前路手术治疗伴椎旁巨大脓肿的胸腰椎结核

The clinical study of anterior approach operation for the thoracic and lumbar tuberculosis with huge abscess

中文关键词:  脊柱结核  椎旁脓肿  病灶清除术  植骨  内固定  前路

英文关键词:Spinal tuberculosis  Paravertebral abscess  Debridement  Bone grafting  Anterior approach  Internal fixation

中文摘要:

  【摘要】 目的：探讨单纯应用前路病灶清除、植骨及内固定术治疗伴椎旁巨大脓肿胸腰椎结核患者的疗效。方法： 2009年1月～2010年1月手术治疗9例伴椎旁巨大脓肿的胸腰椎结核患者，骨质破坏累及2个椎体6例（T9、T10 1例，T10、T11 2例，T12、L1 1例，L2、L3 2例），累及3个椎体3例（T10～T12 1例，T7～T9 1例，L2～L4 1例）。所有病例椎旁脓肿均累及3个椎体以上。脊髓神经功能ASIA分级B级1例，C级5例，D级2例，E级1例。术前后凸Cobb角5°～45°，平均28.3°±13.5°；VAS评分3～8分，平均6.0±1.2分；ODI 50%～95%，平均（68.6±17.6）%。均行前路病灶清除取自体髂骨植骨融合内固定术，1例入院时为不完全性瘫痪行急诊手术，4例术前采用口服异烟肼（H）、利福平（R）、乙胺丁醇（E）、吡嗪酰胺（Z）四联（HRZE）抗结核治疗1周后效果欠佳即行手术治疗，4例术前采用HRZE抗结核治疗2周后择期行手术治疗。术后继续抗结核药物治疗12个月，佩戴胸腰支具3个月。观察患者临床表现，术后1个月、6个月、12个月复查X线片及CT或MRI，观察切口愈合、并发症、植骨融合和神经功能恢复情况等。结果：手术时间120～150min，平均135min；术中出血量400～1400ml，平均900ml。2例术中发生脑脊液漏，1例行修补，1例未行修补；2例术后切口出现窦道Ⅱ期愈合，7例Ⅰ期愈合。1例左侧L3、L4神经根损伤，术后1周左股四头肌肌力3级，应用营养神经药物及针灸、理疗对症处理，术后12个月时随访股四头肌肌力4级。随访12～20个月，平均17个月，脓肿完全吸收时间3~6个月，平均4.5个月。植骨全部融合，融合时间5～14个月，平均8.5个月。末次随访时后凸Cobb角恢复至5°～15°，平均10.3°±3.3°；1例术前ASIA B级患者恢复至D级，余8例均为E级；ODI降至1%～3%，平均（2.8±0.9）%；VAS降至0～1分，平均0.6±0.5分。随访期间无内固定松动及断裂，末次随访所有患者均获临床治愈。结论：在正规抗结核药物治疗基础上，前路病灶清除自体髂骨植骨内固定术治疗伴椎旁巨大脓肿的胸腰椎结核可取得良好效果。

英文摘要:

  【Abstract】 Objectives: To investigate the results of a simple anterior surgical treatment for thoracic and lumbar tuberculosis with huge abscess with debridement, bone grafting and internal fixation. Methods: A total of 9 cases suffering from thoracic and lumbar tuberculosis with huge abscess involvement between January 2009 and January 2010 underwent a simple anterior surgical treatment with debridement, bone grafting and internal fixation. The destruction lession range involving 2 vertebral bodies in 6 cases(T9, T10 1 case, T10, T11 2 cases, T12, L1 1 case, L2, L3 2 cases), involving 3 vertebral bodies in 3 cases(T10-T12 1 case, T7-T9 1 case, L2-L4 1 case). All cases were involved more than 3 vertebral abscesses. Spinal function assessment of ASIA grade B in 1 case, C in 5 cases, D in 2 cases, E in 1 case. The preoperative average Cobb angle of kyphosis was 28.3°±13.5°(range, 5°-45°); average VAS score was 6.0±1.2 points(range, 3 to 8 points); average ODI was (68.6±17.6)%(range, 50% to 95%). All cases underwent anterior debridement with autograft of ilium bone graft fusion and internal fixation. 1 case not completely paralyzed received emergency operation. 4 cases acquired poor effect of preoperative oral isoniazid(H), rifampicin(R), pyrazinamide(Z), ethambutol(E)(HRZE) drug antituberculous therapy for 1 week and then were treated with operation. 4 patients with preoperative HRZE antituberculous therapy for 2 weeks before undergoing operation treatment continued to HRZE postoperative antituberculous therapy for 12 months. The clinical manifestations were observed, the X ray and CT or MRI were received after 1 month, 6 months and 12 months postoperatively, observing the incision healing, complications, bone graft fusion rate, neural symptom recovery. Wear of thoracic and lumbar spine brace for 3 months. Results: The average sugrical time was 135min（range，120-150min）, an average loss of blood was 900ml（range, 400-1400ml）. There was no neurological handicaps, two cases suffered from cerebrospinal fluid leakage, 1 case accepted routine repair and the other one who did not healed itself. 2 cases of postoperative wound healed occurs sinus Ⅱ, the rest were stage Ⅰ healing. 1 case of the injury of left L3, L4 nerve root, the strength of left femoral head four muscle was 3 level until 1 week postoperation. With the application nervous nutrition drugs and acupuncture, physiotherapy and symptomatic treatment, the muscle strength level was 4 level after 12-month follow-up. All cases were followed up for an average of 17 months(ranges, 12-20 months). The time of the abscess completely absorption was an average of 4.5 months(3-6 months). The average time of fusion was 8.5 months(range, 5-14 months). At the last follow-up, the kyphosis Cobb angle was an average of 10.3°±3.3°（5°-15°）. ASIA evaluation of spinal cord function in 1 case of grade B preoperatively returned to grade D, 8 cases recovered to level E. ODI was 1%-3%, average(2.8%±0.9%). VAS to 0-1, average 0.6±0.5 point. During the follow-up period, all patients were without internal fixation loosening and fracture. At the last follow-up, all patients were clinically cured. Conclusions: Based on the regular antituberculosis drug therapy, it is reliable in the treatment of thoracolumbar spinal tuberculosis with huge abscess to use anterior debridement with autologous iliac bone graft and internal fixation.