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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6025_Библиотеки_им_академика_М_И_Перельмана
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(2) Neurogenic claudication.
(a) Shopping cart sign.
i. Relief with for w ard exion .
3. Radiographic ndings.
a. Plain radiographs.
(1) A standing lateral radiograph is more sensitive than a non-w eight-
bearing view.
(2) Flexion–extension views:
(a) Greater than 4 mm of motion is considered indicative of dynam ic
instabilit y.
(b) Greater t han 10° of m ot ion .
19 Lumbar Spondylolisthesis 217
b. CT myelogram.
(1) Determ ines am ount of spinal stenosis.
(2) Evaluates degree of osteopenia.
(3) Detailed view of facet hypertrophy.
(4) The traversing nerve root is compressed by the superior articular
process of the inferior vertebrae.
c. MRI.
(1) Gold standard for evaluation of disk, ligam ents, and neural structures.
(2) Provides inform ation regarding neurological compression.
(3) Delineates synovial cysts and hypertrophic ligam entum avum .
4. Treatment.
a. Nonoperative.
(1) Short-term bed rest (1–2 days).
(2) Nonsteroidal anti-in am m atory drugs.
(3) Oral steroids.
(a) Best reserved for acute exacerbations of leg pain.
(4) Physical therapy.
(a) Range of m otion.
(b) Aerobic conditioning.
b. Operative (Fig. 19.5).
(1) Indications.
(a) Persistent or recurrent severe leg pain.
(b) Progressive neu rological de cit.
(2) Treatm ent options (Table 19.2).
5. Spine patient outcomes research trials (SPORT).
a. Patient populations.
(1) Patients with degenerative spondylolisthesis and spinal stenosis.
(2) Persistent symptom s (e.g., radicular leg pain, neurological
claudication) for 12 weeks.
(3) Assigned random ly to operative and nonoperative cohorts.
b. Operative versus nonoperative treatment outcomes.
(1) Surgery consisted of standard lum bar decompression with or without
single-level fusion.
(a) Iliac crest bone graft with or without posterior pedicle screw
xation.
218
19 Lumbar Spondylolisthesis
a b
c
e
d
Fi g . 1 9 . 5 Im a g e s o f a n 1 8-ye a r-o ld m a n wit h a h ig h -g ra d e L5 – S1 ist h m ic sp o n d ylo lis t h e sis a nd b ila t -
eral L5 radiculopathy. (a) An t eropost e rior ra d io g ra p h sh owing t h at t he L5 t ran sverse pro ce sses overlie
the sacrum due to the severe slip. (b) Late ral radiograph showing the grade 3 slip. (c) Magnetic reso-
nance imaging scan shows typical changes at L5–S1 rounding of the sacral dome. (d,e) Post o p erat ive
radiographs demonstrating the placem ent of interbody cages to increase the fusion rate with supplementary pedicle screw xation.
(2) The surgical cohort dem onstrated greater improvem ents in pain and
funct ion after 2 years com pared w ith th ose treated nonoperatively in
the as-treated analysis.
c. Controversies.
(1) High crossover rate:
(a) Forty-nine percent of patients in the nonoperative cohort
underwent surgery.
(b) Thirty-six percen t of patients in the surgical cohort did not
undergo surgery.
19 Lumbar Spondylolisthesis 219
Ta b l e 1 9 . 2 Su rg ica l o p t io n s for ad ult sp on dylo list he sis
Pro ce dure Advant ag e s Disadvant ag e s Co mplicatio ns
La m i n e c t o m y – R a p i d p a i n r e l i e f
– Avoids morbidity
of a fusion
La m i n e c t o m y
with
posterolateral
– Decreased slip
progression if
fusion obt aine d
fusion
In st ru m e nt e d
fusion with
inte rbod y g ra ft
– Increased fusion
rates
– Partial reduction
of deformity
– Does not address
inst a b ilit y
– Possible failure of
fusion
– Improves slip
angle
– Longer operative
times
– Slip progression
(25–50%)
– Increased rate of
pseudarthrosis as
compared with
noninterbody
techniques
– Instrument
placement
– Increased
infe c t io n ra t e
– Allows for more
– Implant migration
aggressive
decompression
(2) Nonoperative managem ent was not standardized.
(3) Surgical procedures were not standardized.
(a) Decompression alone.
(b) Decom p ression and fusion.
i. Autograft w ith iliac crest bone graft (ICBG).
or failure
ii. Fusion w ith or w ithout posterior instrum entat ion .
iii. Bon e morphogenetic protein was not used.
(4) Intent-to-treat versus as-treated analysis:
(a) Intent-to-treat analysis compared patients according to their
assigned cohort.
i. Th is dem onstrated no di erence in prim ary outcom es
between groups in patients with spondylolisthesis.
ii. Patien ts assign ed to nonoperat ive treatm ent were counted
as nonoperative patients even if they crossed over and had
surgical intervention.
(b) As-t reated analysis com p ared patien t s accord ing to the treatm ent
ultimately received.
(c) Patients who underwent surgery dem onstrated improved and
sustained outcomes com pared w ith those treated nonoperatively
for 4 yea r s.
E. Tr a u m at ic s p on d ylo list h e s is .
1. Extremely rare injuries.
2. A posterior fracture may be part of a larger injury.
a. Be suspicious for a fracture or dislocation of the spine.
220
19 Lumbar Spondylolisthesis
F. Pa t h o l o g i c a l s p o n d y l o l i s t h e s i s .
1. Generalized bone disease.
a. Osteoporosis and osteomalacia.
(1) Instability results from contiguous stress fractures healing in an
elongated pattern.
b. Paget’s disease and osteogenesis imperfecta.
c. Prim ary or secondary neoplasm .
Sugg este d Reading
Blu m e n t h a l C, Cu r r a n J, Be n ze l EC, e t a l. Ra d i o gr ap h ic p re d i c t o r s o f d e l a ye d in s t ab il it y
follow in g d ecom p ress io n w it h o u t fu sion for d e gen erat ive gra d e I lu m ba r sp on d ylo listhesis. J Ne u rosu rg Spin e 201 3;18(4):340–34 6
Lo n g o UG, Lo p p i n i M , Ro m e o G , M a u l li N, De n a r o V. Ev id e n c e - b a s e d s u r g ic a l m a n a g e -
ment of spondylolisthesis: reduction or arthrodesis in situ. J Bone Joint Surg Am
2014;96(1):53–58
Pou ssa M, Re m es V, Lam b erg T, et al. Treat m en t of severe spon dylolisth esis in ad olescen ce
with reduction or fusion in situ: long-term clinical, radiologic, and functional outcom e. Spine 2006;31(5 ):583–590, discu ssion 59 1–5 92
Wat ters WC III, Bon o CM, Gilber t TJ, et al; Nor t h Am erica n Spin e Societ y. An evid e n ce-b ased
clinical guidelin e for the diagnosis an d treatm ent of degen erat ive lum bar spondylolisthesis. Sp in e J 2009;9(7):609– 614
Weinste in JN, Lu rie JD, Tosteson TD, et al. Su rgical versu s non su rgical treatm ent for lu m -
bar degenerative sp ondylolist h esis. N Engl J Med 2007;356 (22):2257–2 270
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared w ith nonoperative treat-
ment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient
Outcom es Research Trial (SPORT) ran d om ized and obser vat ion al coh or t s. J Bone Join t
Surg Am 2009;91 (6):129 5–1304
20 Adult Spinal Deformity
20.1 General Considerations
I. In t r o d u ct ion .
A. Ad u lt sco lio sis is m o r e r igid t h a n a d ole sce n t sp in al d efor m it y (ASD) a n d is m or e
likely to be symptom at ic.
B. Th e cu rve m ay p rogress, esp e cially if th e cu rve is > 50° (Fig. 20.1).
1. The cur ve m ay progress 1 to 2° p er year.
II. Risk factor s for lu m ba r cu r ve p r o gressio n :
A. La t e ra l a n d r ot at o r y list h e s is .
B. La r ge a p ic a l r o t at io n .
III. Sp in al st e n o sis, d isk d is e a se , a n d oste o p en ia a r e asso ciat e d p at h o logies.
A. Asy m m e t ric a l loss o f d isk h eigh t a n d ve r t eb ra m ay co n t r ib u t e t o t h e in cre as e in
Co b b a n gle .
IV. Ad u lt scoliosis is m ore likely to be sym p tom at ic, w it h pain and d isa bilit y.
ab
Fi g . 2 0 . 1 ( a , b ) Co bb a n gle m e a su re m e n t .
221
222
20 Adult Spinal De form ity
A. Pa in o ft en o r igin at e s o n t h e co n ve xit y o f t h e c u r ve d ue t o m u scle fat igu e . Th is is
follow e d by fa ce t d ege n e rat ion o n t h e co n cave sid e .
B. Th ere is in creased incid e n ce of low back pain if t h e lum bar cu rve is > 45°.
C. It is n e c e ss ar y t o r u le o u t o t h e r s o u rce s o f p a in , s u ch a s a b d o m in al a n e u r ysm ,
renal stones, and tumors, as well as disk disease and spinal stenosis.
D. Pain , in th e absen ce of a progressive cur ve, is ra rely an in dicat ion for su r ge r y.
E. Sciat ic a m ay r es u lt fr o m n e r ve r o ot co m p r e s sio n in t h e co n ca v it y o f t h e cu r ve .
V. Re s p i r a t o r y c o m p r o m i s e m a y o c c u r , r e s u l t i n g i n d y s p n e a , p u l m o n a r y h y p e r t e n s i o n ,
and cor pulmonale.
VI. Ad u lt s oft e n h ave o t h e r m ed ica l com or b id it ie s t h at m ake t h e s u rge r y m ore r isk y.
VII. Sacro p elvic r a d iogr a p h ic p ar a m et e r s (Table 20.1) (Fig. 20.2).
VIII. Classi cat io n :
A. Sco lio sis Re s ea r ch So ciet y (SRS)—Sch w a b Ad u lt Sp in al Defo r m it y Cla ss i cat io n
(Schwab et al).
1. Uses radiographic parameters and patient-reported functional assessment
scores.
a. Radiographic parameters were correlated with functional outcomes.
2. Curve type involves the assessment of coronal deformity with added sagittal
deformity modi ers (Fig. 20.3).
a. Cu rve Typ e T: thoracic m ajor cu r ve > 30° (apical T9 or h igh er).
b. Cur ve Type L: thoracolu m b ar or lu m bar m ajor cur ve > 30° (ap ical T10 or
lower).
Ta b l e 2 0 . 1 Sacro p elvic rad io gra ph ic p a ram e t e rs
Ra d i o g r a p h i c
parameter Measurement Note
Pelvic incide n ce
(PI = PT + SS)
An g l e b e t w e e n t h e s t r a ig h t l in e
from the fem o ral he ad t o the
midpoint of the sacral plate and a
Will not change position
after skeletal maturity
(morphological parameter)
perpendicular line to the sacral plate
Pelvic t ilt (PT) Angle bet ween t he st raight line
from the fem o ral head t o t he
midpoint of the sacral plate and a
ve r t ica l lin e fro m t he fe m oral h ead
Ch a ng e s wit h p o sit io n a n d
increase s wit h a g e du e
to compensatory forces
(positional param eter
a
)
Sacra l slo p e (SS) Angle b e t we en t h e sa cral p la t e
and the horizontal axis
Sag it ta l ve rt ical
axis
A p lu m b li n e is d r a w n in t h e
sagittal axis from the C7 vertebral
body, and the distance from the
posterosuperior sacral end plate
to the plumb line is measured
Ch a ng e s wit h p o sit io n
(positional param etera)
Mea s u re m e nt o f g lo b a l
alignment.
If p lu m b lin e is p o st e r io r t o
the S1 vertebral body, it is
negative (normal). If anterior,
it is re fe rre d t o a s p osit ive.
a
If o n e p o s it io n al p a r a m e t e r ch an ge s, it a e ct s a ll o t h e r p ara m e t e rs .
20 Adult Spinal Deformity 223
a
Fi g . 2 0 . 2 ( a , b ) Sa cro p e lvic ra d iog ra p hic p a ram et e rs.
b
Fi g . 2 0 . 3 Th e SRS– Sch wa b a d u lt s p in al d e fo rm it y cla ssi c a t io n: a sse ssm e nt a nd clin ica l co r re lat io ns
based on a prospective operative and nonoperative cohort. (Neurosurgery 2013;73(4):559–568.)
224
20 Adult Spinal De form ity
c. Cur ve Type D: d ouble m ajor cu rves > 30 °.
d. Curve Type N: no major coronal deformity.
3. Sagittal modi ers (three types).
a. All are correlated with pain and disability and are important for
preoperative planning and determination of operative management.
b. Pelvic incidence (PI) – LL.
c. Pelvic tilt (PT) (pelvic retroversion).
d. Sagittal vertical axis (SVA).
IX. Evalu at ion :
A. Carefu l h ist o r y a n d e xa m in at io n , in clu d in g p r e vio u s e va lu at io n s fo r s co lio sis :
1. Assessment of kyphosis, lordosis, rib hump, and curve exibility.
2. Neurological examination.
B. X-r ays : 3 6 in s t an d in g a n te ro p ost e r io r a n d la te ra l t o m ea su r e m a gn it u d e o f t h e
curvatures and obtain radiographic parameters as already de ned:
1. It is important to make sure that the patient is not exing the knees, which
will cause underestimation of sagittal imbalance.
2. Patients with spinal stenosis and deformity may ex forward to relieve
spinal stenosis symptom s. It is important to assess both structural atback and functional or exible kyphosis to avoid overestimating sagittal
im balan ce.
C. Ra dic u la r p ain o r s y m p t o m s o f s p in al s t e n os is w a r r a n t m ag n e t ic r es o n a n ce
im aging to assess for neural com pression.
X. Tre at m e n t :
A. Go a ls o f t rea t m e n t in clu d e im pr ove m e n t of fu n c t io n a l im p rove m en t a n d p ain
and restoration of coronal and sagittal alignment.
B. Co n s e r va t ive t r e at m e n t i s in d ic a t e d fo r n o n p r o gr e ss ive c u r ve s ca u sin g lo ca li z e d
back pain. The treatment plan incorporates the general principles of treating
back pain, including a brief period of rest, nonsteroidal anti-in ammatory
drugs, stretching, an exercise program, and nerve blocks.
C. Ra dio gr a p h i c p a r am e te r s , a s d et er m in e d b y t h e SRS—Sc h w a b Cla ss i c a t io n ,
should guide surgical planning.
1. Goal parameters include the following:
a. LL = PI ± 9.
b. PT < 2 0°.
c. SVA < 50 mm .
XI. Te ch n iq u es:
A. Op e rat ive m a n age m e n t is likely w ar r a n t e d w it h sym pt om at ic p a t ie n t s a n d
should be guided by the target radiographic parameters as already stated.
B. Rela t ive ly e xib le t h or a c i c cu r ve s o r b a l a n ce d d ou b le m a j o r cu r ve s r eq u ir e
posterior fusion and instrumentation.
C. Rigid a n d seve re un balanced thoracic cur ves (> 80° cu rves) m ay requ ire an terior
release and fusion followed by posterior fusion and instrumentation.
D. Relat ively exible t h oracolum b ar or lu m bar cur ves ca n be t reated by an te r ior
fusion w ith inst r u m entation (if th ere is no kyphosis an d the curve is lim ited to
T1 0 t o L4 ).
E. Severe an d rigid t h oracolu m bar or lu m bar cur ves > 75°, redu n dan t statem ent ,
and associated kyphosis may require anterior release and fusion followed by
posterior fusion and instrumentation.
20 Adult Spinal Deformity 225
F. De g e n e r a t i ve s c o l i o s i s w i t h r a d i c u l o p a t h y r e q u i r e s p o s t e r i o r l a m i n e c t o m y
and fusion with transpedicular instrumentation of the lumbar spine with or
without anterior fusion.
XII. Co m p lica t io n s :
A. High e r t h a n a d o les ce n t s p in e, e sp ecia lly p u lm on a r y p ro ble m s .
B. Ps e u d a r t h ro s i s is le s s fo r c o m b i n e d a n t e r io r a n d p o s t e r io r a p p r oa ch t h an fo r
posterior fusion alone.
C. Fla t - b ack sy n d r o m e (lo ss o f lu m b a r lo r d o s is ) m a y r e su lt if t h e p os t er io r
surgical techniques produce a distractive force or if the anterior technique
produces signi cant compression force along the lumbar spine. Segmental
instrum entation and preservation of the lum bar lordosis and sagittal balance
are critical.
D. Proxim al jun ction al k yph osis (PJK) (Fig. 20.4):
1. Postoperative adjacent-segment pathology that is de ned as a kyphosis of
> 10° of t h e ceph alad ver tebrae above a previou sly in str u m en te d segm e n t:
a. If severe enough, may warrant a revision procedure.
Fig . 2 0 . 4 Proxima l junct ional kypho sis.
226
20 Adult Spinal De form ity
2. Risk factors:
a. Increased age.
b. Fusion to sacrum.
c. Circum ferential fusion.
d. Thoracoplasty.
e. Upper instrumented vertebrae at T1–T3.
3. Prevalence of 17 to 39%, mostly at 2 years.
4. There is moderate evidence suggesting that PJK does have deleterious e ects
on functional outcomes.
E. In fe c t io n :
1. Incidence of 0.5 to 8%.
2. More common with posterior surgery.
F. N e u r o l o g i c a l c o m p l i c a t i o n s :
1. Incidence of 1 to 5%.
2. Most common with combined posterior and anterior surgery.
G. Pu lm on ar y e m bo lism :
1. Incidence of 1 to 20%.
Sugg este d Reading
Kim HJ, Le n ke LG, Sh a re y CI, Va n Als t yn e EM, Ske lly AC. Pr ox im a l ju n ct io n a l k yp h o s is
as a distinct form of adjacent segment pathology after spinal deformity surgery: a
syste m at ic review. Spin e 2012;37 (22, Suppl):S144 –S164
Kli n e b e r g E, Gu p t a M , McCa r t h y I, Ho st in R. De t e ct io n o f p se u d a r t h ro s is in a d u lt sp in a l d e -
form it y: The u se of h ealth -related qu a lit y-of-life outcom es to predict pseudar t h rosis.
J Spin al Disord Tech 2013
Sch w a b FJ, Blo n d el B, Bess S, e t al; In t e r n at ion al Sp in e St u d y Grou p (ISSG). Rad iogr ap h ica l
spinopelvic parameters and disabilit y in the setting of adult spinal deformity: a prospect ive m ult ice n ter an alysis. Spin e 2 013;38 (13):E803 –E81 2
Sch w a b F, Un gar B, Blo n d el B, et al. Scolio s is Rese a r ch So cie t y-Sch w a b a d u lt sp in a l d e fo r -
m it y cla ssi cation: a validat ion st u d y. Spin e 2012;3 7(12):1 077–108 2
Te r r a n J , S c h w a b F, S h a r e y CI , e t a l ; I n t e r n a t i o n a l S p i n e St u d y G r o u p . T h e S R S - S c h w a b a d u l t
spinal deformity classi cation: assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery 2013;73(4):559–568
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