Kalani Maziyar A, Kouloumberis Pelagia, Richards Alexandra E, Lyons Mark K, Davila Victor J, Neal Matthew T
Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, USA.
J Spine Surg. 2020 Dec;6(4):650-658. doi: 10.21037/jss-20-597.
High-grade spondylolisthesis (>50% slippage) is infrequently encountered in adults and frequently requires surgical treatment. The optimal surgical treatment is controversial with limited literature guidance as to optimal approach to treatment. An observational study to examine the technique and radiographic outcomes of adult patients treated with anterior lumbar interbody fusion (ALIF) and posterior percutaneous instrumentation for high-grade spondylolisthesis.
ALIF was performed in 5 consecutive patients (3/5 female, 2/5 male) aged 29-67 years old who presented with low back pain and L5 radiculopathy. All patients failed conservative treatment and were treated with L4-5 and L5-S1 ALIF followed by posterior percutaneous L4-S1 pedicle screw and rod fixation. Pre- and postoperative clinical data was collected including L5-S1 posterior disk height in millimeters, millimeters of spondylolisthesis at L5-S1, degrees of segmental lordosis (L4-S1), lumbar lordosis (L1-S1), and lumbar lordosis pelvic incidence (LL-PI) mismatch.
Six weeks following surgery, no patient reported residual L5 radicular symptoms. At last follow up, patient satisfaction, according to Modified Macnab Criteria, was excellent in 4/5 patients and good in 1/5 patient. In the 4 patients with greater than 1 year radiographic follow up, fusion rate was 100% on computed tomography (CT). Mean increase in posterior disk height was 12.5 mm (range, 11.4-13.5 mm). Mean reduction in spondylolisthesis was 58.7% (range, 20.2-100%). Mean segmental (L4-S1) and overall (L1-S1) lumbar lordosis increased by 23.6% (range, 6.5-41.7%) and 16.6% (2.5-31.5%), respectively. Following surgery, LL-PI mismatch decreased from a mean of 16.4 to 10.2 degrees.
ALIF with posterior percutaneous instrumentation is a safe and effective treatment for high-grade lumbosacral spondylolisthesis in properly selected adults. This technique improves lumbar sagittal parameters and reduces spondylolisthesis. The indirect neural decompression from simultaneous disk height restoration and spondylolisthesis reduction may be associated with lower neurological injury rate compared to posterior-only. Future prospective study is needed to validate this hypothesis.
重度腰椎滑脱（滑脱>50%）在成人中并不常见，且常常需要手术治疗。最佳手术治疗方案存在争议，关于最佳治疗方法的文献指导有限。一项观察性研究，旨在探讨接受前路腰椎椎间融合术（ALIF）和后路经皮器械固定治疗重度腰椎滑脱的成年患者的技术及影像学结果。
对5例连续患者（3例女性，2例男性）进行了ALIF手术，患者年龄在29 - 67岁之间，均表现为腰痛和L5神经根病。所有患者保守治疗无效，接受了L4 - 5和L5 - S1节段的ALIF手术，随后进行后路经皮L4 - S1椎弓根螺钉和棒固定。收集术前和术后的临床数据，包括L5 - S1椎间盘后高度（单位：毫米）、L5 - S1节段腰椎滑脱的毫米数、节段性前凸（L4 - S1）、腰椎前凸（L1 - S1）以及腰椎前凸与骨盆入射角（LL - PI）不匹配度。
术后6周，无患者报告残留L5神经根症状。在末次随访时，根据改良Macnab标准，患者满意度为：4例患者为优级，1例患者为良级。在4例有超过1年影像学随访的患者中，计算机断层扫描（CT）显示融合率为100%。椎间盘后高度平均增加12.5毫米（范围为11.4 - 13.5毫米）。腰椎滑脱平均减少58.7%（范围为20.2 - 100%）。节段性（L4 - S1）和整体（L1 - S1）腰椎前凸分别平均增加23.6%（范围为6.5 - 41.7%）和16.6%（2.5 - 31.5%）。手术后，LL - PI不匹配度从平均16.4度降至10.2度。
对于经过适当选择的成年患者，ALIF联合后路经皮器械固定是治疗重度腰骶部腰椎滑脱的一种安全有效的方法。该技术可改善腰椎矢状面参数并减少腰椎滑脱。与单纯后路手术相比，通过同时恢复椎间盘高度和减少腰椎滑脱实现的间接神经减压可能与较低的神经损伤率相关。未来需要进行前瞻性研究来验证这一假设。
