不同入路手术治疗上颈椎结核的疗效观察

Surgical treatment of upper cervical tuberculosis with different approaches and its efficacy evaluation

中文关键词:  上颈椎  结核  手术治疗  疗效

英文关键词:Upper cervical  Tuberculosis  Surgical treatment  Curative effect

中文摘要:

  【摘要】 目的：探讨不同入路手术治疗上颈椎结核的疗效。方法：回顾分析2015年1月~2020年12月在我院行手术治疗的39例上颈椎结核患者的临床资料，男17例，女22例，年龄3~70岁。其中10例伴有吞咽困难，24例患者存在双上肢麻木、疼痛、无力，11例存在下肢无力、行走不稳。术前给予2~4周标准四联抗结核药物治疗。12例患者行单纯前路手术治疗；8例患者行单纯后路手术；19例患者行后前路联合手术。术后继续规律标准抗结核药物治疗12~18个月。记录所有患者手术前后及末次随访时日本骨科学会（Japanese Orthopaedic Association，JOA）颈椎功能评分、枕颈部疼痛视觉模拟评分（visual analogue score，VAS）、美国脊柱损伤协会（American Spinal Injury Association，ASIA）脊髓损伤分级及并发症等。结果：39例患者均顺利完成手术，术中均未发生脊髓、神经根、椎动脉等损伤，且术后病理检查诊断为结核。随访12~30个月（15.5±4.1个月）。单纯前路组术前、术后和末次随访的JOA评分分别为11.1±1.9、13.8±1.3和15.6±1.3分，VAS评分分别为6.8±0.8、3.3±1.0和2.1±1.2分；单纯后路组JOA评分分别为12.9±2.2、14.9±1.8和15.9±1.2分，VAS评分分别为7.1±0.6、3.6±0.7和2.3±1.2分；后前路联合组JOA评分分别为10.0±2.0、12.7±1.4和14.4±1.1分，VAS评分分别为6.5±1.0、3.5±1.0和2.2±1.0分。单纯前路组及后前路联合组患者术后和末次随访时的JOA评分、VAS评分与术前比较均有明显改善（P＜0.01），末次随访时的JOA评分、VAS评分与术后比较亦均有显著改善（P＜0.01）；单纯后路组患者末次随访时的JOA评分与术前比较有明显改善（P＜0.01），术后和末次随访时的VAS评分与术前比较均有显著改善（P＜0.01）。后前路联合组中1例患者于术后3个月随访时发现颈后术区出现窦道、血沉等炎症指标升高，颈椎CT显示术中植骨未完全融合，经清创、换药、调整抗结核药物、延长佩戴颈托时间等治疗1个月后，伤口愈合。单纯前路组患者中术前神经功能ASIA分级C级2例、D级5例，末次随访时由1例由C级改善至D级，余患者均恢复至E级；单纯后路组患者中术前神经功能ASIA分级C级1例、D级1例，末次随访时均恢复至E级；后前路联合组患者中术前神经功能ASIA分级B级2例、C级6例、D级7例，末次随访时1例由B级仅改善至C级，1例由B级改善至D级，2例由C级改善至D级，其余患者均恢复至E级。末次随访39例均达到治愈标准。结论：手术治疗上颈椎结核时应根据患者临床症状、结核病灶特点以及神经功能情况，个体化采用单纯前路或单纯后路或后前路联合手术，可以取得满意的临床疗效。

英文摘要:

  【Abstract】 Objectives: To investigate different approaches in the surgical treatment of upper cervical spine tuberculosis and their clinical efficacy. Methods: The clinical data of 39 patients(17 males and 22 females, aged 3-70 years) with upper cervical tuberculosis who underwent surgery in our hospital from January 2015 to December 2020 were retrospectively analyzed. Among them, 10 cases were accompanied by dysphagia, 24 cases had numbness, pain, and weakness of both upper limbs, and 11 cases had weakness of lower limbs and unstable walking. Standard anti-tuberculosis drug therapy was given 2 to 4 weeks before surgery. 12 patients were treated with simple anterior surgery; 8 patients were treated with simple posterior surgery; 19 patients were treated with combined posterior and anterior surgery. The Japanese Orthopaedic Association(JOA) cervical function score, occipitocervical visual analog scale(VAS), American Spinal Injury Association(ASIA) spinal cord injury grade and complications were recorded before and after operation and at the final follow-up in all patients. Results: All 39 patients completed the operation, no spinal cord, nerve root, vertebral artery and other injuries occurred during the operation, and the postoperative pathological examination was diagnosed as tuberculosis. All patients were followed up for 12-30 months with an average of 15.5±4.1 months. Among them, the JOA scores in the simple anterior group were 11.1±1.9, 13.8±1.3 and 15.6±1.3 before surgery, after surgery and at final follow-up respectively, and the VAS scores were 6.8±0.8, 3.3±1.0 and 2.1±1.2; JOA scores in the simple posterior group were 12.9±2.2, 14.9±1.8 and 15.9±1.2, and VAS scores were 7.1±0.6, 3.6±0.7 and 2.3±1.2; the JOA scores of the posterior-anterior combined group were 10.0±2.0, 12.7±1.4 and 14.4±1.1, and the VAS scores were 6.5±1.0, 3.5±1.0 and 2.2±1.0. The postoperative and final follow-up scores of the simple anterior group and posterior-anterior combined group were significantly improved compared with those before operation(P<0.01), and the final follow-up scores were also significantly improved compared with postoperative ones(P<0.01); the final follow-up JOA score of the simple posterior group was significantly improved than before operation(P<0.01), the postoperative and final follow-up VAS score of the simple posterior group was significantly improved before the operation(P<0.01). 1 patient in the posterior-anterior combined group was found with a sinus in the posterior cervical operation area, and indexes such as erythrocyte sedimentation rate increased at 3 months follow up after operation. After debridement, dressing change, adjustment of anti-tuberculosis drugs, and extension of wearing a neck brace for 1 month, the wound healed. The remaining patients experienced no complications at the final follow-up. Among the patients in the simple anterior group, 2 cases were of ASIA grade C and 5 cases were of grade D, and 1 patient was improved from grade C to grade D at the final follow-up, and the rest recovered to grade E. Among the patients in the simple posterior group, 1 case were of ASIA grade C and 1 case were of grade D, and they recovered to grade E at the final follow-up. Among the patients in the combined posterior- anterior group, 2 cases were of ASIA grade B, 6 cases were of grade C, and 7 cases were of grade D. At final follow-up, 1 improved from grade B to C only, 1 improved from grade B to D, 2 improved from grade C to D, and the rest recovered to grade E. At final follow-up, all 39 cases reached the standard of cure. Conclusions: The surgical treatment of upper cervical tuberculosis should be based on the clinical symptoms, characteristics of tuberculosis lesions, and neurological function, and individualized surgical approaches of simple anterior, posterior or combined posterior-anterior surgery accordingly can achieve satisfactory clinical effects.