经骶2髂骨螺钉内固定在腰骶段结核稳定性重建中的应用

Use of S2-alar-iliac screws for lumbopelvic fixation and reconstruction in the treatment of lumbosacral spinal tuberculosis

中文关键词:  脊柱结核  腰骶段  骶2髂骨螺钉  手术治疗  内固定

英文关键词:Spinal tuberculosis  Lumbosacral region  S2-alar-iliac screw  Surgical treatment  Internal fixation

中文摘要:

  【摘要】 目的：评价徒手置入骶2髂骨（S2AI）螺钉的安全性，评估其在腰骶段结核稳定性重建中的应用价值。方法：2014年10月~2016年10月采用病灶清除、腰椎椎弓根-S2AI螺钉内固定、椎间植骨融合术治疗腰骶段结核患者16例，女9例，男7例，年龄38~73岁（63.5±14.3岁），其中11例大于60岁。10例患者术前骨密度检查T值<-3.5。术前、术后均规范采用抗结核药物治疗方案治疗，术后采用X线片和CT评价S2AI螺钉的位置，观察螺钉的相关并发症以及结核愈合情况。结果：10例采用单纯后路内固定联合病灶清除术，6例采用一期后-前路联合的手术方式。徒手置入30枚S2AI螺钉，冠状面螺钉的外展角（α）为50°～80°（65°±14°），矢状面螺钉与S1上终板的夹角（β）为-15°～16°（0°±12°），横断面上螺钉与中垂线的夹角（θ）为45°～57°（50°±9°）。术后CT检查发现1枚（3.3%）螺钉穿破髂骨内皮质，2枚（6.7%）螺钉穿破髂骨外皮质，穿破均小于5mm，没有神经、血管损伤的情况发生。平均随访时间12个月，1例严重骨质疏松患者的2枚（6.7%）S2AI螺钉周围出现明显透光带（screw halo）。所有患者结核症状得到控制，术后6个月时血沉、C反应蛋白均降至正常，末次随访时患者均恢复正常生活；无内固定断裂的情况发生，植骨均获得融合。腰背部疼痛VAS评分由术前平均7.7±2.1分降至末次随访时的3.2±0.7分（P=0.03）。结论：徒手置入S2AI螺钉是可行且相对安全的，可用于腰骶段结核患者的稳定性重建，为结核病灶治愈提供条件。

英文摘要:

  【Abstract】 Objectives: To investigate the feasibility and safety of free-hand technique of S2-alar-iliac (S2AI) screw placement in the lumbopelvic fixation, and to evaluate the clinic values in the treatment of lumbosacral spinal tuberculosis. Methods: Retrospective analysis the lumbosacral spinal tuberculosis patients who had underwent pelvic fixation using S2AI technique from October 2014 to October 2016. Total of 16 cases were enrolled in this study, consist of 9 females and 7 males, with an average age of 63.5±14.3 years. Of those patients, 11 were older than 60 years, as well as 10 patients had severe osteoporosis based on preoperative bone mineral density examination(T＜-3.5). S2AI screws were used for lumbopelvic reconstruction. Postoperative X-ray and CT scan were used to evaluate the optimal trajectory and direction of S2AI screws. Screw related complications as well as healing process of tuberculosis were recorded. Results: Ten patients underwent posterior only fixation and intervertebral debridement, while six patients received one-stage posterior fixation combined with anterior debridement and fusion. Thirty S2AI screws were inserted by free-hand technique. All trajectories were confirmed by postoperative X-ray and CT scan. The average abduction angle in coronal plan(α angle) was 65°±14°(range, 50°-80°), the average caudal angle related to S1 endplate in sagittal plan(β angle) was 0°±12°(range, -15°-16°), the average angle related to central line in axial plan(θ angle) was 50°±9°(range, 45°-57°). One screw(3.3%) protruded iliac inner cortex, two(6.7%) protruded iliac external cortex. All the protrusions were less than 5mm, without any visceral or neurovascular structures and none required removal or revision. The average follow-up was 12 months. One patient with sever osteoporosis was observed periscrew halo lucency bilaterally(6.7%). ESR and CRP decreased to normal at 6 months of follow-up. All those patients were asymptomatic at last follow-up and returned to normal life without the evidence of instrumentation failure, and solid fusion was confirmed by X-ray in all patients. The average of VAS score on back pain improved significantly from 7.7±2.1 preoperatively to 3.2±0.7 postoperatively(P=0.03). Conclusions: The free-hand technique of S2AI screw placement appears to be a safe and acceptable method of insertion, without major complications. S2AI screw provides rigid lumbosacral fixation and gives conditions for the cure of spinal tuberculosis.