经皮椎体骨水泥强化术后术区感染的临床特点及处理措施

Clinical characteristics and treatment strategy of infection following percutaneous vertebral augmentation with polymethylmethacrylate cement

中文关键词:  经皮椎体骨水泥强化术  骨质疏松性椎体骨折  感染  临床特点  治疗措施

英文关键词:Percutaneous vertebral augmentation  Osteoporotic vertebral fracture  Infecion  Clinical characteristic  Treatment strategy

中文摘要:

  【摘要】 目的：分析经皮椎体骨水泥强化术后术区感染的临床特点及处理措施。方法：回顾性分析2018年1月～2019年12月我科收治经皮椎体骨水泥强化术后术区感染的患者共7例，男性1例，女性6例；年龄64~83岁（71.3±6.7岁）。7例患者均因初诊为骨质疏松性椎体骨折接受经皮椎体骨水泥强化术，术后1~17个月（6.4±5.8个月）确诊术区感染。回顾患者病历资料，统计患者症状及体征、炎症指标[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）]、脊柱影像学检查（X线片、CT及MRI）特征、病原体检测结果、治疗方式及疗效。结果：7例患者均有明显背部疼痛，1例低热，6例体温正常。确诊感染时，4例合并神经损害，美国脊髓损伤协会（American Spinal Injury Association，ASIA）分级C级1例，D级3例。炎症指标中，ESR为29~95mm/h（62.7±27.2mm/h），CRP为10.04~151.8mg/L（46.9±48.7mg/L），均高于正常范围上限值。影像学均呈现骨水泥周围骨质吸收、骨质破坏及术区炎症性信号改变等感染征象。5例检测出病原体，其中结核分枝杆菌感染3例、非特异性细菌感染2例。所有病例依据病原体结果采取规范药物治疗：细菌感染使用敏感抗生素至少6周；结核感染给予异烟肼、利福平、乙胺丁醇及吡嗪酰胺的四联方案抗结核至少12个月。4例在药物治疗基础上辅以手术治疗，其中3例行经后路病灶清除植骨重建术，1例行单纯后路椎弓根钉固定融合术；术后随访7～15个月（12.3±3.8个月），4例均临床治愈，其中3例术前合并神经损害者由术前ASIA分级D级恢复至E级。2例拒绝手术行药物辅以支具治疗，末次随访时仍残存症状。1例在计划翻修手术前因肺部感染死亡。结论：经皮椎体骨水泥强化术术区感染以再发剧烈背痛、炎症指标升高及特征性影像表现为主要临床特点。对于经皮椎体骨水泥强化术术区感染，应在规范药物治疗的基础上辅以手术。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical characteristics and treatment strategy of surgical site infection following percutaneous vertebral augmentation with polymethylmethacrylate (PMMA) cement. Methods: 7 cases of postoperative spinal infections after percutaneous vertebral augmentation with PMMA cement admitted and treated in Fuzhou Second Hospital between January 2018 and December 2019 were retrospectively reviewed. There were 1 male and 6 females, aged from 64 to 83 (mean, 71.3±6.7 years). All 7 patients were initially diagnosed as symptomatic osteoporotic vertebral fractures and underwent percutaneous vertebral augmentation with bone cement, who were diagnosed with surgical site infections 1-17 months(mean, 6.4±5.8 months) postoperatively. Previous medical records were reviewed and the clinical manifestations, inflammatory parameters, imaging characteristics, pathogen detection results, and treatment methods and outcomes were summarized and analysed. Results: On readmission, all 7 patients had severe back pain. All the patients had normal temperature except one who had low fever. Four cases were combined with neurological injury at the time of diagnosis of infections, and one was classified as American Spinal Injury Association(ASIA) grade C and the other three were of ASIA D. Inflammatory parameters were high in all patients, with ESR of 29-95mm/h(62.7±27.2mm/h) and CRP of 10.04-151.8mg/L(46.9±48.7mg/L). Imaging examinations showed bone resorption around bone cement, bone destruction, and inflammatory signal changes at the surgical site. Pathogens were detected in five cases, including three cases of Mycobacterium tuberculosis infection and two cases of nonspecific bacterial infection. Four patients received surgical treatment, of which, three underwent posterior debridement and bone grafting reconstruction, and the other one was treated with stand-alone posterior pedicle screw fixation and fusion. The follow-up period ranged from 7 to 15 months(mean: 12.3±3.8 months) after the revision operation, and all the four patients recovered from infection. Among them, three combined with neurological injury before surgery were recovered to ASIA E from ASIA D. Two patients who refused surgery and received conservative treatment had restricted activities at the end of follow-up. One case died of pulmonary infection before the planned revision surgery. Conclusions: The surgical site infection following percutaneous vertebral augmentation with bone cement features recurrent severe back pain, elevated inflammatory parameters, and characteristic imaging findings as the main clinical manifestations, which shall be treated with surgery on the basis of standard drug therapy.