Central Hospital, P.O. Box 281, 00029 HUS, Finland.
J Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt 1:145-52. doi: 10.2106/JBJS.G.01186.
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.
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.
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.
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.
中期影像学研究表明，前路和环形技术在重度腰椎滑脱患者中可实现较高的融合率，而后外侧融合的成功率较低。我们尚未发现有任何长期比较研究对这三种方法的功能结局进行评估，包括系统的脊柱活动度和躯干力量测量。
1977年至1991年间连续83例重度峡部裂型腰椎滑脱患者中，69例接受了后外侧（21例）、前路（23例）或环形（25例）非器械辅助脊柱融合术的患者参与了本研究。平均随访时间为17.2年。对术前及最近一次随访时的X线片进行融合质量和退变改变的评估。在最近一次随访时，由独立观察者根据体格检查、脊柱活动度、非测力躯干力量测量以及Oswestry功能障碍指数评分对结局进行评估。
后外侧融合组术前椎体滑移平均为61%，前路融合组为63%，环形融合组为71%。后外侧融合组最终融合率为86%（21例中的18例），前路融合组为100%（23例中的23例），环形融合组为96%（25例中的24例）。后外侧融合组有5例、前路融合组有7例、环形融合组有1例患者在融合上方第一个可活动节段的腰椎间盘高度下降（p = 0.037）。后外侧融合组Oswestry功能障碍指数平均评分为9.7，前路融合组为8.9，环形融合组为3.0（p = 0.035）。非测力躯干力量测量结果与参考值相符。异常低的腰椎前屈在外侧和环形融合组中比在前路融合组中更常见（p = 0.0015）。滑移百分比与腰椎前屈、后伸及躯干侧屈呈负相关。
基于患者结局评估，环形原位融合术的长期效果略优于后外侧或前路原位融合术。当将影像学和功能结果与基于患者的结局相结合时，三组之间的总体差异较小。
