前方经胸骨或侧前方经肩胛下入路手术治疗上胸椎结核

Anterior transsternal or anteriorlateral transthoracic approach for upper thoracic vertebral tuberculosis

中文关键词:  上胸椎结核  前方经胸骨手术入路  侧前方经肩胛下入路

英文关键词:Upper thoracic spine tuberculosis  Anterior transsternal approach  Anteriorlateral high transthoracic approach

中文摘要:

  【摘要】　目的：探讨前方经胸骨或侧前方经肩胛下入路治疗上胸椎（T1～T4）结核的手术方法及疗效。方法：2000年6月~2008年12月收治上胸椎结核患者26例，其中16例采用经胸骨入路行一期病灶清除、前路减压、植骨融合及内固定术（A组），年龄37～72岁，平均48.6岁，术前神经功能按Frankel分级A级2例，B级1例，C级2例，D级6例，E级5例，术前胸椎后凸Cobb′s角为15°～40°，平均22°±3.5°；10例采用侧前方经肩胛下入路行一期病灶清除、减压、植骨融合及内固定术（B组），年龄33～69岁，平均45.3岁，术前按Frankal分级A级1例，B级1例，C级1例，D级4例，E级3例，术前胸椎后凸Cobb′s角为13°～39°，平均21°±3.7°。结果：两组患者均能很好耐受手术。A组患者术中显露清楚，病灶清除彻底，手术时间为120～150min，术中出血量为300～600ml；1例患者术后出现声音嘶哑，考虑为喉返神经牵拉伤，术后2周恢复正常；术后胸椎后凸Cobb′s角为10°～25°，平均17°±2.5°；随访6～72个月，末次随访时1例A级恢复到D级，1例B级恢复到C级，2例C级恢复到D级，4例D级恢复到E级，余无变化。B组患者不能完全显露对侧，病灶清除不易彻底，手术时间为150～220min，术中出血量为500～900ml，1例发生胸导管损伤，经对症治疗1周后痊愈；术后胸椎后凸Cobb′s角9°～24°，平均为16°±2.3°，均有肩关节活动障碍；随访12～96个月，末次随访时4例仍有肩关节轻度障碍；1例A级恢复到C级，1例B级恢复到C级，1例C级恢复到D级，4例D级恢复到E级，其余患者神经功能无变化。两组均无结核复发，无内固定物断裂、松动等并发症。所有植骨均愈合，愈合时间为3～6个月，平均4.4个月。结论：与侧前方经肩胛下入路相比，经胸骨入路可以更清楚地显露上胸椎，创伤小，能达到一期病灶清除、前路减压及植骨内固定治疗上胸椎结核的目的。

英文摘要:

  【Abstract】 Objective：To investigate the surgical protocol and its clinical outcome of anterior transsternal or anteriorlateral transthoracic approach for upper thoracic vertebral tuberculosis（T1-T4）.Method：A total of 26 patients with upper thoracic tuberculosis from June 2000 to December 2008 were reviewed retrospectively.Of these，16 cases aged from 37 to 72 years old（mean，48.6 years old） underwent one-stage transsternal debridement，decompression，bone graft and instrumentation（group A）.There were 2 patients of Frankel grade A，1 of grade B，2 of grade C，6 of grade D and 5 of grade E.The kyphosis Cobb′s angle ranged from　15° to 40°（mean，22°±3.5°）.Another 10 cases aged from 33 to 69 years old（mean，45.3 years old） experienced debridement，decompression，bone graft and instrumentation by anteriorlateral high transthoracic approach（group B）.There were 1 patient of Frankel grade A，1 of grade B，1 of grade C，4 of grade D and 3 of grade E.The kyphosis Cobb′s angle ranged from　13° to 39°（mean，21°±3.7°）.Result：All patients in two groups experienced surgery successfully.For group A，good field exposure and complete lesion clearance were ensured，the operation time was 120-150min and the intraoperative blood loss was 300-600ml.One patient was complicated with recurrent laryngeal nerve injury and healed two weeks after operation.The kyphosis Cobb′s angle after operation was 10°-25°（mean，17°±2.5°）.All patients in group A were　followed up for 6-72 months，at final follow-up，1 patient of grade A improved to grade D，1 patient of grade B improved to grade C，2 patients of grade C improved to grade D，4 patients of grade D improved to grade E，while no change was noted in other patients.For group B，unsatisfactory contrallateral exposure and lesion clearance occurred，the operation time was 150-220min and the blood loss was 500-900ml.One patient had injury to thoracic duct which healed two weeks postoperatively.Scapular joint malfunction was noted in all patients of group B.The mean Cobb′s angle as for kyphosis correction was 9°-24°（mean，16°±2.3°）.The patients were　followed up for 12-96 months，at final follow-up，1 patient of grade A improved to grade C，1 patient of grade B improved to grade C，1 patient of grade C improved to grade D，4 patients of grade D improved to grade E，while no change was noted in other patients.During the follow-up，all cases healed without any tuberculosis recurrence，and no pull-out and breakage of screws or plates were noted.Spinal union occurred at 3-6 months（mean，4.4 months） postoperatively.Conclusion：Anterior transsternal approach can provide excellent access to the upper thoracic tuberculosis and is less invasive compared with anteriorlateral high transthoracic approach.