单纯前路及前后路联合手术治疗上颈椎结核的疗效分析

Simple anterior approach and anterior combined with posterior approach for upper cervical tuberculosis

中文关键词:  上颈椎结核  前路手术  前后路联合手术  疗效

英文关键词:Upper cervical tuberculosis  Anterior surgery  Combined anterior and posterior surgery  Effective

中文摘要:

  【摘要】 目的：总结应用单纯前路手术及前后路联合手术治疗上颈椎结核的临床疗效。方法：回顾分析2014年1月~2018年1月在我院接受手术治疗的31例上颈椎结核患者，男12例，女19例；年龄3.5~70岁。31例患者均有不同程度的颈肩部疼痛；19例颈部活动受限，上肢肌力和感觉减退，症状持续1~12个月。23例患者有不同程度的结核中毒症状。病变累及单椎体14例，相邻2个椎体16例，多节段1例。术前给予四联抗结核治疗2~4周，17例椎体骨质破坏较轻的患者行单纯前路病灶清除植骨融合内固定术（A组），14例椎体骨质破坏较重的患者行前路病灶清除植骨融合联合后路内固定术（AP组）。术后继续抗结核药物治疗12~18个月。记录两组患者手术前后及末次随访时的临床症状、美国脊柱损伤协会脊髓损伤分级（ASIA）、日本骨科学会（JOA）颈椎功能评分、颈椎功能障碍指数（NDI）、颈肩部疼痛视觉模拟评分（VAS）、植骨融合情况、复位程度及并发症。结果：31例患者均顺利完成手术，其中A组手术时间80~200min（128.8±40.8min），术中出血量50～120ml（73.5±23.2ml）；AP组手术时间120～300min（212.9±56.2min），术中出血量200～450ml（295.7±74.3ml）。术中AP组1例C2神经损伤，其余均未发生脊髓、神经根、椎动脉等损伤。病理检查结果为结核病灶。31例患者均获得随访，随访时间为18.1±8.2个月。A组术前、术后和末次随访时的JOA评分分别为9.9±1.6、14.1±1.2和15.1±0.9分，颈肩痛VAS评分分别为6.8±1.5、2.9±1.4和1.9±1.1分，NDI分别为31.8±4.3、14.2±2.7和10.2±2.1；AP组JOA评分分别为9.4±1.2分、14.0±1.2和15.3±1.1分，颈肩痛VAS评分分别为6.9±1.4、2.9±1.4和3.1±0.9分，NDI分别为33.3±3.8、15.6±2.8和10.4±2.0；两组术后和末次随访时与术前比较均有统计学差异（P＜0.05），术后与末次随访时比较亦有统计学差异（P＜0.05）。AP组1例患者术后术区出现窦道，经清创、调整抗结核药物治疗后治愈；其余患者未出现并发症，切口愈合良好。随访过程中内固定无断裂和移位，颈椎稳定性均得到重建，结核无复发。A组8例（C级3例，D级5例）术前有神经功能障碍的患者末次随访时均恢复至E级；AP组11例（B级1例，C级7例，D级3例）术前有神经功能障碍的患者中，1例由ASIA B级改善到C级，1例由C级恢复至D级，其余患者均恢复至E级。结论：在上颈椎结核的手术治疗时，根据患者病灶特点、椎体损害程度和累及范围、脊髓和神经受压损害程度选择单纯前路或前后路联合手术可以安全有效地实现神经减压，病灶清除、植骨融合和重建颈椎稳定性。

英文摘要:

  【Abstract】 Objectives: To evaluate the clinical efficacy of single anterior approach and combined anterior and posterior approach for the treatment of tuberculosis involved upper cervical spine. Methods: A total of 31 patients with upper cervical tuberculosis who underwent surgery in our hospital from January 2014 to January 2018 was reviewed, including 12 males and 19 females aged from 3.5 to 70 years. All 31 patients had different degrees of neck and shoulder pain; 19 cases had limited neck activity, decreased strength and sensation of upper limb muscle, with symptoms from 1 to 12 months. Twenty-three patients had varying degrees of tuberculosis symptoms. In them, 14 cases involved single vertebral body, 16 cases involved 2 adjacent vertebral bodies, and 1 case involved multiple segments. Four-drug anti-tuberculosis regimen was given before surgery for 2 to 4 weeks. 17 patients with mild vertebral destruction were treated with simple anterior debridement, bone graft fusion and internal fixation(group A), 14 patients with severe vertebral destruction were treated with anterior debridement and bone graft fusion combined posterior internal fixation(group AP). All the patients received postoperative anti-tuberculosis drug treatment for 12-18 months. The clinical data before and after surgery in the two groups were recorded: the American Spinal Injury Association(ASIA), the Japanese Orthopaedic Association(JOA), the cervical spine dysfunction index(NDI), and visual analog score(VAS) of neck and shoulder pain, bone graft fusion and complications. Results: All the 31 patients were operated successfully. The operation time and intraoperative blood loss in group A were 80-200min(128.8±40.8min) and 50-120ml(73.5±23.2ml), and the operation time and intraoperative blood loss in group AP were 120-300min (212.9±56.2min) and 200-450ml(295.7±74.3ml). There was no injury of spinal cord, nerve root, vertebral artery or other tissue, except 1 case of C2 nerve injury in group AP. The postoperative pathological result was all tuberculosis. All the 31 patients were followed up for 18.1±8.2 months. The JOA scores in group A were 9.9±1.6, 14.1±1.2 and 15.1±0.9 before operation, after operation, and at the last follow-up respectively. The VAS scores of neck and shoulder pain were 6.8±1.5, 2.9±1.4 and 1.9±1.1 respectively. The NDI scores were 31.8±4.3, 14.2±2.7 and 10.2±2.1. The JOA scores in group AP was 9.4±1.2, 14.0±1.2 and 15.3±1.1 before operation, after operation, and at the last follow-up respectively. The VAS scores of neck and shoulder pain were 6.9±1.4, 2.9±1.4 and 3.1±0.9 respectively. The NDI scores were 33.3±3.8, 15.6±2.8 and 10.4±2.0. There were significant differences of the scores between before operation and after operation immediately, before operation and at the last follow-up in the two groups(P<0.05). There was significant difference between after operation immediately and at the last follow-up in the two groups(P>0.05). In group AP, 1 patient had sinus in the operation area and was cured after debridement and adjustment of anti-tuberculosis drugs. In the other patients, there was no complication such as internal fixation failure, and all the incision healed well. The cervical stability was all reconstructed, and there was no recurrence of tuberculosis. 8 patients in group A had neurological dysfunction(ASIA grade C in 3 cases, grade D in 5 cases) before surgery and recovered to grade E at the last follow-up; 11 patients in group AP had neurological dysfunction(ASIA grade B in 1 case, grade C in 7 cases, grade D in 7 cases) before surgery, 1 case improved from grade B to C, 1 case recovered from grade C to D, and the rest recovered to grade E. Conclusions: In upper cervical tuberculosis, surgical choice is made according to the tuberculosis characteristics, the extent of vertebral damage, the rang of involvement, and the degree of spinal cord and nerve compression damage. Simple anterior and anterior combined with posterior approach can safely and effectively achieve nerve decompression, lesion clearance, bone graft fusion and cervical stability reconstruction.