Guigui P, Ferrero E
Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, AP-HP, université Paris V, 20, rue Leblanc, 75015 Paris, France.
Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, AP-HP, université Paris V, 20, rue Leblanc, 75015 Paris, France.
Orthop Traumatol Surg Res. 2017 Feb;103(1S):S11-S20. doi: 10.1016/j.otsr.2016.06.022. Epub 2016 Dec 30.
Degenerative spondylolisthesis is a common pathology, often causing lumbar canal stenosis. There is, however, no strong consensus regarding the various medical and surgical treatments available. Surgery is indicated mainly for perceived functional impairment; when the indication is accepted, several questions determine the choice of surgical strategy. Improvement in neurological symptoms is one of the main treatment objectives. For this, it is useful to perform radicular decompression. Some authors recommend indirect decompression by interbody fusion (ALIF, TLIF, XLIF), others by means of an interspinous spacer but the most frequent technique is direct posterior decompression. In degenerative spondylolisthesis, functional results seem to be improved by associating stabilization to decompression, to prevent secondary destabilization. The following risk factors for destabilization are recognized: anteroposterior hypermobility, angular hypermobility and large disc height. Two stabilization techniques have been described: "dynamic" stabilization and (more frequently) fusion. Spinal instrumentation is frequently associated to fusion, in which case, it is essential for fusion position and length to take account of pelvic incidence and the patient's overall pattern of balance. Posterolateral fusion may be completed by interbody fusion (PLIF or TLIF). This has the theoretic advantage of increasing graft area and stability, restoring local lordosis and opening the foramina. Surgical treatment of degenerative spondylolisthesis usually consists in posterior release associated to instrumented fusion, but some cases can be more complex. It is essential for treatment planning to take account of the patient's general health status as well as symptomatology and global and segmental alignment.
退变性腰椎滑脱是一种常见的病理状况，常导致腰椎管狭窄。然而，对于现有的各种内科和外科治疗方法，尚未达成强有力的共识。手术主要适用于明显的功能障碍；当手术指征被认可时，有几个问题决定了手术策略的选择。神经症状的改善是主要治疗目标之一。为此，进行神经根减压是有用的。一些作者推荐通过椎间融合术（前路腰椎椎间融合术、经椎间孔腰椎椎间融合术、斜外侧腰椎椎间融合术）进行间接减压，另一些作者推荐使用棘突间撑开器，但最常用的技术是直接后路减压。在退变性腰椎滑脱中，通过将稳定化与减压相结合以防止继发性失稳，功能结果似乎会得到改善。已确认以下失稳风险因素：前后向活动过度、角向活动过度和椎间盘高度过大。已描述了两种稳定化技术：“动态”稳定化和（更常见的）融合术。脊柱内固定器械常与融合术联合使用，在这种情况下，考虑骨盆入射角和患者的整体平衡模式对于融合的位置和长度至关重要。后外侧融合术可通过椎间融合术（后路腰椎椎间融合术或经椎间孔腰椎椎间融合术）完成。这具有增加植骨面积和稳定性、恢复局部前凸以及扩大椎间孔的理论优势。退变性腰椎滑脱的手术治疗通常包括后路松解联合器械辅助融合术，但有些病例可能更复杂。治疗计划必须考虑患者的一般健康状况以及症状表现、整体和节段性对线情况。
