脊柱结核前后路不同术式的选择及其疗效

Selection and outcome of anterior vs posterior approach for spinal tuberculosis

中文关键词:  脊柱结核  手术治疗  术式选择  疗效

英文关键词:Spinal tuberculosis  Surgery treatment  Choice of operation methods  Outcome

中文摘要:

  【摘要】 目的：探讨成人脊柱结核前后路不同术式的选择及其疗效。方法：2004年1月~2009年12月采用不同手术方法治疗成人胸腰椎与腰骶段结核患者241例，其中181例非跳跃性结核患者获得平均37个月（22～72个月）的随访。25例合并脊髓功能障碍，Frankel分级D级14例，C级11例。连续4个椎体（均为胸椎）受累11例，3个椎体45例，2个椎体98例，1个椎体27例。CT或MRI显示有明显死骨132例，椎旁脓肿153例。后凸Cobb角-23°~30°者104例，31°～60°者49例，61°～70°者28例。血沉升高169例。据病灶部位和病变程度采用4种手术方式：A组（74例）行前路病灶清除、植骨融合及内固定术；B组（70例）行后路椎弓根螺钉内固定椎板间植骨融合、一期或二期前路病灶清除植骨融合术；C组（10例）行侧前方病灶清除、植骨融合及后方椎弓根螺钉内固定术； D组（27例）行后路病灶清除、椎弓根螺钉内固定及植骨融合术。25例伴脊髓受压症状者入院6~18h应用抗结核药物后急诊手术，其余156例患者术前抗结核药物治疗3～6周，术后继续抗结核治疗，总疗程12个月。结果：A组手术时间平均3.5h，术中出血量平均450ml，B组分别为4.5h、640ml，C组和D组均为3.0h、350ml。4组患者术中均无严重并发症发生。术后8～12周血沉均恢复正常。A组脊柱后凸畸形矫正率为（47.5±11.8）%，B组为（61.5±18.6）%，C组为（58.7±15.9）%，D组为（59.9±17.4）%。末次随访时，A组矫正角度丢失率为（64.8±19.3）%，B组为（53.6±15.6）%，C组为（56.9±11.8）%，D组为（54.9±15.4）%。25例术前脊髓功能损害患者末次随访时，18例Frankel分级改善1级，7例改善2级。A、B、C组各1例分别于术后半个月、1个月和1个半月切口形成窦道，换药治疗1～2个月后治愈。A组1例术后1年随访时发现内固定松动，但植骨已融合，未处理。末次随访时均无结核复发。结论：只要手术适应证选择正确，不同手术方式治疗脊柱结核都能达到清除病灶、脊髓减压及矫正脊柱后凸畸形的目的；但后路固定在矫正脊柱后凸畸形及维持矫形方面优于前路固定。

英文摘要:

  【Abstract】 Objective：To investigate the surgical procedures and their outcomes for spinal tuberculosis（TB） in adults.Method：Between January 2004 and December 2009，241 adult patients with thoracolumbar and lumbosacral TB undergoing different surgical procedures were reviewed retrospectively.A total of 181 patients with multiple-level continuous spinal TB were followed up for 22-72 months（mean，37 months）.Of 25 patients with neurological deficit，there were 14 Frankel D and 11 Frankel C.The involved vertebrae included 4 continuous vertebrae in 11（thoracic），3 continuous vertebrae in 45，2 continuous vertebrae in 98，and 1 vertebra in 27 cases.It showed obvious defect in 132 patients and paraspinal abscess in 153 cases by CT and MRI examination.The kyphosis Cobb angle ranged from -23° to 30° in 104 cases，31° to 60° in 49 cases and 61° to 70° in 28 cases.Erythrocyte sedimentation rates（ESR） raised in 169 cases.All patients were divided into 4 groups according to site and extent of the lesion.Group A included 74 cases who underwent anterior radical debridement and instrumentation.Group B included 70 cases who underwent posterior instrumentation and interlaminar bone graft plus anterior radical debridement and strut graft either by one-stage or two-stage.Group C included 10 cases who underwent front side radical debridment，strut graft and posterior instrumentation in thoracic or thoracolumbar spine.Group D included 27 cases who underwent single-stage posterior debridement and instrumentation.Emergency surgery was performed in 25 patients with neurological impairment following short term chemotherapy prior 6-18h before surgery.The chemotherapy medicine was administered to the remaining 156 cases over 3 weeks before surgery and continued till 12 months after operation.Result：The average operation time and blood loss were 3.5h and 450ml in group A，4.5h and 640ml in group B，3.0h and 350ml in group C and group D.Severe complications were not noted in each group.ESR returned to normal 8-12 weeks after operation.Kyphosis was corrected by（47.5±11.8）% in group A，（61.5±18.6）% in group B，（58.7±15.9）% in group C and （59.9±17.4）% in group D，with loss of correction at final follow-up of （64.8±19.3）% in group A，（53.6±15.6）% in group B，（56.9±11.8）% in group C and （54.9±15.4）% in group D.And at final follow-up，18 cases had Frankel level improved 1 level，and 7 cases had it improved 2 levels.Sinus was found in the each of Group A，B and C at half a month，one month and one and a half months respectively，which was healed by proper intervention 1-2 months later.Instrument loosening was found in 1 patient of group A one year later，however no intervention was performed due to evidenced fusion.No recurrence was observed at final follow-up in all groups.Conclusion：Different surgical approaches are indicated for debridement, decompression and kyphosis correction，which are reliable for spinal tuberculosis.Posterior approach is superior than anterior approach due to its deformity correction and maintaining of correction.