脊柱结核彻底病灶清除术后3～4.5个月超短程化疗方案的疗效观察

Efficacy of 3-4.5 months ultra-short-course chemotherapy on spinal tuberculosis after thorough focus debridement

中文关键词:  脊柱结核  彻底病灶清除  超短程化疗  疗效

英文关键词:Spine tuberculosis  Thorough focus debridement  Ultra-short-course chemotherapy  Efficacy

中文摘要:

  【摘要】 目的：观察彻底病灶清除术后3～4.5个月超短程化疗方案治疗脊柱结核的疗效，探讨脊柱结核彻底病灶清除术后3～4.5个月的超短程化疗方案的可行性。方法：2003年12月～2014年12月116例彻底病灶清除术后应用3～4.5个月化疗方案治疗的脊柱结核患者，其中男60例，女56例，年龄40.98±17.09岁（3~78岁）。低热31例，盗汗47例，乏力53例，病变节段局部疼痛113例，脓肿78例，纳差、消瘦43例，神经功能障碍38例；胸腰椎后凸畸形33例，术前Cobb角28.46°±7.19°（19°～42°）；病灶部位：颈椎1例，颈胸段1例，胸椎39例，胸腰段17例，腰椎48例，腰骶段9例，骶椎1例；累及单节段87例，双节段19例，3节段及以上10例。术前SHRZ四联抗结核治疗2～4周（平均3.2周）。手术均以彻底病灶清除为基础，其中前路手术37例，后前路手术70例，后路手术9例。术后化疗方案为2SHRZ/1～2.5HRZ，化疗期间全程督导化疗。术后观察临床表现、神经功能Frankel分级、病灶清除情况、植骨融合及病灶治愈情况、畸形矫正情况、血沉（ESR）、C反应蛋白（CRP）、药物不良反应情况。停药指征：（1）无脊柱结核的症状、体征，无脓肿及窦道形成；（2）ESR、CRP正常；（3）B超检查未发现与脊柱结核相关的脓肿；（4）影像学检查示病灶全部治愈，无新发病灶，植骨融合。结果：116例患者术后化疗时间3～4.5个月（3.89±0.60个月）。随访时间2～3年20例，3～5年15例，5~13年81例。停药时，116例患者无结核中毒症状，无局部疼痛及脓肿、窦道，生活及工作能力恢复，ESR、CRP均降至正常，病灶均彻底清除，植骨融合，病灶治愈。1例L4椎体结核患者术后服药4个月后治愈，于停药后6年复发，再次行前路彻底病灶清除髂骨植骨术，术后抗结核治疗24个月后治愈。33例胸腰椎后凸畸形的术后Cobb角为15.30°±5.13°（3°～25°），末次随访时为18.63°±6.06°（10°～36°），矫正率为46.2%，丢失率为11.8%，畸形矫正满意。末次随访时，神经功能Frankel分级较术前明显恢复，A级1例恢复至C级，B级1例恢复至D级，C级8例恢复至D级1例、E级7例，D级28例恢复至E级。17例出现术后化疗相关并发症。结论：在彻底病灶清除的基础上，严格把握适应证，全程督导化疗，脊柱结核术后3～4.5个月的超短程化疗方案是可行的。

英文摘要:

  【Abstract】 Objectives: To observe the efficacy of 3-4.5 months ultra-short-course chemotherapy after thorough focus debridement in the treatment of spinal tuberculosis, and to explore the feasibility of 3-4.5 months ultra-short-course chemotherapy for spinal tuberculosis after thorough focus debridement. Methods: In December 2003 to December 2014, 116 patients with spinal tuberculosis after thorough focus debridement treated with 3-4.5 months of chemotherapy were reviewed retrospectively. There were 60 males and 56 females, the average age of patients was 40.98±17.09 years(range, 3 to 78 years). Presentations included fever in 31 cases, night sweats in 47 cases, fatigue in 53 cases, local pain of lesions in 113 cases, abscess in 78 cases, anorexia and weight loss in 43 cases, neurological dysfunction in 38 cases, thoracolumbar kyphosis in 33 cases. Involved levels included cervical lesions in 1 case, cervicothoracic lesions in 1 case, thoracic lesions in 39 cases, thoracolumbar lesions in 17 cases, lumbar lesions in 48 cases,lumbosacral lesions in 9 cases, sacral lesions in 1 case. Involved segments included single segment in 87 cases, double segments in 19 cases, more than 3 segments in 10 cases. Preoperative SHRZ quadruple anti tuberculosis treatment was used for 2 to 4 weeks(average, 3.2 weeks). Debridement was performed in all cases, among these, anterior approach was used in 37 cases, posterior approach was used in 9 cases. The ultra-short-course chemotherapy was 2SHRZ/1-2.5HRZ after operation. Postoperative observation indexes included: clinical manifestation, nerve function Frankel grade, erythrocyte sedimentation rate(ESR), C-reactive protein(CRP), lesion clearance, correction of deformity, bone graft fusing and lesion healing, the incidence of complications of anti-TB drugs. Withdrawal indicators: ①patients with no spinal tuberculosis symptoms or signs, no local abscess and fistula formation; ②the ESR and CRP were normal; ③no abscess associated with spinal tuberculosis was found by B ultrasonic examination; ④imaging examination showed that the lesions were all cured, no new lesion, bone graft fusion. Results: The course of treatment in 116 patients was 3-4.5 months，with an average of 3.89±0.60 months. Follow-up time(2-13 years): ＜3 years in 20 cases, 3 to 5 years in 15 cases, more than 5 years in 81 cases. Among withdrawal patients, 116 patients had no tuberculosis poisoning symptom, no local pain and local abscess and fistula, all patients reached recovery of life and work ability, the lesions were thoroughly debrided, bone graft fusion was reached. 1 case of patients with lumbar vertebral tuberculosis was cured after the treatment of 4 months and got, recurrence at 6 years after drug withdrawal, then underwent reoperation with anterior debridement and lliac bone graft, cured with postoperative anti-tuberculosis after 24 months. The preoperative Cobb angle of 33 cases of thoracolumbar kyphosis was 28.46°±7.19°(19°-42°), postoperative Cobb angle was 15.30°±5.13°(3°-25°), Cobb angle at the last follow-up was 18.63°±6.06°(10-36°), the correction rate was 46.2%, the loss of rate was 11.8%, deformity correction was satisfactory. At the end of the last follow-up, neurologic Frankel grade of preoperation recovered obviously, 1 case with grade A recovered to grade C, 1 case with grade B recovered to grade D, 8 cases with grade C recovered to grade D in 1 case and grade E in 7 cases, 28 cases with grade D recovered to grade E. Chemotherapy related complications occurred in 17 cases. Conclusions: On the basis of thorough focus debridement, under strict indications and supervision of chemotherapy, 3-4.5 months ultra-short-course chemotherapy for spinal tuberculosis is feasible.