McAfee Paul C, Shucosky Erin, Chotikul Liana, Salari Ben, Chen Lun, Jerrems Dan
Spine and Scoliosis Center, University of Maryland, St. Joseph Medical Center, Towson, MD.
Int J Spine Surg. 2013 Dec 1;7:e8-e19. doi: 10.1016/j.ijsp.2012.10.001. eCollection 2013.
This is a retrospective review of 25 patients with severe lumbar nerve root compression undergoing multilevel anterior retroperitoneal lumbar interbody fusion and posterior instrumentation for deformity. The objective is to analyze the outcomes and clinical results from anterior interbody fusions performed through a lateral approach and compare these with traditional surgical procedures.
A consecutive series of 25 patients (78 extreme lateral interbody fusion [XLIF] levels) was identified to illustrate the primary advantages of XLIF in correcting the most extreme of the 3-dimensional deformities that fulfilled the following criteria: (1) a minimum of 40° of scoliosis; (2) 2 or more levels of translation, anterior spondylolisthesis, and lateral subluxation (subluxation in 2 planes), causing symptomatic neurogenic claudication and severe spinal stenosis; and (3) lumbar hypokyphosis or flat-back syndrome. In addition, the majority had trunks that were out of balance (central sacral vertical line ≥2 cm from vertical plumb line) or had sagittal imbalance, defined by a distance between the sagittal vertical line and S1 of greater than 3 cm. There were 25 patients who had severe enough deformities fulfilling these criteria that required supplementation of the lateral XLIF with posterior osteotomies and pedicle screw instrumentation.
In our database, with a mean follow-up of 24 months, 85% of patients showed evidence of solid arthrodesis and no subsidence on computed tomography and flexion/extension radiographs. The complication rate remained low, with a perioperative rate of 2.4% and postoperative rate of 12.2%. The lateral listhesis and anterior spondylolisthetic subluxation were anatomically reduced with minimally invasive XLIF. The main finding in these 25 cases was our isolation of the major indication for supplemental posterior surgery: truncal decompensation in patients who are out of balance by 2 cm or more, in whom posterior spinal osteotomies and segmental pedicle screw instrumentation were required at follow up. No patients were out of sagittal balance (sagittal vertical line <3 cm from S1) postoperatively. Segmental instrumentation with osteotomies was also more effective for restoration of physiologic lumbar lordosis compared with anterior stand-alone procedures.
This retrospective study supports the finding that clinical outcomes (coronal/sagittal alignment) improve postoperatively after minimally invasive surgery with multilevel XLIF procedures and are improved compared with larger extensile thoracoabdominal anterior scoliosis procedures.
这是一项对25例严重腰椎神经根受压患者进行回顾性研究，这些患者接受了多节段前路腹膜后腰椎椎间融合术及后路器械辅助治疗脊柱畸形。目的是分析经外侧入路行前路椎间融合术的疗效及临床结果，并与传统手术方法进行比较。
连续纳入25例患者（共78个极外侧椎间融合术[XLIF]节段），以阐明XLIF在矫正三维畸形中最严重畸形方面的主要优势，这些畸形符合以下标准：（1）脊柱侧凸至少40°；（2）存在2个或更多节段的椎体平移、椎体前滑脱及侧方半脱位（两个平面的半脱位），导致有症状的神经源性间歇性跛行和严重的椎管狭窄；（3）腰椎前凸减小或平背综合征。此外，大多数患者躯干失衡（骶骨中央垂直线距垂直铅垂线≥2 cm）或矢状面失衡，定义为矢状垂直线与S1之间的距离大于3 cm。有25例患者畸形严重，符合这些标准，需要在外侧XLIF基础上辅以后路截骨术及椎弓根螺钉内固定。
在我们的数据库中，平均随访24个月，85%的患者在计算机断层扫描及屈伸位X线片上显示有牢固的椎间融合且无下沉。并发症发生率仍然较低，围手术期发生率为2.4%，术后发生率为12.2%。通过微创XLIF可在解剖学上矫正侧方椎体滑脱及椎体前滑脱半脱位。这25例患者的主要发现是我们明确了补充后路手术的主要指征：躯干失衡超过2 cm的患者，随访时需要行后路脊柱截骨术及节段性椎弓根螺钉内固定。术后无患者矢状面失衡（矢状垂直线距S1<（此处原文有误，应为≥）3 cm）。与单纯前路手术相比，截骨节段性内固定在恢复生理性腰椎前凸方面也更有效。
这项回顾性研究支持以下发现，即采用多节段XLIF手术的微创手术术后临床疗效（冠状面/矢状面排列）得到改善，且与更大范围的扩展性胸腹前路脊柱侧凸手术相比有所提高。
