Liquois F, Tournier C, Xu B S, Le Huec J-C
Service d'orthopédie, clinique Aquitaine santé Jean-Villar, avenue Maryse-Bastié, 33523 Bruges cedex, France.
Rev Chir Orthop Reparatrice Appar Mot. 2008 May;94(3):273-81. doi: 10.1016/j.rco.2007.12.010. Epub 2008 Mar 10.
The aim of this prospective clinical study was to assess outcome after anterior retroperitoneal interbody arthrodesis for L5-S1 discopathy. We used a cage filled with an autologous corticocancellous graft and plate fixation.
Forty patients with low back pain unresponsive to medical treatment for more than six months were included in this series. We noted the clinical signs and radiculalgia. Patients were assessed preoperatively, postoperatively, at one year and at last follow-up using the Oswestry score and a visual analog scale (VAS). The plain X-rays disclosed 30 cases of discopathy (16 primary and 14 postdiscectomy) and 10 cases of spondylolisthesis by L5 isthmic lysis (three Meyerding grade 0 and seven grade 1). MRI revealed signs of disc degeneration in all cases with a black disc or modification of the endplate signals (Modic type 1 in 23 and type 2 in 13). The anterior retroperitoneal approach was used in all cases for complete discectomy, arthrodesis with cage insertion and an autologous corticocancellous graft harvested from the iliac bone and fixation using a triangular plate (Pyramid, Medtronic, Memphis TN). Clinical and radiographic follow-up data were available at six weeks and three, six and 12 months in addition to last follow-up. A follow-up using MRI was performed in the event of complications.
The population was composed of 25 women and 15 men, mean age 44 years and eight months (range 29-693 years). Thirteen patients presented radiculalgia. There were no vascular or gastrointestinal complications with the anterior approach. Bone healing was achieved at one year in 38 patients (95%). The mean Oswestry score improved from 52 to 16% and the mean VAS from 7.8 to 1.83 at 18 months follow-up. All occupationally-active patients but one resumed their former activity at mean 4.7 months. There were no sexual complications in this series. Low back pain persisted in three patients and five developed transient facet joint symptoms. Two patients developed secondary radiculalgia. We noted two cases of nonunion, in one grade 1 spondylolisthesis and in one grade 1 spondlylolisthesis (with revision for complementary posterior arthrodesis and a good outcome at latest follow-up).
Anterior L5-S1 interbody fusion with a cage filled with a corticocancellous autograft fixed with a plate provides good clinical and radiographic results for the stabilization of painful discopathy. The results have been good for isolated L5-S1 discopathy and for grade 0 spondylolisthesis. The limit for this technique would appear to be grade 1 spondylolisthesis with a degraded disc. Performed via an anterior retroperitoneal approach, this method is a good alternative to the classical posterior approach, enabling very low morbidity.
本前瞻性临床研究的目的是评估L5 - S1椎间盘病变行前路腹膜后椎间融合术的疗效。我们使用了填充自体皮质松质骨移植骨的椎间融合器和钢板固定。
本系列纳入了40例经药物治疗6个月以上仍有腰痛的患者。我们记录了临床体征和神经根性疼痛。术前、术后、术后1年及末次随访时使用Oswestry评分和视觉模拟量表（VAS）对患者进行评估。X线平片显示30例椎间盘病变（16例原发性和14例椎间盘切除术后）以及10例L5峡部裂性椎体滑脱（3例Meyerding 0级和7例1级）。MRI显示所有病例均有椎间盘退变征象，表现为黑椎间盘或终板信号改变（23例Modic 1型和13例2型）。所有病例均采用前路腹膜后入路进行彻底椎间盘切除术、植入椎间融合器并取自体髂骨皮质松质骨移植骨，使用三角钢板（Pyramid，美敦力，田纳西州孟菲斯）进行固定。除末次随访外，还在术后6周、3个月、6个月和12个月获得了临床和影像学随访数据。如有并发症则进行MRI随访。
研究对象包括25名女性和15名男性，平均年龄44岁零8个月（范围29 - 69岁）。13例患者出现神经根性疼痛。前路手术未发生血管或胃肠道并发症。38例患者（95%）在1年时实现了骨愈合。在18个月随访时，Oswestry评分平均从52%改善至16%，VAS评分平均从7.8降至1.83。除1例患者外，所有从事职业活动的患者平均在4.7个月时恢复了以前的活动。本系列未发生性功能相关并发症。3例患者持续存在腰痛，5例出现短暂的小关节症状。2例患者出现继发性神经根性疼痛。我们注意到2例不愈合病例，1例为1级椎体滑脱，另1例为1级椎体滑脱（行补充后路融合术翻修，末次随访时效果良好）。
使用填充皮质松质骨自体移植骨并固定钢板的椎间融合器行L5 - S1前路椎间融合术，对于疼痛性椎间盘病变的稳定提供了良好的临床和影像学结果。对于孤立的L5 - S1椎间盘病变和0级椎体滑脱，结果良好。该技术的局限性似乎是1级椎体滑脱合并退变椎间盘。通过前路腹膜后入路实施，该方法是经典后路手术的良好替代方案，发病率极低。
