经皮椎体后凸成形术后化脓性脊柱炎的原因分析和预防策略

Causes and preventive strategies of pyogenic spondylitis after percutaneous kyphoplasty

中文关键词:  化脓性脊柱炎  椎体后凸成形术  预防策略  原因分析

英文关键词:Percutaneous kyphoplasty  Pyogenic spondylitis  Prevention strategy  Cause analysis

中文摘要:

  【摘要】 目的：探讨经皮椎体后凸成形术（percutaneous kyphoplasty，PKP）后化脓性脊柱炎的原因和预防策略。方法：回顾性分析2013年6月~2018年9月西南医科大学附属医院骨科采用PKP治疗的疼痛性骨质疏松性椎体压缩性骨折（painful osteoporotic vertebral compression fractures，POVCF）患者1065例，其中男性217例，女性848例，年龄70.4±6.8岁（56~93岁）。A组（n=332）患者术前未严密筛查感染灶直接行PKP术，B组（n=733）患者对术前感染指标[白细胞计数（white blood cell，WBC）、血沉（erythrocyte sedimentation rate，ESR）、C反应蛋白（C-reactive protein，CRP）、降钙素原（procalcitonin，PCT）]一项或多项升高者予抗感染治疗有效后再行PKP术。记录并比较两组患者的年龄、体重指数（body mass index，BMI）、骨密度（T值）、术前视觉模拟评分（visual analogue scale，VAS）、随访时间，统计其术前PCT、WBC、ESR、CRP、全脊柱MRI、全身骨扫描、胸椎和（或）腰椎正侧位X线片。通过回顾既往病历资料比较两组患者术前潜在感染灶部位，通过术后患者症状、体征、实验室检查及脊柱MRI观察并比较两组患者PKP术后发生责任椎化脓性脊柱炎的情况。结果：两组患者的年龄、BMI、骨密度、术前VAS评分、术前感染指标升高的病例数及随访时间之间差异无统计学意义（P＞0.05）。A组术前感染指标一项或多项升高者236例，均未使用抗生素，术后发生责任椎化脓性脊柱炎2例，均为高龄患者，抗感染治疗后症状无缓解，行翻修手术，其中1例术前合并高血压、尿路感染，翻修术后死亡，1例术前合并高血压、糖尿病及帕金森病，翻修术后治愈；B组感染指标有一项或多项升高514例，口服或静脉使用抗生素进行抗感染治疗有效后行PKP术，1例术后症状加重，结合术前实验室检查结果与影像资料，考虑为术前将化脓性脊柱炎误诊为POVCF并接受PKP术，行翻修手术后治愈。A组术前感染指标异常的患者中搜寻潜在感染灶，发现尿路感染18例、肺部感染24例、皮肤软组织感染1例、前列腺炎2例，均未处理；在B组中发现尿路感染37例、肺部感染60例、皮肤软组织感染3例、前列腺炎5例、慢性结石性胆囊炎7例，均在潜在感染灶控制后手术，B组感染灶控制较A组感染灶控制好，差异有统计学意义（P＜0.05）。结论：POVCF患者术前身体内存在的或潜在的感染灶未得到有效控制及术前将脊柱感染性病变误诊为POVCF是PKP术后责任椎化脓性脊柱炎的主要原因，术前使用抗生素有效控制存在的或潜在的感染病灶可减少其发生。

英文摘要:

  【Abstract】 Objectives: To explore the causes and prevention strategies of pyogenic spondylitis after percutaneous kyphoplasty(PKP). Methods: The data of 1065 patients with painful osteoporotic vertebral compression fractures(POVCF) received PKP treatment in the Department of Orthopaedics, The Affiliated Hospital of Southwest Medical Universityt from June 2013 to September 2018 were retrospectively reviewed. There were 217 males and 848 females, with an average age of 70.4±6.8 years(56-93 years). Patients in group A(n=332) received PKP directly without strict searching of infection foci before operation. Patients in group B(n=733) received effective anti-infective therapy before PKP for patients with one or more elevated infection indexes of the white blood cell count(WBC), erythrocyte sedimentation rate(ESR), C-reactive protein(CRP), procalcitonin(PCT) before operation. The age, body mass index(BMI), BMD(T value), visual analog scale(VAS) and follow-up time of the two groups were recorded and compared. Preoperative WBC, ESR, CRP, PCT, MRI, magnetic resonance imaging(MRI) of the whole spine, bone scan of the whole body, thoracic and/or lumbar spine anteroposterior X-ray were analyzed respectively. Previous medical records were reviewed and compared between the two groups of patients with potential infectionfoci before operation. Symptoms, signs, laboratory tests and spinal MRI were observed and compared between the two groups of patients with responsible vertebral pyogenic spondylitis after PKP. Results: There was no significant difference in age, BMI, BMD, VAS score, number of cases with increased preoperative infection index and follow-up time between the two groups(P>0.05). In group A, there were 236 patients with one or more elevated infection indicators of POVCF were not treated with antibioticsand there were 2 cases of responsible vertebral pyogenic spondylitis after PKP, all of whom were elderly patients. After failure of antibiotics treatment, the 2 cases received revision operation. Among them, 1 case was complicated with hypertension and urinary tract infection before operation, and died after revision operation; 1 case was complicated with hypertension, diabetes and Parkinson′s disease before operation, which was cured after revision surgery. These 2 patients were all elderly patients. In group B, there were 514 patients with one or more elevated infection indicators, and PKP was performed after effective anti-infection treatment with oral or intravenous antibiotics, 1 case with postoperative symptoms worsen, combined with preoperative laboratory examination results and the image data, consider to preoperative pyogenic spondylitis misdiagnosed as POVCF and accept PKP, and was cured after revision operation. Among the patients with abnormal preoperative infection indicators in group A, 18 cases of urinary tract infection, 24 cases of pulmonary infection, 1 case of skin and soft tissue infection, and 2 cases of prostatitis were found by searching for potential infection foci, which were not treated. In group B, 37 cases of urinary tract infection, 60 cases of pulmonary infection, 3 cases of skin and soft tissue infection, 5 cases of prostatitis, and 7 cases of chronic calculous cholecystitis were found, and all of which were operated after the control of latent infection foci. The infection foci of group B were better controlled than group A, with statistically significant differences(P＜0.05). Conclusions: The main reasons for the responsible vertebral pyogenic spondylitis after PKP include the existed and potential infection in the body without effectively controlling and misdiagnosed the responsible vertebral infectious foci as POVCF before operation. The predisposing factors include old age, diabetes, chronic hepatic, and renal insufficiency and so on. The use of antibiotics before operation can effectively control the existing or potential infectious foci and may reduce the incidence of responsible vertebral infection.