上颈椎结核的诊断与治疗

Diagnosis and treatment of upper cervical tuberculosis

中文关键词:  上颈椎  结核  诊断  治疗

英文关键词:Upper cervical spine  Tuberculosis  Diagnosis  Treatment

中文摘要:

  【摘要】 目的：探讨上颈椎结核的诊断与治疗方法。方法：对1998年1月~2008年12月我院收治的29例上颈椎结核患者进行回顾性分析，男18例，女11例；年龄2~64岁，平均33.6岁。其中9例有神经功能障碍，Frankel C级3例，D级6例。C1 8例，C2 11例， C1、C2 10例；骨质破坏29例，寰枢椎脱位10例，椎前脓肿13例。27例患者术前在CT引导下行病灶穿刺活检病理诊断为结核；另2例患者因年龄小，CT引导下穿刺有困难，影像学诊断为上颈椎结核，术中活检确诊为结核。均应用抗结核药物治疗18个月并经不同的外科方法治疗。按照我院新制定的上颈椎结核分级系统（Ⅰ级：骨质轻、中度破坏；Ⅱ级：骨质重度破坏，寰枢椎脱位；Ⅲ级：骨质破坏或寰枢椎脱位合并神经功能障碍）对上述患者进行分级，观察不同分级患者的外科干预疗效。结果：Ⅰ级12例，其中11例行Halo架外固定5~8个月，1例因骨质破坏轻微仅予颈围领外固定3个月。Ⅱ级：8例，均颅骨牵引复位后行Halo架外固定，其中6例手术清除死骨并行植骨融合，术后Halo架外固定3个月；另2例未行手术，持续外固定6个月。Ⅲ级：9例，均行手术减压及植骨融合，术后Halo架外固定3~6个月。15例手术患者术后病理检查均证实为结核。随访18个月~7年，平均30个月，有神经功能障碍者Frankel分级均恢复至E级。复查X线片及CT显示椎前脓肿消失、骨质愈合、植骨融合，寰枢椎脱位患者均复位良好。上颈椎结核均治愈，随访期间无复发。结论：上颈椎结核确诊有赖于病理诊断。有神经功能障碍者，确定压迫因素后应通过手术或牵引复位减压；无神经功能障碍者，即便有寰枢椎脱位，经颅骨牵引复位后行Halo架外固定亦可达到良好效果。结核的最终治愈要依靠规范的化疗。

英文摘要:

  【Abstract】 Objective：To investigate the determination and treatment of upper cervical tuberculosis.Method：29 patients suffering from upper cervical tuberculosis and treated surgically between January 1998 and December 2008 were reviewed retrospectively.There were 18 males and 11 females with age ranging from 2 to 64 years old（mean，33.6 years old）.9 cases had neurological deficits including 3 Frankel C and 6 Frankel D.8 cases had C1 involved；11 had C2 involved；and 10 had both C1 and C2 involved.Bony lesion was noted in all patients.10 patients were complicated with atlantoaxial dislocation.CT-guided fine-needle aspiration biopsy was performed in 27 patients；while 2 failed due to young age，so the tuberculosis was confirmed by the intra-operative biopsy.All patients received 18 months routine antituberculous chemotherapy and respective surgical intervention.The classification for upper cervical tuberculosis grading system presented in our institute was used in all cases（grade Ⅰ：mild to moderate bony destruction，grade Ⅱ：severe bony destruction combined with atlantoaxial dislocation，grade Ⅲ：grade Ⅰ or grade Ⅱ plus neurological deficits）.The clinical outcome surgical intervention of varied grade cases was reviewed.Result：11 of 12 cases of grade Ⅰ experienced Halo-vest external fixation for 5-8 months，while the other 1 wear hard collar for 3 months due to no obvious bony destruction.8 cases of grade Ⅱ underwent skull traction followed by Halo-vest external fixation，6 of whom underwent debridement and fusion followed by Halo-vest for 3 months，while the other 2 cases underwent Halo-vest external fixation alone for 6 months.9 cases of grade Ⅲ underwent decompression and fusion followed by Halo-vest for 3-6 months.All patients were followed up for a mean of 30 months（range，18-84 months）.All patients with neuro-logical deficit improved to Frankel E.Radiology demonstrated absence of paravertebral abscess，bony fusion and good alignment of C1/2 achieved in all cases.And there was no tuberculosis recurrence during the follow-up.Conclusion：Pathological determination is critical for upper cervical tuberculosis.The patients with neurological defect should be managed by surgery or dislocation reduction.The surgery should be simple and effective aiming at decompression.The patients with intact neurological status can be treated non-operatively.Atlantoaxial dislocation can be reduced by skull traction and maintained by Halo-vest with perfect outcome.Routine chemotherapy is the key for the prognosis.