脊柱结核手术治疗方式的选择

Surgical management of thoracic and lumbar 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：探讨脊柱结核手术治疗方式的选择原则。方法：2003年1月～2008年12月收治并获得随访的胸腰椎和腰骶段结核患者57例，男28例，女29例；年龄11～68岁，平均43岁。胸椎20例，胸腰段25例，腰椎9例，腰骶段3例；病灶侵犯1个椎体2例，2个椎体46例，3个椎体6例，4个椎体3例。患者均有胸腰背部疼痛史，5例伴脊髓受压症状，按照Frankel分级：C级1例，D级4例。术前、术后按标准化疗方案进行化疗。根据结核病灶的部位、椎体破坏程度、患者一般情况等选择手术入路和内固定方式，其中单纯前路病灶清除术3例，后路椎弓根螺钉内固定+一期或二期前路病灶清除植骨融合术26例（一期手术11例，二期手术15例），一期前路病灶清除植骨融合内固定术27例，后路病灶清除三柱截骨矫形植骨融合内固定术1例。20例采用切除的肋骨植骨，34例取髂骨植骨（其中1例同时应用异体骨）。随访患者临床疗效。结果：手术时间70~340min，平均130min；术中出血100~2600ml，平均520ml。术后无神经损伤加重及脑脊液漏等并发症；2例腹部切口形成窦道，经切口换药1例5个月后愈合，1例7个月后愈合。随访2～6年，平均3.4年，患者症状明显改善，5例伴有脊髓受压症状者术后6个月均恢复至E级。植骨全部融合，融合时间4～11个月，平均5.8个月。末次随访时所有患者均获临床治愈，随访期间结核无复发、内固定无松动及断裂。13例后路内固定患者术后3~6年取出内固定物。结论：在规范抗结核治疗的基础上，根据患者结核病灶的部位、椎体破坏程度、患者的一般情况选择不同的方法进行病灶清除植骨融合内固定术可取得良好的治疗效果。

英文摘要:

  【Abstract】 Objective：To discuss the surgical principle for different types of thoracic and lumbar vertebrae tuberculosis.Method：A total of 57 cases with thoracic and lumbar vertebral tuberculosis between January 2003 and December 2008 were reviewed retrospectively.There were 28 males and 29 females with an average age of 43 years（range，11 to 68 years）.Of these，there were 20 thoracic vertebral tuberculosis，25 thoracolumbar vertebral tuberculosis，9 lumbar vertebral tuberculosis，3 lumbosacral vertebral tuberculosis.2 cases had 1 vertebral body involved；46 cases had 2 vertebral bodies involved；6 cases had 3 vertebral bodies involved；and 3 cases had 4 vertebral bodies involved.All cases presented with back pain，while 5 cases had neurological deficit prior to surgery.According to the Frankel classification，there were 1 Frankel C and 4 Frankel D.All patients received anti-tuberculosis chemotherapy before and after operation．The operative approach and instrumentation were determined by tuberculosis site，the vertebrae defect and the patients′ general conditions.3 cases underwent anterior focal debridement；26 cases（one stage in 11 cases and two-stage in 15 cases） underwent combined posterior pedicle screw fixation and anterior focal debridement and bone graft；27 cases underwent anterior spinal internal fixation and focal debridement；and 1 case underwent spinal osteotomy correction and instrumentation.20 cases used rib，and 34 cases used iliac bone as bone graft，while 1 case used auto iliac and allograft.The surgical outcome of all patients was followed up.Result：The average surgical time was 130 minutes（range，70-340min），with the average intraoperative blood loss of 520ml（range，100-2600ml）.No complications such as neurological injury and cerebrospinal fluid leakage were noted.Tuberculous sinus developed in 2 cases and healed by correspondent interventions for 5-7 months.All patients were followed up for an average of 3.4 years（range，2-6 years） and healed clinically at final follow-up.No recurrence and instrument failure were noted at final follow-up.5 cases with spinal cord injury recovered to Frankel E 6 months later.Bony fusion was achieved in all cases in the mean fusion period of 5.8 months（range，4-11 months）.13 cases undergoing posterior approach had instrument removed 3-6 years later.Conclusion：On the premise of standard anti-tuberculosis chemotherapy，varied surgical management can be determined according to defect site，degree of destruction and patient′s general condition.