郭新虎1，李危石1，郭昭庆1、2，陈仲强1、2，齐 强1，曾 岩1，孙垂国1，钟沃权1（1 北京大学第三医院骨科 脊柱疾病研究北京市重点实验室 骨与关节精准医学教育部工程中心 100191 北京市；2 北京大学国际医院骨科 102206 北京市）第一作者简介：男（1989-），医学博士，主治医师，研究方向：脊柱外科E-mail：guoxinhu007@foxmail.com【摘要】 目的：分析高度发育不良性腰椎滑脱（high dysplastic developmental spondylolisthesis，HDDS）的手术复位程度与脊柱-骨盆矢状位参数变化的关系，以了解复位至何种程度能够显著改善术后脊柱-骨盆矢状位序列。方法：回顾性分析2007年3月~2019年4月在我院骨科接受手术治疗的35例HDDS患者，滑脱节段均为L5，年龄14.9±5.9岁（9~35岁）。均行减压、部分复位或完全复位、椎弓根螺钉内固定融合术。随访42.5±33.1个月（3~120个月）。依据术后末次随访时的Dubousset腰骶角（Dubousset lumbosacral angle，Dub-LSA）将患者分为<70°（7例）、70°~79.9°（8例）、80°~89.9°（4例）及≥90°（16例）四组，依据末次随访时滑脱的Meyerding分度将患者分为Ⅲ度及以上（5例）、Ⅱ度（6例）、Ⅰ度以内（24例）三组，分别对比各组的术前、末次随访时脊柱-骨盆参数的变化。结果：滑脱率术前为（66.7±22.5）%（35%~100%），末次随访时为（18.9±20.9）%（0%~72%）；Dub-LSA术前为61.9°±14.7°，末次随访时82.1°±17.3°。末次随访时Dub-LSA越大、滑脱程度越低，脊柱-骨盆矢状位参数较术前改善越明显；直至Dub-LSA≥90°和滑移程度在Ⅰ度以内时，骨盆倾斜角（pelvic tilt，PT）和骶骨倾斜角（sacral slope，SS）均有显著性改善，由后倾型骨盆转变为平衡型骨盆的比例显著增加。Dub-LSA≥90°组术前与末次随访时PT分别为36.4°±6.5°与27.2°±4.9°（P<0.001）、SS分别为33.5°±9.1°与42.1°±9.3°（P<0.001）、平衡型骨盆比例分别为0%（0/16）与43.8%（7/16）（P=0.007）， 末次随访时与术前比较均有统计学差异。末次随访时滑脱程度在Ⅰ度以内组，术前与末次随访时PT分别为38.9°±8.6°与30.6°±7.4°（P<0.001）、SS分别为31.4°±11.5°与41.2°±8.7°（P<0.001）、平衡型骨盆比例分别为0%（0/24）与29.2%（7/24）（P=0.009），末次随访时与术前比较均有统计学差异。结论：将HDDS患者的Dub-LSA复位至≥90°和将滑移复位至Ⅰ度以内能够显著改善脊柱-骨盆矢状位参数，并且能够将部分（43.8%）后倾型骨盆改善为平衡型骨盆。【关键词】 高度发育不良性腰椎滑脱；复位；脊柱-骨盆参数doi：10.3969/j.issn.1004-406X.2020.08.02文章编号：1004-406X（2020）-08-0679-08The relationship between the extent of reduction and the change of spino-pelvic parameters in high dysplastic developmental spondylolisthesis/GUO Xinhu, LI Weishi, GUO Zhaoqing, et al//Chinese Jour?鄄nal of Spine and Spinal Cord, 2020, 30(8): 679-686【Abstract】 Objectives: To investigate the relationship between the extent of reduction and the change of spino-pelvic parameters in high dysplastic developmental spondylolisthesis(HDDS), so as to know about what extent of reduction could significantly improve postoperative spino-pelvic sagittal alignment. Methods: Thirty-five young patients of HDDS, aged 9 to 35 (14.9±5.9) years old and treated between March 2007 and April 2019 in our hospital were studied retrospectively, with an average follow-up time of (42.5±33.1) months (3-120 months). They were divided into four groups of <70°(7 cases), 70°-79.9°(8 cases), 80°-89.9°(4 cases) and ≥90° (16 cases) based on the final follow-up Dubousset lumbosacral angle(Dub-LSA), and were also divided into three groups of high-grade (grade Ⅲ and above) (5 cases), grade Ⅱ(6 cases), and grade Ⅰ(24 cases) based on the final follow-up Meyerding grade. Then, the preoperative and final follow-up spino-pelvic param?鄄eters of each group were compared to find out what extent of reduction could significantly improve these pa?鄄rameters and pelvic balance. Results: The slip percentage was [pre-operation (66.7±22.5)% (range 35%-100%) vs. final follow-up (18.9±20.9)% (range 0%-72%)]. The Dub-LSA was (pre-operation 61.9°±14.7° vs. final follow-up 82.1°±17.3°). The differences between preoperative and final follow-up parameters became more significant with the increase of Dub-LSA and the decrease of slippage. In the Dub-LSA ≥90° and the grade Ⅰ group, pelvic tilt(PT) and sacral slope(SS) were improved significantly, and the ratio of retroverted pelvis changing into balanced type was increased significantly. Dub-LSA ≥90° group: PT [pre-operation (36.4°±6.5°) vs. final follow-up (27.2°±4.9°), P<0.001], SS [pre-operation (33.5°±9.1°) vs. final follow-up (42.1°±9.3°), P<0.001], and the ratio of balanced pelvis [pre-operation 0%(0/16) vs. final follow-up 43.8% (7/16), P=0.007]. Grade Ⅰ group: PT [pre-operation (38.9°±8.6°) vs. final follow-up (30.6°±7.4°), P<0.001], SS [pre-operation (31.4°±11.5°) vs. final follow-up (41.2°±8.7°), P<0.001], and the ratio of balanced pelvis [pre-operation 0%(0/24) vs. final follow-up 29.2%(7/24), P=0.009]. Conclusions: Reduction of HDDS to Dub-LSA ≥90° and Meyerding grade Ⅰ could improve the spino-pelvic alignment significantly, and could convert part (43.8%) of the retroverted pelvis to balanced pelvis.【Key words】High dysplastic developmental spondylolisthesis; Reduction; Spino-pelvic alignment【Author′s address】Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China图1 a 低度发育不良性腰椎滑脱，Ⅱ度，局部发育异常不重，椎体平行滑移，无腰骶部后凸，脊柱-骨盆参数大致正常 b 高度发育不良性腰椎滑脱，Ⅱ度，腰骶部明显发育异常，S1上关节突发育不良，骶骨上终板拱顶样改变，L5峡部延长，腰骶部后凸，骨盆后倾，躯干前倾，脊柱-骨盆参数异常Figure 1 a Low dysplastic developmen?鄄tal spondylolisthesis(grade Ⅱ) shows mild dysplastic deficiencies, and the slippage is parallel to the S1 endplate, with nearly normal spino-pelvic alignment b High dysplastic developmental spondylolisthesis (grade Ⅱ) shows major deficiencies of the neural arches, including S1 facets dysplasia, rounding S1 endplate, elongation of the L5 pars. This patient has obvious lumbosacral kyphosis, abnormal spino-pelvic alignment and sagittal imbalance图2 高度发育不良性腰椎滑脱S1上终板（ab）的划定，其中a、b两点为S1椎体前、后缘所对应直线与S1拱顶的交点，线段ab即为S1上终板。由L5椎体后下角向ab作垂线，交点为c，滑脱率的计算方法为（ac/ab）×100% 图3 Dubousset腰骶角（Dub-LSA）为L5上终板对应的直线与S1椎体后缘对应的直线所成夹角，若小于90°，则认为存在腰骶部后凸，其越小，后凸越严重 a 正常人腰骶部为前凸，图中Dub-LSA=107° b 高度发育不良性腰椎滑脱患者腰骶部呈明显后凸状态，图中Dub-LSA=47.8°
Figure 2 The method of drawing S1 upper endplate(ab) in HDDS patients. Two best-fit lines are drawn along the an?鄄terior and posterior border of S1 vertebral body, points a and b are the tangent points of the above lines and the sacral dome, line ab represents the S1 upper endplate. A perpendicular line is drawn from posterior lower point of L5 vertebral body to line ab, the intersection point is c. The slippage percentage is calculated by formula (ac/ab)×100% Figure 3 The Dubousset lumbosacral angle (Dub-LSA) is described as the angle between the L5 upper endplate and the posterior border line of S1 vertebrae. If Dub-LSA is less than 90°, this is a significant lumbosacral kyphosis a Normally the lum?鄄bosacral junction is lordotic, in this case Dub-LSA=107° b The lumbosacral junction of high dysplastic developmental spondylolisthesis is kyphotic, in this case Dub-LSA=47.8°图4 10岁女性 a 术前V度滑脱（滑脱率100%），Dub-LSA=49.7° b 行前后联合入路L5椎体切除、L4~S1固定融合，术后1年随访提示腰骶部后凸完全纠正，Ⅰ度滑脱（滑脱率11%）、Dub-LSA=103°，矢状位序列明显改善，PT减小、SS增大，由后倾型骨盆变为平衡型骨盆 图5 12岁女性 a 术前V度滑脱（滑脱率100%）、Dub-LSA=27.6° b 行单侧后路减压、部分复位、L4~S1固定融合术，术后2年随访，提示腰骶部后凸仍较明显，Ⅲ度滑脱（滑脱率72%）、Dub-LSA=53.4°，矢状位序列无明显改善，PT较术前增大、SS较术前减小，仍为后倾型骨盆
Figure 4 Images of a 10-year old female patient a Preoperative X-ray shows grade V spondylolisthesis(slippage rate 100%) and Dub-LSA=49.7° b L5 resection with L4-S1 fixation and fusion was performed with combined anterior and posterior approach. Image of 1-year postoperative follow-up shows restoration of lumbosacral lordosis with grade Ⅰ slippage(slippage rate 11%) and Dub-LSA=103°. The sagittal alignment is improved significantly and the retroverted pelvis is converted to balanced pelvis with decreased PT and increased SS Figure 5 Images of a 12-year old female patient a Preoperative X-ray shows grade V spondylolisthesis(slippage rate 100%) and Dub-LSA=27.6° b L4-S1 decompression, partial reduction and fixation was performed in this patient with a posterior-only approach. Image of 2-year postoperative follow-up shows obvious lumbosacral kyphosis with grade Ⅲ slippage(slippage rate 72%) and Dub-LSA=53.4°. There is no improvement of sagittal alignment with increased PT and decreased SS, and the retroverted pelvis is unchanged本文为删节版，原文见《中国脊柱脊髓杂志》2020年8月刊![]()