一期前后路联合手术治疗儿童活动性胸腰椎结核的中长期临床疗效

Mid-term and long-term follow-up of one-stage combined anterior-posterior approach in the treatment of pediatric active thoracic and lumbar tuberculosis

中文关键词:  活动性胸腰椎结核  儿童  椎体破坏  椎弓根螺钉  同种异体大块骨块  中长期随访

英文关键词:Active pediatric spinal tuberculosis  Vertebral body destruction  Pedicle-screw fixation  Allograft bone strut  Mid- or long-term follow up

中文摘要:

  【摘要】 目的：探讨应用一期后路椎弓根螺钉内固定融合联合前路病灶清除、同种异体骨重建术治疗儿童活动性脊柱结核的中、长期效果。方法：回顾性分析我院2008年1月~2013年1月共19例采用一期后路椎弓根螺钉内固定融合联合前路病灶清除、同种异体骨支撑重建的术式治疗胸、腰椎结核感染导致至少连续两个椎体破坏的患儿资料，年龄3～10岁，平均6.3±2.1岁，随访时间5～11年，平均7.5±2.0年，受累椎体2～4个。所有患儿分别于术后1周、3、6、12个月行X线检查，随后每年行X线检查一次，测量后凸Cobb角，同时观察有无植骨块移位、松动、塌陷以及有无后凸畸形发生，记录患儿术前、术后1周及每次复查时的Frankel分级、后凸角、红细胞沉降率（ESR）、C-反应蛋白（CRP），对于随访超过5年的患儿（19例）行高分辨率三维CT扫描通过Bridwell分级评估植骨块融合情况。结果：随访期间均未发现结核复发，未发现钉棒松动、断裂，术后6个月ESR、CRP与术前相比均有明显统计学差异（P＜0.05）。术前Frankel神经功能分级：B级2例，C级5例，D级9例，E级3例，术后1周时Frankel分级：B级1例，C级3例，D级1例，E级14例，末次随访时D级1例（术前B级），E级18例，术后1周及末次随访与术前相比有统计学差异（P＜0.05）。术前后凸角平均41.32°±13.19°，术后即刻后凸角度平均9.74°±5.80°，即刻矫正率76.4%，末次随访后凸角平均12.32°±6.40°，平均丢失2.58°±0.60°，末次随访时矫正度数为29.0°±8.9°，矫正率为70.1%，术后即刻后凸角与术前相比有统计学差异（P<0.05），末次随访后凸角与术后即刻相比，无统计学差异（P>0.05）。19例患儿植入的同种异体骨的上下两端及后方的附件均与周围骨形成骨性连接，Bridwell分级1级融合；2例发生骨块下端轻度塌陷但形成骨痂且有骨小梁通过植骨接触面并且无明显植骨块松动及移位，1例出现局部轻度后凸畸形，但无神经损害及局部疼痛。结论：一期后路椎弓根螺钉内固定融合联合前路病灶清除、同种异体骨重建的方法治疗儿童胸腰椎结核导致的椎体破坏是一种安全可行的术式，中、远期随访观察获得了满意的临床结果。

英文摘要:

  【Abstract】 Objectives: To observe the mid-or long-term efficacy of posterior pedicle-screw fixation and fusion combined with anterior debridement and reconstruction with allograft bone strut in the treatment of pediatric active thoracic and lumbar tuberculosis. Methods: Retrospectively reviewed data of 19 pediatric patients (aged 3-10 years, mean age 6.3±2.1 years) with spinal active tuberculosis infection which resulted in at least two consecutive vertebral destruction treated in our hospital from January 2008 to January 2013. All patients underwent one-stage posterior pedicle-screw fixation and fusion combined with anterior debridement and reconstruction of spinal stability with allograft bone strut. The duration of follow-up ranged from 5 to 11 years, averaged 7.5±2.0 years, and the affected vertebral bodies ranged from 2 to 4. All patients were examined clinically and radiologically at 1 week, 3, 6 and 12 months after surgery and received X-ray examination once per 12 months to measure the Cobb angle and observe displacement, loosening, collapse of allograft bone, and any kyphotic deformity. The Cobb angle, Frankel grade, ESR and CRP before and one-week after surgery and at every reexamination of each patient were also collected and compared. All 19 patients were followed up more than 5 years, and underwent high resolution 3-D CT scan to evaluate the fusion of bone grafts. Results: During the following up, no recurrence of tuberculosis or instrumentation failure occurred. ESR and CRP at 6 months after operation were significantly different from those before surgery (P<0.05). The Frankel classification grading before surgery was: 2 cases of Grade B, 5 cases of Grade C, 9 cases of Grade D and 3 cases of Grade E; 1-week after: 1 case of Grade B, 3 cases of Grade C, 1 cases of Grade D and 14 cases of Grade E; and at final follow-up: 1 cases of Grade D (of Grade B before surgery) and 18 cases of Grade E. According to the Frankel motor score system, neurological deficits were improved at one week after surgery (an average improvement of 0.80 grades) and at final follow-up (an average improvement of 1.26 grades) than before surgery, and the differences were of statistical significance(P<0.05). The average kyphotic angle was changed significantly from a preoperative value of 41.32°±13.19° to a immediate postoperative value of 9.74°±5.80° and, with an average correction rate of 76.4%(P＜0.05). The average kyphotic angle at final follow-up was 12.32°±6.40°, with an average loss of 2.58°±0.60°. The stable kyphosis correction was 29.0°±8.9°, with an correction rate of 70.1%, and there was no significant difference in the Cobb angle between final follow-up and immediate postoperative values(P>0.05). All 19 patients gained solid fusion at both upper and lower ends of allograft bone strut, achieving Bridwell grade 1 fusion. The lower end of grafts of 2 cases out of the 19 slightly subsided, but osteophyte formed and there were trabeculae through the contact surface with no obvious loosening and dislocation of bone grafts; 1 case exhibited slight local kyphosis, with no neurological deficit and clinical symptoms. Conclusions: It is effective, practical and safe to treat vertebral destruction caused by pediatric thoracic and lumbar spinal active tuberculosis by posterior pedicle-screw fixation and fusion combined with anterior debridement and spinal stability reconstruction with allograft bone strut, and in our study, satisfactory clinical results were obtained after mid-term and long-term follow-up.