Mori Gen, Mikami Yasuo, Arai Yuji, Ikeda Takumi, Nagae Masateru, Tonomura Hitoshi, Takatori Ryota, Sawada Koshiro, Fujiwara Hiroyoshi, Kubo Toshikazu
Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
J Neurosurg Spine. 2016 Mar;24(3):367-74. doi: 10.3171/2015.6.SPINE141298. Epub 2015 Nov 27.
There are reports that fusion is the standard treatment of choice for cases of lumbar degenerative spondylolisthesis (LDS) associated with lumbar spinal canal stenosis with a large degree of slippage. The reasons why, however, have not been clarified. On the other hand, it is known that the progress of slippage decreases and restabilization occurs over the natural course of LDS. Therefore, if minimally invasive decompression could be performed, there would be little possibility of it influencing the natural course of LDS, so it would not be necessary to include preoperative percentage slip in the criteria for the selection of fusion. This study examined the course of LDS cases more than 5 years after treatment with minimally invasive decompression to determine whether pre- and postoperative slippage and disc changes influence the clinical results.
A total of 51 intervertebral segments in 51 cases with the chief complaint of radicular or cauda equina symptoms due to lumbar spinal canal stenosis were examined after prospective treatment with minimally invasive decompression for LDS. The mean age of the patients at the time of surgery was 66.7 years and the mean follow-up period was 7 years 4 months. Minimally invasive decompression was performed regardless of the degree of low-back pain or percentage slip. The outcome variables were clinical results and changes in imaging findings.
Over the follow-up period, postoperative percentage slip increased and disc height decreased, but the Japanese Orthopaedic Association score improved. Regardless of the preoperative percentage slip, disc height, or degree of intervertebral disc degeneration or segmental instability, the clinical results were favorable. In the high preoperative percentage slip group, low disc height group, and progressive disc degeneration group, there was little postoperative progress of slippage. In the group with a postoperative slippage increase of more than 5%, slippage increased significantly at postoperative year 2, but no significant difference was observed at the final follow-up.
When minimally invasive decompression was performed to treat LDS, the postoperative change in slippage was no different from that during the natural course. Furthermore, regardless of the degree of preoperative slippage or intervertebral disc degeneration, the clinical results were favorable. Also, the higher the preoperative percentage slip and the more that disc degeneration progressed, the more the progress of postoperative slippage decreased. Because the postoperative progress of slippage decreased, it is believed that even after minimally invasive decompression, restabilization occurs as it would during the natural course. If minimally invasive decompression can be performed to treat LDS, it is believed that preoperative percentage slip and intervertebral disc degeneration do not have to be included in the appropriateness criteria for fusion.
有报道称，融合术是治疗伴有严重滑脱的腰椎退变性椎体滑脱症（LDS）合并腰椎管狭窄病例的标准治疗选择。然而，其原因尚未阐明。另一方面，已知在LDS的自然病程中，滑脱进展会减缓且会重新稳定。因此，如果能够进行微创减压，那么它影响LDS自然病程的可能性很小，所以在融合术的选择标准中没有必要纳入术前滑脱百分比。本研究对接受微创减压治疗5年以上的LDS病例的病程进行了研究，以确定术前和术后的滑脱及椎间盘变化是否会影响临床结果。
对51例因腰椎管狭窄以神经根或马尾神经症状为主诉的患者进行前瞻性微创减压治疗后，对其51个椎间节段进行了检查。患者手术时的平均年龄为66.7岁，平均随访时间为7年4个月。无论腰痛程度或滑脱百分比如何，均进行微创减压。观察指标为临床结果和影像学表现的变化。
在随访期间，术后滑脱百分比增加，椎间盘高度降低，但日本骨科协会评分改善。无论术前滑脱百分比、椎间盘高度、椎间盘退变程度或节段性不稳定情况如何，临床结果均良好。在术前滑脱百分比高的组、椎间盘高度低的组和进行性椎间盘退变组中，术后滑脱进展很小。在术后滑脱增加超过5%的组中，术后第2年滑脱显著增加，但在最后随访时未观察到显著差异。
对LDS进行微创减压治疗时，术后滑脱变化与自然病程中的情况无异。此外，无论术前滑脱程度或椎间盘退变程度如何，临床结果均良好。而且，术前滑脱百分比越高、椎间盘退变进展越明显，术后滑脱进展就越小。由于术后滑脱进展减缓，据信即使在微创减压后，也会像在自然病程中一样发生重新稳定。如果能够进行微创减压治疗LDS，据信术前滑脱百分比和椎间盘退变不必纳入融合术的合适标准中。
