非典型胸腰椎结核的临床诊断和手术治疗

Diagnosis and surgical treatment of atypical thoracic and lumbar spinal tuberculosis

中文关键词:  脊柱结核  非典型结核  诊断  手术

英文关键词:Spinal tuberculosis  Atypical tuberculosis  Diagnosis  Surgery

中文摘要:

  【摘要】 目的：总结和分析非典型胸腰椎结核的临床诊断和手术治疗特点，为非典型脊柱结核的诊治提供参考。方法：回顾性分析我院骨科2013年12月～2018年12月明确诊断并手术治疗的脊柱结核患者资料，根据影像学特点筛选出非典型胸腰椎结核13例，男8例，女5例，年龄20～71岁（44.2±18.7岁）。2例以腹股沟区包块为首发表现，2例患者以发热和咳嗽首发症状，其余患者均以腰背痛首发症状。术前疼痛视觉模拟评分（visual analogue scale，VAS）为5～8分（6.2±0.8分）。神经功能Frankel分级C级1例，D级3例，E级9例。术前均行X线片、CT和MRI检查，影像学上未见明显椎间隙狭窄、后凸畸形，CT可见不同程度的椎体骨破坏或囊性变、边缘硬化灶、“磨玻璃”样改变，MRI表现为椎体破坏、炎症水肿和椎旁脓肿改变。4例行正电子发射计算机断层显像（positron emission tomography-computer tomography，PET-CT）检查，10例行T细胞酶联免疫斑点试验（enzyme-linked immuno Spot, ELISPOT）检查均为阳性，4例术前行病灶活检。术前四联抗结核药物治疗至少1~2周，根据病灶位置及椎体破坏情况，7例行后路手术，6例行前后路联合手术。术后继续采用标准疗程抗结核药物治疗。结果：非典型胸腰椎结核患者占同期手术治疗脊柱结核的20.3%（13/64）。胸椎6例，腰椎5例，胸腰椎均累及2例。根据CT及MRI影像学分类，单脊椎型2例，椎间盘型1例，多脊椎连续型10例。手术时间130～260min（177.7±43.0min），出血量400～1000ml（638.5±198.1ml），无术中并发症。手术清除病灶组织均送病理检查，报告为肉芽肿性病变和/或凝固性坏死；结核菌涂片和培养各有1例阳性。术后伤口感染1例，经清创后好转。术后随访12～72个月（45.1±22.2个月），随访期间钛网移位1例，因无明显症状，未翻修，术后32个月随访无继续移位及内固定断裂；其余患者末次随访时均无内固定断裂。植骨在术后3~6时可见融合，随访期间无复发病例。术后疼痛及神经功能均有明显改善，末次随访时VAS评分1～4分（1.8±0.9分），神经功能Frankel分级末次随访均为E级。结论：非典型胸腰椎结核确诊需多种诊断手段相结合，手术结合抗结核药物治疗可取得较好的疗效。

英文摘要:

  【Abstract】 Objectives: To analyze and summarize the clinical diagnosis and surgical treatment features of atypical thoracic and lumbar spinal tuberculosis. Methods: Patients with spinal tuberculosis who were surgically treated from December 2013 to December 2018 were reviewed. A total of 13 patients with atypical spinal tuberculosis were selected according to the imaging features, including 8 males and 5 females. The clinical features, diagnosis and treatment procedures, follow-up results were analyzed. The average age of patients was 44.2±18.7 years old(ranged 20 to 71 years old). As the initial symptoms, the inguinal mass occurred in 2 patients, fever and cough occurred in 2 patients, back pain occurred in the remaining patients. Visual analogue scale(VAS) for preoperative pain was 5-8, with an average of 6.2±0.8. Frankel′s grade for neurological function was C in 1 case, D in 3 cases, and E in 9 cases. All patients were investigated by X-rays, CT and MRI. There was no radiological collapse of intervertebral disc or spinal kyphosis. CT showed various vertebral bone destruction, cystic change, sclerosis at the edge of the lesion, and glass-like opacity. MRI showed vertebral bone destruction, edema signal and abscess. Positron emission tomography-computer tomography(PET-CT) was performed in 4 patients. Enzyme-linked immuno spot(ELISPOT) was performed in 10 patients, and all of whom were positive. Preoperative biopsy was performed in 4 patients. Quadruple anti-tuberculosis drugs were used in all the patients for at least 1-2 weeks preoperatively. Seven patients underwent posterior surgery and six underwent anterior combined posterior surgery. Standard course of chemotherapy was performed postoperatively. Results: There were 13 patients in 64 cases with spinal tuberculosis were atypical cases in the same period, with the rate of 20.3%, 6 cases of thoracic tuberculosis, 5 cases of lumbar tuberculosis, and 2 cases of thoracolumbar tuberculosis. Classification of atypical spinal tuberculosis according to imaging features: 2 cases of single vertebral involvement, 1 case of intervertebral disc involvement, and 10 cases of multiple vertebral involvement. The operation time lasted for 130-260min(177.7±43.0min), and the bleeding volume was 400-1000ml(638.5±198.1ml). The pathological reports of lesion tissue were granulomatous lesion and/or coagulative necrosis. There was 1 patient of positive tissue smears, and 1 patient of positive tissue culture of tuberculosis bacteria. There was no obvious intraoperative complication. One patient had postoperative wound infection, which was healed after debridement. The follow-up time was 45.1±22.2 months(ranged, 12-72 months). One patient had titanium mesh displacement during follow-up, who was kept under observation because of no clinical symptom. And there was no internal fixation displacement and rupture at the last follow-up of 32 months. Bone graft fusion was observed at 3-6 months. There was no other failure of internal fixations or recurrence of tuberculosis. The VAS score at the last follow-up was 1-4, with an average of 1.8±0.9. Frankel′s grade returned to E at the last follow-up. Conclusions: Multiple diagnostic methods are required for atypical spinal tuberculosis. Surgery combined with anti-tuberculosis drugs can achieve satisfactory results.