Spine Surgery Department, Istituti Ortopedici Rizzoli, Bologna, Italy.
Spine (Phila Pa 1976). 2010 Jan 15;35(2):227-34. doi: 10.1097/BRS.0b013e3181bd3be6.
A retrospective study.
To analyze outcomes after dynamic stabilization without fusion in degenerative lumbar scoliosis in elderly patients.
Frequent complications of posterolateral instrumented fusion have been reported after treatment of degenerative lumbar scoliosis in elderly patients. The use of dynamic stabilization without fusion can be advocated to reduce such adverse effects, being less invasive, with shorter operation time and less blood loss. No study in the literature has analyzed outcomes of dynamic stabilization without fusion in these degenerative deformities.
Twenty-nine elderly patients (average age, 68.5 years; range, 61-78) with degenerative lumbar scoliosis, undergoing dynamic stabilization (Dynesys system) without fusion combined with decompressive laminectomy, in cases with associated stenosis, were analyzed. Stenosis of the vertebral canal was associated in 27 patients (93.1%); 13 cases (44.8%) also presented a degenerative spondylolisthesis. An independent spine surgeon retrospectively reviewed all the patients' medical records and radiographs to assess operative data and surgery-related complications. Preoperative, postoperative, and follow-up questionnaires were obtained to evaluate clinical outcomes.
The mean follow-up time was 54 months (range, 39-68). Oswestry Disability Index, Roland Morris Disability Questionnaire, and back pain and leg pain visual analogue scale scores received a statistically significant improvement at last control; the mean improvement was 51.6% for Oswestry Disability Index (P = 0.01), 58.2% for Roland Morris Disability Questionnaire (P = 0.01), 51.7% for leg pain (P = 0.02), and 57.8% for back pain (P = 0.01). Radiographically, degenerative scoliosis and associated spondylolisthesis resulted stable at follow-up with a moderate correction: the average scoliosis Cobb angle was 16.9 degrees (range, 12 degrees -37 degrees) before surgery and 11.1 degrees (range, 4 degrees -26 degrees) at last follow-up, with a 37.5% mean correction (P = 0.01); the anterior vertebral translation was 18.9% (range, 12%-27%) before surgery and 17% (range, 0%-27%) at follow-up, for a 14.6% mean correction (range, 0%-100%) (P = 0.02). No implant-related complications (screw loosening or breakage) or loss of correction were observed. Four cases (13.8%) presented an asymptomatic radiolucent line around screws of the S1 level without screw loosening. Six patients (20.7%) showed minor complications (ileus in 2 cases, urinary tract infection in 2, transient postoperative delirium in one, and respiratory difficulties after surgery in another patient). In 2 other patients (6.8%) incurred major complications, both requiring a revision surgery, for a misplaced screw on L5 and junctional disc degeneration at the lower level respectively. No neurologic complications occurred.
Dynamic stabilization with pedicle screws in addition to decompressive laminectomy resulted a safe procedure in elderly patients with degenerative lumbar scoliosis; it was able to maintain enough stability to prevent progression of scoliosis and instability, enabling a wide laminectomy in cases of associated lumbar stenosis. This nonfusion stabilization technique was less aggressive than instrumented fusion and obtained a statistically significant improvement of the clinical outcome at last follow-up.
回顾性研究。
分析老年退行性腰椎侧凸患者行动态稳定非融合治疗的疗效。
老年退行性腰椎侧凸患者行后路脊柱融合术常发生多种并发症。使用动态稳定非融合技术可减少这些不良反应，该技术具有微创、手术时间短、出血量少的优势。但目前尚无研究分析动态稳定非融合技术在退行性脊柱畸形中的疗效。
回顾性分析 29 例老年退行性腰椎侧凸患者（平均年龄 68.5 岁；范围 61-78 岁），均行后路减压联合动态稳定（Dynesys 系统）非融合治疗，对于合并椎管狭窄的患者同期行侧路减压。27 例（93.1%）患者存在椎管狭窄，13 例（44.8%）患者存在退行性腰椎滑脱。由一位独立的脊柱外科医生对所有患者的病历和影像学资料进行回顾性分析，评估手术数据和与手术相关的并发症。通过术前、术后和随访问卷评估临床疗效。
平均随访时间为 54 个月（范围 39-68 个月）。Oswestry 功能障碍指数、Roland Morris 残疾问卷、腰背疼痛视觉模拟评分在末次随访时均有显著改善，Oswestry 功能障碍指数改善率为 51.6%（P=0.01），Roland Morris 残疾问卷改善率为 58.2%（P=0.01），腰背疼痛视觉模拟评分改善率为 51.7%（P=0.02），下肢疼痛视觉模拟评分改善率为 57.8%（P=0.01）。影像学方面，退行性脊柱侧凸和合并的腰椎滑脱在随访时均保持稳定，且获得了中度矫正：术前平均脊柱侧凸 Cobb 角为 16.9°（范围 12°-37°），末次随访时为 11.1°（范围 4°-26°），平均矫正率为 37.5%（P=0.01）；术前的椎体前缘移位率为 18.9%（范围 12%-27%），末次随访时为 17%（范围 0%-27%），平均矫正率为 14.6%（范围 0%-100%）（P=0.02）。无内植物相关并发症（螺钉松动或断裂）或矫正丢失。4 例（13.8%）患者 S1 水平螺钉周围出现无症状透亮线，但无螺钉松动。6 例（20.7%）患者出现轻微并发症（2 例出现肠梗阻，2 例出现尿路感染，1 例出现短暂性术后谵妄，另 1 例患者术后出现呼吸困难）。另外 2 例（6.8%）患者出现严重并发症，均需行翻修手术，其中 1 例为 L5 侧螺钉位置不当，另 1 例为下位椎间盘退行性变导致交界处失稳。无神经并发症发生。
后路减压联合椎弓根螺钉固定的动态稳定非融合技术是治疗老年退行性腰椎侧凸的一种安全方法，能够维持足够的稳定性以防止脊柱侧凸和不稳定的进展，同时能够对合并腰椎管狭窄的患者行广泛的减压。这种非融合稳定技术比后路融合术侵袭性更小，末次随访时患者的临床疗效有显著改善。
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