| BackgroundsSpondylolisthesis in the absence of a pars defect was first described as early as in 1930 by Junghanns. The term "degenerative spondylolisthesis" was coined by Newman in 1955. Degenerative Lumbar Spondylolisthesis (DLS) is the slippage of one vertebra relative to the adjacent vertebrae due to spinal degenerative changes. The main manifestations are mechanical low back pain, the radicular pain with numbness, paraesthesia, and sensory or motor deficit, and neurogenic claudication. It mostly associated with lumbar spinal stenosis. It has traditionally been considered as one of the major causes of low back and leg pain among the elderly.Usually expectant treatment was taken to whom has gently or midrange lower back pain, or whose string-halt was min due to DLS. When the symptom was severity, regular expectant treatment was ineffective or recurrent attacks, nerve dysfunction was aggravating, obviously affect daily life and work, urination and defecation disfunction appeared, it is essential to operate.In recent decades, great progress was got in surgical treatment of DLS. Its pathological change was spinal stenosis, especially spinal nerve root canal stenosis, so the surgical decompression of the core issue is to relieve the pain of neurogenic claudication and radicular symptoms. Reset can relieve spinal stenosis, spinal reconstruction and restoration of the normal sequence of physiological function, vertebral slip should be reset as far as possible by surgery. Postoperative recovery depend on the stability of fixation. Reduction and fixation techniques by pedicle screw have been widely used in the surgical treatment of DLS. Fusion can eliminate the motion segment instability, ease pain from the disc and (or) degenerative facet joint. Postoperative long-term stability rely on fusion to maintain. At present, posterior decompression, reduction, fusion, internal fixation had became the standard surgical treatment of DLS. Frequently used posterior fusion methods included posterolateral lumbar fusion (PLF), posterior lumbar interbody fusion (PLIF) and PLIF with Cage.With the extensive clinical application of the operate, more and more doctors start to pay close attention to its curative effect and complication. At present there are a lot of reports about its clinical results and complication, but they were different and full of debate. However, the operative management of DLS has still remained controversial. Furthermore they were mostly short follow-up. This retrospective study analyzed the clinical and radiological data of patients who were treated with posterior fusion methods due to DLS from January in 2001 to July in 2005. Investigate the long-term results and complication of posterior fusion in the treatment of DLS, compare the clinical and radiographic results of three different posterior fusion methods, discuss the prognostic factors for DLS treated by posterior fusion in order to become an initial clinical summary and provid a reference.Objective1,To investigate the long-term results and complication of posterior fusion in the treatment of DLS.2,To compare the clinical and radiographic results of three different posterior fusion methods.3,To discuss the prognostic factors for DLS treated by posterior fusion.MethodsThe retrospective study analyzed the clinical data of patients who were treated with posterior fusion methods due to degenerative lumbar spondylolisthesis in Nanfang hospital from January in 2001 to July in 2005. The patients were divided into three groups according to different fusion methods. Group A:posterolateral lumbar fusion (PLF), Group B:posterior lumbar interbody fusion(PLIF) with autologous ilium, Group C:PLIF with Cage.The surgical approach was performed with general anesthesia. The patient was taken at prone position, posterior midline incision was taken to expose the bilateral lamina, articular process and transverse process base. Posts the vertebral arch root bolt under the C-arm fluoroscopy machine, resection of part of the lamina, facet cohesive proliferation, prominent yellow ligament and intervertebral disc degeneration. The spinal canal, lateral recess and nerve root canal were fully decompressed, let the nerve root thoroughly loose. Assemble fixtures, the disc space was braced, reset the vertebral through the rowing motion role of pedicle screws. Posterolateral fusion method was taken with intertransverse autogenous cancellous bone grafting (A group), posterior lumbar interbody fusion with three sides cortical autologous iliac bone (B group), posterior lumbar interbody fusion with 2 Cages (C group). Then moderately intervertebral pressurize and fix, wash the wound, stop bleeding after set a catheter drainage, close the wound. After this operation use antibiotics for three days routinely, drainage tube was removed after 24 to 48 hours, get out of bed after 3 to 7 days, lumbar X-ray film was reviewed after 3 to 5 days, wearing waist protection for 3 months.The final follow-up used the telephone revisit, the outpatient service reexamination revisit, visit the way revisit and the questionnaire survey form inquiry. All revisit patients filled in the revisit survey form. The JOA score and satisfaction degree was investigated, the JOA score improvement rate was calculated. According to Greenough standard determine clinical curative effect and appraise fine rate. All patients underwent standard Lumbar X-rays in antero-posterior, lateral projections, dynamic flexion/extension and MRI. The changes of spondylolisthesis, intervertebral heights and angles, lumbar curvature, fusion, adjacent segment degeneration and so on were observed. The imageology material's parameter were measured two times through the JW-PACS system of our hospital, average value was taken, precisely to 0.01mm or 0.01° The preoperative, postoperative and last follow-up datas were evaluated through satistics analysis by SPSS 13.0. All datas were expressed as the mean±standard deviation, the significance levelα=0.05. Repeated measures analysis of variance was taken to compare the imaging and clinical data among preoperative, postoperative and the last follow-up, so that we can know the long-term results of posterior decompression, reduction and internal fixation in the treatment of DLS. One-way ANOVA or more of the non-parametric test for independent samples were used to compare the long-term efficacy and complications among three posterior fusion methods. Univariate analysis and Logistic regression analysis were taken to know if age, gender, body mass index, diabetes, disease duration, preoperative slip rate, preoperative JOA score, fusion segments, fusion method, spondylolisthesis reduction rate, intervertebral disc height and angle improvement, follow-up time may affect the long-term results.ResultsOne hundred and twenty-two patients were available for complete clinical and radiographic datas.62 patients of them had been evaluated with a follow-up of average 6.4 years (5-9 years). The follow-up rate was 50.8%. There were 11 males and 51 females with an average age of 56.7 years (42-78 years).The mean duration of symptoms was 4.5 years (3 months-24 years). Surgical fixation single segment in 37 cases,21 cases of double segment, the three segments in 4 cases.Postoperative 24 hours drainage quantity and in-hospital time of each group had not statisticly difference (P>0.05). Surgery time, volume of blood and in-hospital expense had statisticly difference (P＜0.05). Surgery time of Group A is the shortest, the volume of blood and in-hospital expense are the least. Surgery time of Group C is the longest, the volume of blood and in-hospital expense are the most. No complications such as dura mater spinalis tearing, leakage of cerebrospinal fluid, post-operative infection, fixation instruments break and so on were observed in these cases. The true character symptom of 2 cases aggravated, after dehydrate and nerve nutrition treatment they restored. Loose of fixation instruments were found in one patient. Fixation instruments of 9 cases had been removed.2 cases had been accepted revision surgery.The last follow-up JOA score was (23.7±3.3) points, comparing with preoperative it significantly improved (t=-28.068, P<0.001). The JOA scores recovery rate was (67.7±19.4)%. According to Greenough standard:22 cases were excellent,31 cases were good,8 cases were general and 1 case was poor. The excellent and good rate was 85.5%. The satisfaction degree was 87.1%. According to the standard of Suk,59 cases were strong fusion, the fusion rate was 95.2%.5 cases occurred possible interbody fusion in patients with posterolateral fusion. Adjacent segment degeneration occurred or existing degeneration aggravated in 26 cases (41.9%), in which degeneration of simple imaging in 21 cases, the symptoms in 5 cases. The JOA score improvement rate, excellent and good rates, the satisfaction degree, fusion rate and rate of adjacent segment degeneration were no statistical difference among the three groups (P> 0.05).The slip rate, intervertebral height, disc angle and segmental scoliosis angle were improved significantly postoperative than preoperative (P<0.05). Intervertebral height of Group C increased the largest, followed by Group B, Group A increased at least. Segment scoliosis angle of Group C reduced the most, followed by Group B, Group A at least. At the time of last follow-up, spondylolisthesis reduction, intervertebral height and disc angle lost statistically significant (P<0.05), Group A lost the most, followed by Group B, Group C lost at least.Univariate analysis showed that age, gender, preoperative slip rate, fusion method, postoperative spondylolisthesis reduction rate, postoperative intervertebral disc height and angle improvement, and follow-up time had no significant effect to long-term results(P> 0.05). BMI, duration of symptoms, preoperative JOA score, fusion segments and diabetes were prognostic factors to long-term results(P<0.05). BMI, duration of symptoms, preoperative JOA score, fusion segments and diabetes were classified into Binary logistic regression analysis model. BMI, duration and preoperative JOA score were included. Duration of symptoms and preoperative JOA score were the statistically significant factors predicting clinical results (P<0.05). Conclusions1. Posterior decompression, reduction, fusion and fixation with pedicle screw system can achieve satisfactory long-term results in treatment of degenerative lumbar spondylolisthesis.2. Three fusion methods all can achieve good long-term results. PLIF with cage can have a better radiographic improvement.3. Total good long-term effect can been achieved after complete intraoperative decompression, fit reduction, good fusion and fixation in treatment of degenerative lumbar spondylolisthesis. Satisfactory individual effect need both doctor and patient to make efforts. Patient must receive medical treatment early, fat patient must reduce weight, diabetic must control blood glucose. Doctor must seize the best timing of operation and choose short-segment fusion as far as possible. |
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