一期后路椎弓根螺钉固定联合前路经腹膜后病灶清除治疗腰骶段脊柱结核

Anterior debridement and fusion via paramedian retroperitoneal approach combined with posterior pedicle screw fixation for the treatment of lumbosacral junction tuberculosis

中文关键词:  脊柱结核  腰骶段  前路病灶清除  后路内固定

英文关键词:Spinal tuberculosis  Lumbosacral junction  Anterior debridement  Posterior instrumentation

中文摘要:

  【摘要】 目的：探讨一期后路椎弓根螺钉固定联合前路经腹膜后病灶清除治疗腰骶段脊柱结核的疗效。方法：2012年10月～2015年3月共收治12例腰骶段脊柱结核患者，其中男9例，女3例；年龄24～77岁（43.9±18.4岁）；病变节段位于L4～S1。术前抗结核药物治疗2～4周，血沉下降及结核中毒症状改善后，行手术治疗。均为一期后前路手术，即后路微创置入椎弓根螺钉内固定系统后，前路经腹旁正中腹膜后入路行结核病灶清除植骨融合术。术后继续系统抗结核治疗12~18个月。记录手术时间、术中出血量、手术入路相关并发症、植骨融合情况，比较术前、术后疼痛视觉模拟评分（VAS）、美国脊髓损伤协会（ASIA）分级、红细胞沉降率（ESR）、腰椎局部前凸角（local lordotic angle，LLA）。结果：12 例患者均顺利完成手术，术中切除的病灶组织行病理检查，均符合结核改变。手术时间165～380min（268.8±76.7min）；出血量160～2500ml（627.5±640.3ml）。共有3例手术相关并发症，均发生于前路手术时，1例为静脉丛撕破，经压迫后止血；2例腹膜撕裂，术中进行修补。随访12～48个月（31.1±9.8个月），12例均获骨性融合，无结核复发征象，无内固定松动、断裂征象。8例术前神经功能损害者术后有不同程度的恢复。术前VAS评分为7.1±1.1分，末次随访时为2.1±1.0分；术前ESR为65.8±29.9mm/h，末次随访时为15.1±8.5mm/h；VAS和ESR均较术前显著降低（P<0.05）。术前LLA为3.0°±8.3°，术后即刻矫正为11.0°±6.0°，末次随访时为10.4°±5.9°；与术前相比较，术后即刻LLA显著改善（P<0.05），末次随访时LLA无明显丢失。结论：一期后路椎弓根螺钉固定联合前路经腹膜后病灶清除治疗腰骶段脊柱结核，可以显著矫正脊柱畸形并获得满意的临床疗效，但前路经腹膜后入路存在一定的并发症发生率，需谨慎操作。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical effects of anterior debridement and fusion via paramedian retroperitoneal approach combined with posterior pedicle screw fixation for the treatment of lumbosacral junction tuberculosis. Methods: Twelve patients diagnosed with lumbosacral junction tuberculosis from October 2012 to March 2015 were analyzed retrospectively. Among whom, there were 9 males and 3 females, the average age was 43.9±18.4 years old. The levels of lesions were L4-S1. All cases underwent minimally invasive posterior fixation followed by anterior debridement and interbody fusion via the mini-open anterior paramedian retroperitoneal approach. All cases received anti-tuberculosis medications for 2 to 4 weeks, and surgery was performed when the toxic symptoms of tuberculosis were controlled and erythrocyte sedimentation rates(ESR) decreased. After operation, they were systematically and routinely treated with anti-tuberculous medications for 12-18 months. The operation time, the amount of bleeding during operation, major complications associated with approach, bone fusion were recorded. Visual analogue scale(VAS) pain, ESR, local lordotic angle(LLA) and neurological function were assessed before and after surgery. Results: All surgical procedures were performed successfully. The lesions removed during operation were proceeded by pathological examination and conformed to tuberculosis. The average operation time was 268.8±76.7min and the average amount of bleeding was 627.5±640.3ml. Intraoperative complications occurred in 3 patients which included iliolumbar vein tear in 1, peritoneal tear in 2. All 3 patients were not noted with severe sequelae after successful management. Patients were followed up for 12-48 months(mean 31.1 months), interbody fusion was obtained in all of them. There were no instances of spinal tuberculosis recurrence and signs of implant failure at the last follow-up. 8 cases with spinal cord injury recovered in different degrees after surgery. The mean VAS scores and ESR significantly decreased from preoperative levels(7.1±1.1 and 65.8±29.9mm/h, respectively) to 2.1±1.0 and 15.1±8.5mm/h at final follow-up, respectively(both P<0.05). The mean LLA significantly increased from the mean preoperative angle 3.0°±8.3° to postoperative 11.0°±6.0° and 10.4°±5.9° at final follow-up(both P<0.05). Conclusions: Based on systemic and routine anti-tuberculosis treatment, anterior debridement and fusion through paramedian retroperitoneal approach combined with posterior pedicle screw fixation is an effective treatment option for lumbosacral junction tuberculosis, which provides a less invasive, thorough debridement, high fusion rate and effective reconstruction of lumbosacral stability.