Loubeyre Jeanne, Ferrero Emmanuelle, Jmal Mohamed Mokhtar, Guigui Pierre, Khalifé Marc
Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris-Cité, Paris, France.
Service de chirurgie orthopédique, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris-Cité, Paris, France.
Orthop Traumatol Surg Res. 2023 Oct;109(6):103541. doi: 10.1016/j.otsr.2022.103541. Epub 2023 Jan 3.
The surgical treatment of lumbar degenerative spondylolisthesis (LDS) remains controversial. The aim of this study was to determine the effect of adding transforaminal lumbar interbody fusion (TLIF) to posterolateral fusion (PLF) on the local lordosis, sagittal alignment and potential complications. The second aim was to evaluate the effect of slip reduction on the same parameters.
The initial hypothesis was that TLIF provides better correction of the local lordosis and that reducing the slip improves the global sagittal balance.
In this retrospective, single-center study, patients who had been operated on for LSD at one or two levels by laminectomy and PLF, with or without a TLIF cage, were included. Data collected consisted of age, sex, number of levels fused and whether or not a TLIF cage was used. Fusion was defined as the absence of indirect nonunion signs on radiographs at 2 years postoperative. The occurrence and time frame of any complications and the need for reoperation were documented. Lateral radiographs of the entire spine were analyzed preoperatively, in the early postoperative period (3 to 6 months) and at a minimum follow-up of 2 years. The following parameters were measured: pelvic parameters, C7 sagittal tilt (C7ST), spinosacral angle (SSA), maximum lumbar lordosis (LL), lordosis at slipped level (LS), slip percentage. The analysis compared patients treated by PLF and TLIF and determined the impact of slip reduction.
One hundred and three patients were included in the study (71% women). The mean follow-up was 38 months. The mean age was 69 years. Seventy-seven patients (75%) underwent PLF. Comparing the preoperative and early postoperative data identified 5.4% better spondylolisthesis reduction in the TLIF group than the PLF group (-8.9±9.5% vs -3.5±7.6%; p=0.04) that was not maintained at the final follow-up. The fusion rate was comparable between groups: 94% in APL and 89% in TLIF (p=0.7). The overall complication rate was 46% in the TLIF group versus 33% in the PLF group (p=0.35). A comparison based on whether or not the slip was reduced found significant improvement in the reduction group of the SSA by more than 6° (6.8°±6° vs 0.5°±7.4°; p=0.04). The fusion rate was 91% in the reduced group and 95% in the non-reduced group (p=0.81); the complication rate was 44% versus 28% in the non-reduced group (p=0.10).
This study shows that slip reduction helps to improve the sagittal alignment by increasing the SSA when treating LDS. Posterolateral fusion and TLIF produce comparable radiographic outcomes at 2 years postoperative in the segmental lordosis, slip reduction, global sagittal alignment and fusion rate.
IV.
腰椎退行性椎体滑脱（LDS）的手术治疗仍存在争议。本研究的目的是确定在腰椎后外侧融合术（PLF）基础上加用经椎间孔腰椎椎体间融合术（TLIF）对局部前凸、矢状面排列及潜在并发症的影响。第二个目的是评估滑脱复位对相同参数的影响。
最初的假设是TLIF能更好地矫正局部前凸，且减少滑脱可改善整体矢状面平衡。
在这项回顾性单中心研究中，纳入了接受过单节段或双节段LDS椎板切除术和PLF手术（使用或未使用TLIF椎间融合器）的患者。收集的数据包括年龄、性别、融合节段数以及是否使用TLIF椎间融合器。融合定义为术后2年X线片上无间接不愈合征象。记录任何并发症的发生情况、时间范围以及再次手术的必要性。对整个脊柱的侧位X线片在术前、术后早期（3至6个月）以及至少2年的随访时进行分析。测量以下参数：骨盆参数、C7矢状倾斜角（C7ST）、棘骶角（SSA）、最大腰椎前凸（LL）、滑脱节段的前凸（LS）、滑脱百分比。分析比较了接受PLF和TLIF治疗的患者，并确定了滑脱复位的影响。
103例患者纳入研究（71%为女性）。平均随访时间为38个月。平均年龄为69岁。77例患者（75%）接受了PLF。比较术前和术后早期数据发现，TLIF组的椎体滑脱复位效果比PLF组好5.4%（-8.9±9.5%对-3.5±7.6%；p = 0.04），但在最终随访时未保持。两组的融合率相当：APL组为94%，TLIF组为89%（p = 0.7）。TLIF组的总体并发症发生率为46%，而PLF组为33%（p = 0.35）。基于是否进行滑脱复位的比较发现，复位组的SSA改善超过6°（6.8°±6°对0.5°±7.4°；p = 0.04）。复位组的融合率为91%，未复位组为95%（p = 0.81）；未复位组的并发症发生率分别为44%和28%（p = 0.10）。
本研究表明，治疗LDS时，滑脱复位通过增加SSA有助于改善矢状面排列。在术后2年，后外侧融合术和TLIF在节段性前凸、滑脱复位、整体矢状面排列和融合率方面产生了相当的影像学结果。
IV级。
