经后路全脊椎切除治疗结核治愈型胸腰椎角状后凸畸形

Posterior vertebal column resection for correct severe focus-healed tubercular angular kyphosis in thoracal and lumbar spine

中文关键词:  脊柱结核  后凸畸形  后路全脊椎切除  截骨术

英文关键词:Spinal tuberculosis  Post-tubercular kyphosis  Posterior vertebral column resection  Osteotomy

中文摘要:

  【摘要】 目的：探讨经后路全脊椎切除术治疗结核治愈型胸腰椎角状后凸畸形的有效性和安全性。方法：2008年１月~2012年１月，采用后路全脊椎切除手术治疗17例结核治愈型胸腰椎角状后凸畸形患者，男5例，女12例，年龄9～40岁，平均23.6岁。病程16～122个月，平均37.5个月，其中2例病例既往有经肋横突入路结核病灶清除手术史。病灶累及1～2个椎体8例，≥3个椎体9例。后凸畸形顶椎位于胸椎（T5～T10）5例，胸腰段（T11～L1）10例，腰椎2例。术前Cobb角60°～90°者13例，＞90°者4例，最大为102°，平均81.3°±12.8°。所有患者均可见驼背畸形，无低热、盗汗等结核中毒症状。术前、术后和末次随访时分别测量患者后凸Cobb角，并评估神经功能ASIA分级。结果：本组病例手术均顺利完成，手术时间330～450min，平均364min；术中出血量1600～2500ml，平均2218ml；术中输血1000～2000ml，平均1863ml。术中2例患者出现胸膜破裂，及时予以修补，经观察未发现气胸或血气胸。所有病例术后伤口均一期愈合，无窦道形成，内固定未见松动，未见神经功能加重者。术后Cobb角矫正至10°～28°，平均17.3°±3.6°，较术前明显改善（P<0.01），后凸畸形矫正率平均为（68.7±6.5）%；术后随访13～34个月，平均18.7个月，末次随访时后凸Cobb角10°～32°，平均20.6°±3.9°，较术后平均丢失3.3°（P>0.05），但与术前相比仍有明显改善（P<0.01）；植骨融合时间5～9个月，平均6.5个月；术前神经功能为D级的5例患者，4例恢复到E级，另1例仍为D级，但后凸畸形及局部疼痛已明显好转。结论：经后路全脊椎切除可安全有效地用于结核治愈型胸腰椎角状后凸畸形的矫形手术。

英文摘要:

  【Abstract】 Objectives: To evaluate the safety and efficacy of posterior vertebral column resection in treatment for severe focus-healed tubercular angular kyphosis in thoracal and lumbar spine. Methods: From January 2008 to January 2012, 17 patients with severe focus-healed tubercular angular kyphosis in thoracal and lumbar spine underwent posterior vertebral column resection(PVCR) in our institute. They were 5 males and 12 females, with an average age of 23.6 years old(range, 9 to 40 years). The disease duration ranged from 16 to 122 months(average 37.5 months), two of them underwent debridement through rib-processus transverse approach. One or two vertebral bodies were involved in 8 cases and more than two vertebral bodies were involved in 9 cases. The location of apical vertebrae of angular kyphosis was thoracal spine(T5-T10) in 5 cases, thoracolumbar spine(T11-L1) in 10 cases and lumbar spine in 2 cases. The kyphotic Cobb angle was equal to or larger than 60°, among them 13 cases had Cobb angle betweem 60° to 90°, 4 cases had angle over 90°, with the biggest angle of 102°. All patients had a humpback appearance, no other tuberculosis clinical symptom such as fever or night sweatening was noted. In these cases, kyphotic Cobb angle and ASIA grade were measured before operation, after operation and at final follow-up. Results: All operations were performed successfully. The operation time ranged from 330 to 450min(average, 364min); blood loss during the operation ranged from 1600 to 2500ml(average, 2218ml), and blood transfusion ranged from 1000 to 2000ml(average, 1863ml). Pleura rupture occurred in two cases, and no pneumothorax or hemopneumothorax occurred after repairment. All incisions healed perfectly without sinus formation. No instrument failure or neurological deterioration was noted. The preoperative kyphosis ranged from 60° to 102°(average, 81.3°±12.8°), and postoperative kyphosis ranged from 10° to 28°(average, 17.3°±3.6°), which showed significant difference(P＜0.01). The average kyphosis correction rate was (68.7±6.5)%. The follow-up ranged from 13 to 34 months(average, 18.7 months) and kyphosis at final follow-up ranged from 10° to 32°(average, 20.6°±3.9°), with a loss of correction of 3.3°. Compared with preoperation, these parameters showed significant differences(P＜0.01). Bony union occurred at an average of 6.5 months(range, 4 to 9 months). Among the 5 patients with preoperative ASIA grade D, 4 cases improved to grade E, the other 1 case remained unchanged, but the kyphosis improved and the local back pain relieved very well. Conclusions: Posterior vertebral column resection is an effective and safe way to treat severe focus-healed tubercular angular kyphosis in thoracal and lumbar spine.