一期侧前方入路病灶清除植骨融合内固定联合局部闭式冲洗引流治疗腰椎结核伴椎旁脓肿

One-stage anterolateral debridement, bone graft and internal fixation combined with local closed irrigation drainage for lumbar spinal tuberculosis with abscess

中文关键词:  腰椎结核  椎旁脓肿  一期手术  闭式冲洗引流  疗效

英文关键词:Lumbar spinal tuberculosis  Abscess  One-stage surgery  Closed irrigation drainage  Curative effect

中文摘要:

  【摘要】 目的：探讨一期侧前方入路病灶清除植骨融合内固定联合局部闭式冲洗引流治疗腰椎结核伴椎旁脓肿的有效性。方法：我院自2006年1月~2012年12月收治腰椎结核并椎旁巨大脓肿的患者18例，男8例，女10例；年龄21~65岁，平均44.6岁。病变累及节段：L1~L2 1例，L2~L3 9例，L3~L4 7例，L4~L5 1例。脓肿范围：L1~L3 1例，L2~L4 6例，L2~L5 3例，L3~L5 5例，L3~S1 3例。17例伴神经功能障碍，Frankel分级C级3例，D级14例。术前Barthel指数50~75分，平均65±10分；JOA评分12~23分，平均18±4分。血沉（ESR）57±16.2mm/h；C反应蛋白（CRP）22.4±5.6mg/L。椎管狭窄率（35.0±13.1）%，脊柱后凸Cobb角为25.3°±7.1°。均在全身抗结核药物治疗下行一期侧前方入路病灶清植骨融合内固定，术后应用异烟肼生理盐水持续局部闭式冲洗引流，并继续全身抗结核治疗12~24个月（平均18个月）。比较术前、术后神经功能Frankel分级、Barthel指数（BI）、腰椎JOA评分以及术前、术后、随访时Cobb角、椎管狭窄率、ESR和CRP水平。结果：手术时间2.5~5.0h（平均3.0h），术中出血270~750ml（平均450ml），均未发生严重术中或术后并发症；术后异烟肼生理盐水持续局部闭式冲洗引流时间10~16d（平均14d）。随访时间12~30个月，平均20个月。1例C级患者恢复至D级，2例恢复至E级；13例D级患者恢复至E级，1例无变化；1例E级患者术后无神经损害。术后BI为75~90分，平均85±5分，15例达到显效（83.3%）；JOA评分17~29分，平均23±5分，17例达到显效（94.4%）。椎管狭窄率纠正至（1.4±3.5）%，脊柱后凸Cobb角为8.7°±2.6°，平均纠正16.6°。ESR及CRP在术后3个月内均恢复至正常，X线显示获得骨性融合时间为4~12个月（平均6个月）；术后1年随访期内脊柱后凸畸形矫正有1°~4°丢失；所有病例至末次随访时均未见复发。结论：在全身规范抗结核药物治疗的前提下，一期侧前方入路病灶清除、植骨融合内固定联合局部闭式冲洗引流术治疗腰椎结核伴椎旁脓肿安全有效，临床效果确切，是治疗腰椎结核伴椎旁脓肿的有效方法。

英文摘要:

  【Abstract】 Objectives: To explore the outcome of one-stage anterolateral debridement, bone graft and internal fixation combined with local closed irrigation drainage for lumbar spinal tuberculosis with abscess. Methods: From January 2006 to December 2012, 18 patients(8 males and 10 females, aged 21-65 years, mean 44.6 years) suffering from lumbar spinal tuberculosis with abscess were reviewed retrospectively. The vertebral tuberculosis sites included L1-L2 in 1 patients, L2-L3 in 9 patients, L3-L4 in 7 patients, L4-L5 in 1 patient. Abscess was noted at L1-L3 in 1 case， L2-L4 in 6 cases， L2-L5 in 3 cases， L3-L5 in 5 cases， and L3-S1 in 3 cases. Based on Frankel′s classification, there were 3 cases of grade C, 14 of grade D, 1 of grade E. The average preoperative Barthel index(BI) was 65±10(range, 50-75); the average JOA was 18±4(range, 12-23). The preoperative ESR and CRP was (57±16.2)mm/h and (22.4±5.6)mg/L respectively; stenosis rate was(35.0±13.1)%; kyphosis angle was 25.3°±7.1°. Under systemic and routine antituberculosis chemotherapy, all patients received one-stage anterolateral debridement, bone graft and internal fixation. Postoperative persistent closed irrigation drainage and local chemotherapy with isoniazid were performed. Systemic antituberculosis therapy continued for 12-24 months(range, 18 months). The preoperative and postoperative Frankel neural function classification, lumbar JOA score, Barthel index as well as the preoperative, postoperative and follow-up Cobb angle, stenosis rate, ESR and CRP level were compared. Results: The average operation time was 3.0h(range, 2.5-5.0h), the average intraoperative blood loss was 450ml(range, 270-750ml), all patients had no serious complications. Postoperative persistent closed irrigation drainage and local chemotherapy with isoniazid lasted for 10 to 16 days(average, 14 days). The mean follow-up was 20 months(range, 12-30 months). Among 18 cases, 1 patients with Frankle C returned to D, 2 increased to E, 13 Frankle D recovered to E(88.9%, 16 cases with various degrees of recovery), 1 case remained no change, 1 Frankle E showed no neurological deficit. Postoperative Barthel index averaged 85±5(range, 75-90), 15 cases(83.3%) improved markedly; JOA score averaged 23±5(range, 17-29), 17 cases(94.4%) improved markedly. Postoperative ESR(18.2±6.3mm/h) and CRP(7.0±3.8mg/L) decreased significantly; stenosis rate recovered to (1.4±3.5)%, kyphosis angle recovered to 8.7°±2.6°. The postoperative ESR and CRP returned to normal within three months in all patients. X-ray showed bone fusion within 4-12 months(average, 6 months). During 1-year follow-up, the loss of correction was 1°-4°. At final follow-up, no recurrence was noted. Conclusions: Under systemic and routine antituberculosis chemotherapy, one-stage anterolateral debridement, bone graft and internal fixation combined with local closed irrigation drainage is effective and feasible for lumbar spinal tuberculosis with abscess.