腹膜后入路腹腔镜下手术治疗腰椎结核

Retroperitoneal laparoscopic surgery for lumbar spine tuberculosis

中文关键词:  腰椎结核  手术  腹腔镜  腹膜后入路

英文关键词:Lumbar tuberculosis  Surgery  Laparoscopy  Retroperitoneal space

中文摘要:

  【摘要】 目的：总结腹膜后入路腹腔镜下手术治疗腰椎结核的疗效。方法：2009年10月～2011年10月采用腹膜后入路腹腔镜下手术治疗腰椎结核患者16例，男11例，女5例，年龄26~62岁，平均38.2岁。L1~L2 2例，L2~L3 5例，L3~L4 4例，L2~L4 2例，L3~L5 1例，L3 1例，L4 1例；均有椎旁脓肿，单侧12例，双侧4例。12例合并腰椎后凸畸形， Cobb角5°～20°，平均11.2°±3.6°。神经功能受损2例，ASIA分级C级1例，D级1例。均采用腹膜后入路，其中4例双侧脓肿选择左侧入路，12例单侧脓肿选择脓肿侧入路。5例破坏L1或椎体破坏超过50%患者，采用传统腹腔镜技术操作，行前路单纯病灶清除及植骨，联合后路椎弓根螺钉内固定；9例病变累及2个椎体（椎体保留50%以上）者采用单孔腹腔镜技术行一期前路病灶清除、植骨及内固定；2例病变累及2个以上椎体（椎体保留50%以上）者采用改良单孔腹腔镜技术，行一期前路病灶清除、植骨及内固定。术前均用异烟肼、利福平、乙胺丁醇、链霉素四联抗结核化疗2周，术后抗结核治疗9～12个月。结果：均顺利完成手术，手术时间240~365min，平均280min；术中出血量50~400ml，平均112ml。无术中并发症。2例术前神经功能受损患者术后神经功能完全恢复正常，ASIA分级均为E级。1例右侧入路患者术后即出现植物神经功能紊乱，患侧下肢皮肤温度高于对侧，未行特殊处理，术后1周症状消失。1例L4~L5前路内固定患者术后3个月摔倒后出现L5椎体螺钉松动，予内固定拆除，行后路椎弓根螺钉固定。术后2周Cobb角-10°~5°，平均-5.1°±2.7°，与术前比较有统计学差异（P<0.01）。随访3~22个月，平均12.1个月。末次随访Cobb角-10°~8°，平均-4.2°±2.1°，与术前比较有统计学差异（P<0.01），Cobb角丢失2.6°±1.8°。末次随访植骨融合11例，融合时间6~12个月。11例完成抗结核治疗疗程者，末次随访均未见结核复发。结论：腹膜后入路腹腔镜下手术治疗腰椎结核安全，近期效果良好。

英文摘要:

  【Abstract】 Objectives: To investigate the outcome of balloon-assisted laparoscopic retroperitoneal approach for lumbar spine tuberculosis. Methods: From October 2009 to October 2011, 16 cases of lumbar tuberculosis underwent balloon-assisted laparoscopic retroperitoneal approach. There were 5 females and 11 males with a mean age of 38.2 years(range, 26-62). The diseased levels included L1-L2 in 2 patients, L2-L3 in 5 patients, L3-L4 in 4 patients, L2-L4 in 2 patients, L3-L5 in 1 patient, L3 in 1 patient and L4 in 1 patient. All patients presented with paraspinal abscesses, and unilateral abscesses in 12 patients and bilateral abscesses in 4 patients. Lumbar kyphosis was noted in 12 patients with a mean sagittal Cobb′s angle of 11.2°±3.6°(5°-20°) before operation. According to ASIA scale, there were 1 grade D and 1 grade C. Anterior debridement, decompression, auto bone graft and one-stage posterior instrumentation under conventional laparoendoscopic approach was performed in 5 patients. One-stage anterior debridement, bone graft and anterior single rod instrumentation for 1 level under LESS technique was performed in 9 patients. Modified LESS technique(one-stage anterior debridement, bone graft and single rod instrumentation for 2-levels) was performed in 2 patients. The standard chemotherapy including isoniazid, rifampicin, pyrazinamide and streptomycin was administered for 2 weeks before operation, and continued for 2 months and followed by rifampicin/INH for 9-12 months. Results: The mean operation time was 280min(240-365min), and the mean intraoperative blood loss was 112ml(50-400ml). Patients were followed up for 3-22(average 12.1) months. ASIA grade revealed good recovery(ASIA E) of patients with neurological deficit. Complications included screw loosening at the L5 level, and removed 3 months after operation and presented with temporal sympathetic nerve dysfuntion. The mean sagittal Cobb′s angle increased significantly to -5.1°±2.7°(P<0.01) 2 weeks after operation, with the mean correction of 15.7°±5.1°. At final follow-up, the mean sagittal angle was -4.2°±2.1°(P<0.01), with the loss of correction of 2.6°±1.8°. 11 patients had a radiographic bony fusion in a time of 6-12 months. No tuberculosis recurrence was found at final follow-up. Conclusions: Laparoscopic retroperitoneal approach is safe and reliable for lumbar spine tuberculosis.