Gille O, Challier V, Parent H, Cavagna R, Poignard A, Faline A, Fuentes S, Ricart O, Ferrero E, Ould Slimane M
Service de chirurgie orthopédique et traumatologique, hôpital Tripode, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France.
Service de chirurgie orthopédique et traumatologique, hôpital Tripode, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France.
Orthop Traumatol Surg Res. 2014 Oct;100(6 Suppl):S311-5. doi: 10.1016/j.otsr.2014.07.006. Epub 2014 Sep 5.
Degenerative spondylolisthesis is common in adults. No consensus is available about the analysis or surgical treatment of degenerative spondylolisthesis. In 2013, the French Society for Spine Surgery (Societe francaise de chirurgie du rachis) held a round table discussion to develop a classification system and assess the outcomes of the main surgical treatments. A multicentre study was conducted in nine centres located throughout France and Luxembourg. We established a database on a prospective cohort of 260 patients included between July 2011 and July 2012 and a retrospective cohort of 410 patients included in personal databases between 2009 and 2013. For patients in the prospective cohort clinical assessments were performed before and after surgery using the self-administered functional impact questionnaire AQS, SF12, and Oswestry Disability Index (ODI). Type of treatment and complications were recorded. Antero-posterior and lateral full-length radiographs were used to measure lumbar lordosis (LL), segmental lordosis (SL), pelvic incidence (PI), pelvic tilt (PT), sagittal vertical axis (SVA), and percentage of vertebral slippage. Mean follow-up was 10 months. We started a randomised clinical trial comparing posterior fusion of degenerative spondylolisthesis with versus without an inter-body cage. 60 patients were included, 30 underwent 180° fusion and 30 underwent 360° fusion using an inter-body cage implanted via a transforaminal approach. We evaluated the quality of neural decompression achieved by minimally invasive fusion technique. In a subgroup of 24 patients computed tomography (CT) was performed before and after the procedure and then compared. Mean age was 67 years and 73% of degenerative spondylolisthesis were located at L4-L5 level. The many surgical procedures performed in the prospective cohort were posterior fusion (39%), posterior fusion combined with inter-body fusion (36%), dynamic stabilization (15%), anterior lumbar fusion (8%), and postero-lateral fusion without exogenous material (2%). Peri-operative complications of any severity occurred in 17% of patients. The AQS, ODI and SF12 scores were improved significantly at follow-up. We found no differences in clinical improvements across surgical procedure types. Circumferential fusion (360°) was associated with greater relief of nerve root pain and better lordosis recovery after 1 year compared to postero-lateral fusion (180°). Post-operative CT images showed effective decompression of nervous structures after minimally invasive fusion. Longer follow-up of our patients is needed to assess the stability of the results of the various surgical procedures. Based on a radiological analysis, the authors propose a new classification with five types of degenerative spondylolisthesis: type 1, SL>5° and LL>PI-10°; type 2, SL<5° and LL>PI-10°; type 3, LL<PI-10°; type 4, LL<PI-10° and compensated sagittal balance with PT>25°; and type 5, sagittal imbalance with SVA>4 cm.
IV Observational cohort study. Retrospective review of prospectively collected outcome data.
退变性腰椎滑脱在成年人中很常见。关于退变性腰椎滑脱的分析或手术治疗尚无共识。2013年，法国脊柱外科学会召开了一次圆桌会议，以制定一种分类系统并评估主要手术治疗的结果。在法国和卢森堡各地的九个中心进行了一项多中心研究。我们建立了一个数据库，其中包括2011年7月至2012年7月纳入的260例患者的前瞻性队列以及2009年至2013年纳入个人数据库的410例患者的回顾性队列。对于前瞻性队列中的患者，在手术前后使用自我管理的功能影响问卷AQS、SF12和Oswestry功能障碍指数（ODI）进行临床评估。记录治疗类型和并发症。使用前后位和侧位全长X线片测量腰椎前凸（LL）、节段性前凸（SL）、骨盆入射角（PI）、骨盆倾斜度（PT）、矢状垂直轴（SVA）和椎体滑脱百分比。平均随访时间为10个月。我们启动了一项随机临床试验，比较有或没有椎间融合器的退变性腰椎滑脱后路融合术。纳入60例患者，30例行180°融合，30例行360°融合，通过经椎间孔入路植入椎间融合器。我们评估了微创融合技术实现的神经减压质量。在24例患者的亚组中，在手术前后进行计算机断层扫描（CT），然后进行比较。平均年龄为67岁，73%的退变性腰椎滑脱位于L4-L5节段。前瞻性队列中进行的许多手术操作包括后路融合（39%）、后路融合联合椎间融合（36%）、动态稳定（15%）、前路腰椎融合（8%）和无外源性材料的后外侧融合（2%）。17%的患者发生了任何严重程度的围手术期并发症。随访时AQS、ODI和SF12评分显著改善。我们发现不同手术类型在临床改善方面没有差异。与后外侧融合（180°）相比，环形融合（360°）在1年后神经根疼痛缓解更明显，前凸恢复更好。术后CT图像显示微创融合后神经结构有效减压。需要对我们的患者进行更长时间的随访，以评估各种手术操作结果的稳定性。基于影像学分析，作者提出了一种新的退变性腰椎滑脱分类，分为五种类型：1型，SL>5°且LL>PI-10°；2型，SL<5°且LL>PI-10°；3型，LL<PI-10°；4型，LL<PI-10°且矢状位平衡代偿，PT>25°；5型，矢状位失衡，SVA>4 cm。
IV级观察性队列研究。对前瞻性收集的结局数据进行回顾性分析。
