Mediterranean University, Marseille Timone Children Hospital, Pediatric Surgery and Orthopaedics Department, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France.
Orthop Traumatol Surg Res. 2011 Apr;97(2):179-85. doi: 10.1016/j.otsr.2010.11.003. Epub 2011 Feb 26.
Describing and assessing of a new surgical procedure to achieve circumferential fusion and translumbosacral fixation using a custom-made canulated screw.
Seven patients aged 13-18 years old underwent surgery with this technique (mean age: 15). All patients had high-grade spondylolisthesis (Meyerding stage III or IV). There were five girls and two boys. A posterior surgical approach alone was used in all cases. The posterior neural arch of L5 was removed and a sacral laminectomy, extending to S2, was performed. Sacral nerve roots S2 and S3 were carefully dissected and transposed. A K-wire was placed medially across the vertebrae from the posterior edge of S2 extending to the anterosuperior corner of L5. Fluroscopic perioperative fluroscopic control confirmed correct K-wire placement. The custom-made 10mm diameter canulated screw was then inserted along the K-wire as a guide. Screw fixation was obtained by placing a specific large diameter screw head to obtain compression by a lag screw effect. Once fixation was obtained, the sacral dome was excised and interbody fusion was performed (tricorticocancellous graft on each side of the screw). Additional bilateral posterolateral fusion was then performed. A half body custom fit thoracolumbar orthosis brace was prescribed 3 months postoperatively, followed by a Lombostat flexible lumbar support for an additional 3 months period.
One neurological complication occurred. A dural tear occurred during dissection requiring simple repair. All of the patients were on their feet on the fifth postoperative day and began walking. The half bodybrace was worn for 4 months in four patients and 2 months in the three others. At final follow-up patients had no residual pain.
The lumbar spine in children with high-grade spondylolisthesis adapts to the new mechanical conditions after surgery. Therefore the principal goal of treatment is to obtain stable osseous fusion. Our treatment philosophy is based on the concept of a dual instability. We believe that a general instability exists which causes the development of spondylolisthesis; this must be respected by not attempting to correct the displacement beyond what can be obtained on the operating table with complete muscle release. The other, locoregional instability, must be stabilized during circumferential fusion. The custom-made, 10mm screw has been shown to be effective in neutralizing the mechanical stress during circumferential fusion with a posterior approach alone, thus avoiding the risks of an anterior approach. Long-term results show that the preoperative posture is not the sole mechanical determinant in children and adolescents but that this posture is largely a reaction to pain.
Level IV. Retrospective study.
描述并评估一种新的手术方法，通过定制的套管螺钉实现周向融合和腰骶固定。
7 名 13-18 岁的患者接受了该技术的手术（平均年龄：15 岁）。所有患者均为高度脊椎滑脱（Meyerding Ⅲ或Ⅳ期）。其中有 5 名女孩和 2 名男孩。所有病例均采用单纯后路手术。切除 L5 的后神经弓，并进行骶骨椎板切除术，延伸至 S2。仔细解剖和移位 S2 和 S3 的骶神经根。一根 K 线穿过 S2 的后缘，向 L5 的前上顶角延伸，穿过中线。术中透视证实 K 线的正确位置。然后，沿着 K 线插入定制的 10mm 直径套管螺钉作为引导。通过放置特定的大直径螺钉头，利用滞后螺钉效应获得固定。一旦固定，切除骶骨穹窿，进行椎间融合（每个螺钉两侧进行三叶皮质松质骨移植物）。然后进行双侧后外侧融合。术后 3 个月，患者佩戴半身定制式胸腰椎矫形支具，再佩戴 Lombostat 柔性腰椎支撑 3 个月。
发生 1 例神经并发症。在解剖过程中发生硬脑膜撕裂，需要简单修复。所有患者术后第 5 天即可下地行走。4 例患者佩戴半身支具 4 个月，3 例患者佩戴 2 个月。末次随访时，患者无残留疼痛。
儿童高等级脊椎滑脱术后腰椎会适应新的力学条件。因此，治疗的主要目标是获得稳定的骨性融合。我们的治疗理念基于双重不稳定的概念。我们认为存在一种一般的不稳定，导致脊椎滑脱的发展；在手术中，通过完全肌肉松解，尽可能纠正位移，不要试图超越这个程度。另一种局部不稳定，必须在周向融合过程中得到稳定。定制的 10mm 螺钉已被证明可有效抵抗单纯后路融合过程中的力学应激，从而避免前路手术的风险。长期结果表明，术前姿势不是儿童和青少年的唯一机械决定因素，而是这种姿势在很大程度上是对疼痛的反应。
IV 级。回顾性研究。
