儿童期起病腰骶结核手术治疗的临床疗效

Clinical efficacy of the surgical treatment of childhood onset lumbosacral tuberculosis

中文关键词:  腰骶结核  腰骶后凸畸形  手术治疗  儿童

英文关键词:Lumbosacral tuberculosis  Lumbosacral kyphosis  Surgical treatment  Child

中文摘要:

  【摘要】 目的：探讨儿童时期起病腰骶结核的临床特点和手术治疗的初步疗效。方法：纳入2009年1月~2019年1月期间收治的17例儿童期起病的腰骶结核病例，其中男性7例，女性10例；就诊时年龄9~26岁，平均17岁。术前4例合并腰骶神经根功能障碍；14例合并骶前脓肿及死骨形成，术前采用四联抗结核药物治疗4周以上；3例为静止期结核。单纯后路手术治疗11例，后前路手术治疗6例；7例采用同种异体骨植骨，10例采用自体髂骨植骨；近端均采用2~3对椎弓根螺钉固定，远端9例采用骶骨翼螺钉和S2螺钉固定，8例采用髂骨钉固定。术后继续抗结核药物治疗18个月。采用全脊柱正侧位X线片、三维CT、MRI等评估腰骶椎破坏程度，测量术前、术后腰骶角、侧凸Cobb角、C7铅垂线至骶骨中垂线距离（central sacral vertical line，CSVL）、矢状面轴向距离（sagittal vertical axis，SVA）等影像学指标，评价手术治疗效果和并发症。结果：术前腰骶椎破坏丢失2.95±3.62（1.9~4.6）个，腰骶角为后凸16.22°±7.42°（4°~36°），SVA 11.43±8.12mm；4例合并矢状面失平衡，CSVL偏移23.12±2.12mm；侧凸Cobb角13.57°±5.51°。术后腰骶角为-13.21°±5.12°，矫形29.32°±6.32°（16°~48°）。随访2.5~11年，平均7.4年，术后出现腰骶神经损害症状3例，1例术后即刻进行探查松解后缓解，2例采用保守治疗治愈；髂骨钉断裂3例，1例合并腰骶疼痛行翻修手术，更换髂骨钉和骶髂关节融合，另外2例无症状未行特殊处理。所有病例均获得骨性愈合，随访期间无复发。结论：儿童期起病的腰骶结核常合并严重的椎体缺损和后凸畸形，但因骨盆代偿良好，大部分无明显矢状面失平衡，采用后路手术或后前路手术治疗矫形效果良好，但应注意内固定及神经根并发症。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical features of childhood onset lumbosacral tuberculosis and the preliminary efficacy of surgical treatment. Methods: 17 patients with childhood onset lumbosacral tuberculosis treated in our hospital between January 2009 and January 2019 were included into this study, including 7 males and 10 females, aged 17(9-26) years old on admission. Before operation, 4 cases were found combined with lumbar or sacral nerve root deficits, 14 cases were found combined with presacral abscess and dead bone formation and treated with quadruple antituberculosis drugs for more than 4 weeks, and the rest 3 cases were at quiescent stage of tuberculosis. Of all the cases, 11 underwent single posterior surgery and 6 underwent posterior-anterior surgery; 7 cases were treated with allograft bone grafting and 10 cases with autograft iliac bone; the proximal end was fixed with 2-3 pairs of pedicle screws, and for distal instrumentation, 9 cases were fixed with alar screws and S2 screws and 8 cases with iliac screws. Antituberculosis drug treatment was continued for at least 18 months after surgery. The destruction conditions of lumbosacral vertebrae were evaluated with full spine anteroposterior and lateral radiographs, 3D CT images, and MRIs, and the imaging parameters, such as preoperative and postoperative sacral-lumbar angle, Cobb angle of scoliosis, sagittal vertical axis(SVA), and central sacral vertical line(CSVL) deviation from C7 plumbline were measured, and clinical outcomes and complications were assessed. Results: Before operation, the loss of vertebral bodies was 2.95±3.62(1.9－4.6) with lumbosacral kyphosis angle of 16.22°±7.42°(4°－36°) and SVA of 11.43±8.12mm, and sagittal imbalance was presented in 4 patients with CSVL deviation of 23.12±2.12mm and scoliosis Cobb angle of 13.57°±5.51°. After operation, the lumbosacral angle was reduced to -13.21°±5.12°, corrected by 29.32°±6.32°(16°－48°). All patients were followed up for an average of 7.4 years(2.5－11 years) and bone healing was obtained in all patients without recurrence during follow-up. Postoperative complications included 3 cases of iatrogenic lumbosacral nerve root injury, of whom 1 was relieved after immediate postoperative release and 2 received conservative treatment; 3 cases of iliac screw breakage, 1 of whom with lumbosacral pain underwent revision surgery replacing iliac screw and receiving sacroiliac joint bone grafting, and the other 2 cases with no symptoms were given no special treatment. Conclusions: Childhood onset lumbosacral tuberculosis usually associated with prominent vertebral body loss and lumbosacral kyphosis. Sagittal imbalance was an uncommon presentation because of good adaptation of pelvic compensation. Single posterior or combined posterior-anterior procedures had good correction effects, but attention should be paid to internal fixation and nerve root complications.