Putzier M, Koehli P, Khakzad T
Abteilung für Orthopädie und Unfallchirurgie, Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Luisenstr. 64, 10117, Berlin, Deutschland.
Oper Orthop Traumatol. 2024 Feb;36(1):43-55. doi: 10.1007/s00064-023-00830-w. Epub 2023 Oct 10.
Establishment of a physiological profile of the spine via reduction of the kyphotic slipped vertebra in the transverse and sagittal planes. Achieving solid fusion. Improvement of preoperative pain symptoms and prevention or elimination of neurological deficits.
High-grade spondylolisthesis (Meyerding grade 3 and 4) as well as spondyloptosis after conservative treatment and corresponding symptoms. Serious neurological deficits, hip-lumbar extensor stiffness, are emergency indications.
CONTRAINDICATIONS (CI): Individual risk assessment must be made. Absolute CI are infections with the exception of serious neurological deficits. Multiple abdominal operations or interventions on the large vessels can be a relative contraindication for ventral intervention.
For spondylolistheses of grade 3 according to Meyerding, we recommend a one-stage dorso-ventro-dorsal procedure with radicular decompression, correction and fusion in the index segment. From grade 4 according to Meyerding, reduction of the fifth lumbar vertebral body in the index segment L5/S1 is preceded by resection of the sacral dome. In cases of spondyloptosis, a two-stage procedure is often indicated. In this case, a screw-rod system spanning the index segment is implanted in the first step, which is used to distract the index segment for several days. Ventrodorsal reduction is performed in the second step.
Axis-appropriate full mobilization from postoperative day 1. We recommend a light diet until the first defecation. Dorsal suture removal after 12 days if the wound is dry and free of irritation. Lifting and carrying heavy loads and also competitive or contact sports should be avoided for 12 weeks.
From January 2000 to December 2020, a total of 43 patients with high-grade spondylolisthesis were treated in our clinic in the manner described. The Numeric Rating Scale (NRS) and the Oswestry Disability Index (ODI) improved significantly during the observation period of 3 months and 1 year. The 1‑year radiological data in 28 of the 36 patients showed complete reduction of the slipped vertebra, in 6 grade 1, and in 2 patients grade 2 according to Meyerding. Also, the kyphosis of the index vertebra was significantly corrected from a mean of 15° (0-52°) preoperatively to a lordotic profile of a mean of 4° (0-11°). No complications requiring revision were observed. One patient with preoperative cauda equina syndrome was left with right radicular sensorimotor S1 syndrome.
通过在矢状面和横断面矫正后凸滑脱椎体，建立脊柱的生理形态。实现牢固融合。改善术前疼痛症状并预防或消除神经功能缺损。
重度腰椎滑脱（迈耶丁分级3级和4级）以及保守治疗后出现椎体滑脱及相应症状。严重神经功能缺损、髋部 - 腰部伸肌僵硬，均为急诊适应症。
禁忌症（CI）：必须进行个体风险评估。绝对禁忌症是除严重神经功能缺损外的感染。多次腹部手术或对大血管的干预可能是前路干预的相对禁忌症。
对于迈耶丁分级3级的腰椎滑脱，我们推荐一期背 - 腹 - 背手术，在病变节段进行神经根减压、矫正和融合。对于迈耶丁分级4级的患者，在L5/S1病变节段对第五腰椎椎体进行复位前，先切除骶骨穹窿。对于椎体滑脱症，通常需要两期手术。在这种情况下，第一步植入跨越病变节段的螺杆系统，用于在数天内撑开病变节段。第二步进行腹背侧复位。
术后第1天开始进行适度的全身活动。在首次排便前，建议清淡饮食。如果伤口干燥且无刺激，术后12天拆除背部缝线。12周内应避免提举重物以及竞技性或接触性运动。
从2000年1月至2020年12月，我院共对43例重度腰椎滑脱患者采用上述方法进行治疗。在3个月和1年的观察期内，数字评分量表（NRS）和奥斯威斯利功能障碍指数（ODI）均有显著改善。36例患者中的28例1年影像学数据显示，根据迈耶丁分级，滑脱椎体完全复位，6例为1级，2例为2级。此外，病变椎体的后凸畸形从术前平均15°（0 - 52°）显著矫正为平均4°（0 - 11°）的前凸形态。未观察到需要翻修的并发症。1例术前患有马尾神经综合征的患者遗留右侧S1神经根感觉运动综合征。
