儿童胸腰椎结核手术治疗的效果及并发症分析

Efficacy and complication of the surgery for thoracic and lumbar spinal tuberculosis in children

中文关键词:  儿童  胸腰椎结核  手术并发症  相关因素

英文关键词:Children  Thoracic and lumbar spine tuberculosis  Postoperative complications  Correlation factor

中文摘要:

  【摘要】 目的：回顾性分析儿童胸腰椎结核病灶清除、矫形、植骨融合内固定手术治疗的效果和并发症的发生情况及其原因分析。方法：2002年1月～2012年12月收治31例12岁以下儿童胸腰椎脊柱结核患者，男20例，女11例，年龄8.1±2.3岁（4～12岁），胸椎结核14例，胸腰段结核9例，腰椎结核8例。术前Frankel瘫痪分级，B级3例，C级6例，D级11例，E级11例。对仅有1个椎体部分破坏或椎体周围冷脓肿，脊柱稳定者，行前路椎体结核病灶清除植骨融合内固定术，本组3例；对椎体破坏较重或椎体破坏数量2个以上伴较重的后凸畸形者，行经后路前柱结核病灶清除，截骨矫形，钛网/异体或自体骨前柱支撑+后路椎弓根螺钉固定，本组18例；对于结核病灶破坏椎体严重，椎体破坏3个以上，冷脓肿蔓延广泛，同时伴有严重的后凸畸形者，行联合前后路手术，本组5例；对于冷脓肿以及脊柱结核破坏病灶较少，以严重后凸畸形为主要表现者，行后路截骨矫形术，本组4例；对于仅有较大冷脓肿，椎体破坏轻微者，行单纯病灶清除术，本组1例。采用X线、三维CT扫描、MRI等影像学手段评估内固定情况、畸形矫正与丢失、植骨融合效果、邻近节段畸形发生情况以及应用VAS评分、ODI评分、Frankel神经功能分级评价手术效果。随访观察并发症发生情况并分析其相关因素。结果：平均随访时间38±11个月（12～52个月），所有患者均顺利完成手术，无神经功能障碍加重者，末次随访时Frankel分级提高1～2级以上，分别为C级2例，D级3例，E级26例。VAS从术前的7.6±1.1分改善至末次随访时的2.1±1.4分；ODI评分从术前的75.3±12.1改善至末次随访时的26.2±12.4；病椎平均后凸Cobb角从术前的56.0°±2.5°改善至末次随访时的35°±1.9°，上述指标均显著改善（P＜0.05），所有病例通过二维CT证实全部骨性融合，平均骨愈合时间为6.1±1.1个月。手术相关并发症发生率32%（10/31）：其中后凸畸形加重3例，交界性后凸畸形5例，椎弓根切割1例，结核复发1例；并发症病例和无并发症病例比较，其平均年龄较小，病变节段数较多，病程较长。上述病例经延长固定节段和翻修手术全部治愈。结论：手术治疗儿童胸腰椎结核可取得较好效果，主要并发症是出现交界性后凸畸形以及原有固定节段后凸畸形加重，其发生的原因和患儿的年龄、病变节段和范围、病程长短等密切相关。

英文摘要:

  【Abstract】 Objectives: To retrospectively analyze the efficacy and complication of the surgery for thoracic and lumbar spinal tuberculosis in children, including focus debridement, deformity correction, bone graft fusion and internal fixation. Methods: From January 2002 to December 2012, 31 children with thoracic or lumbar spinal tuberculosis were retrospectively analyzed, including 20 males and 11 females. All the children were under 12 years old, with an average age of 8.1±2.3 years old. The tuberculosis located in thoracic vertebra in 14 cases, thoracolumbar vertebra in 9 cases, and lumbar vertebra in 8 cases. The Frankel classification at preoperation was B in 3 cases, C in 6 cases, D in 11 cases and E in 11 cases. The surgical procedure was as follows: 3 cases who had only 1 vertebral body damaged or cold abscess around vertebral body with stable spine, underwent focus debridement, bone graft fusion and internal fixation via anterior approach; 18 cases who had more than 2 vertebral bodies damaged with spinal kyphosis deformity, underwent anterior focus debridement and implantation with allograft or autograft in mesh, deformity correction, and posterior fixation with pedicle screws; 5 cases who had more than 3 vertebral bodies damaged with severe kyphosis deformity and cold abscess spread widely, underwent combined anterior and posterior approach surgery; 4 cases who showed severe kyphosis deformity with less cold abscess and less damaged vertebral bodies, underwent osteotomy and deformity correction; 1 case who had only larger cold abscess and mild vertebral body destruction, underwent focus debridement. Radiographic images, VAS and ODI were applied to evaluate the patients preoperatively and postoperatively. Nerve function was evaluated by Frankel score. Results: The treatment outcomes, complications and bone fusion were observed after an average of 38±11 months. Operations were successfully completed in all the cases, with no aggravated nerve dysfunction. Frankel classification improved to C in 2 cases, D in 3 cases and E in 26 cases at the final follow-up postoperatively. VAS improved from 7.6±1.1 preoperatively to 2.1±1.4 at final follow-up postoperatively, ODI improved from 75.3±12.1 preoperatively to 26.2±12.4 at final follow-up, kyphosis Cobb′s angle improved from 56.0°±2.5° to 35°±1.9° at final follow-up, all of these improved significantly. All the bone grafts were fused which confirmed by two-dimension CT, and the fusion time averaged 6.1±1.1 months. The rate of complications related to the operation was 32%(10/31): 3 cases suffered from aggravation of kyphosis, 5 cases suffered from proximal adjacent kyphosis, 1 case suffered from pedicle penetration, 1 case suffered from recurrence of tuberculosis. The patients with complications had younger age, more involving segments and longer course of disease than patients without complications. All the patients with complications recovered after extension of segmental fixation and revised surgery. Conclusions: The main complications of treating spinal tuberculosis in children are the proximal adjacent kyphosis and aggravation of kyphosis in fixed segments. Complications are related to patient′s age, number of involving segments and the length of disease course.