不同入路手术治疗成人胸腰椎结核的中远期临床疗效分析

Mid- to long-term clinical efficacy analysis of different surgical approaches in the treatment of adult thoracolumbar tuberculosis

中文关键词:  脊柱结核  手术入路  胸椎和腰椎  中远期  临床疗效

英文关键词:Spinal tuberculosis  Surgical approach  Thoracic and lumbar spine  Mid- to long-term  Clinical efficacy

中文摘要:

  【摘要】 目的：对比分析后路（Wiltse′s入路）、前路及后前路联合入路手术治疗成人胸椎和腰椎结核中远期疗效。方法：2008年1月～2016年1月共有421例胸椎和腰椎结核患者在我科行手术治疗，其中获得中远期随访者341例，男性190例，女性151例；年龄18～73岁（42.1±15.1岁）。330例术前接受标准化抗结核治疗至少2周（异烟肼+利福平+吡嗪酰胺+乙胺丁醇），11例行急诊手术。T1~T10 82例，T11~L2 165例，L3~L5 94例。179例采用经后路（Wiltse′s入路）病灶清除椎体间植骨融合内固定术（A组）；98例采用经前路病灶清除椎体间植骨融合内固定术（B组），64例经Wiltse′s入路内固定+前路病灶清除椎体间植骨融合术（C组）。术后采用规范抗结核药物治疗1.5~2.0年。收集三组患者手术时间、术中出血量和住院天数，术前、术后1周的血沉（ESR）和C-反应蛋白（CRP）；术前、术后1周和末次随访时的胸腰背部疼痛VAS评分，在X线片上测量胸腰椎后凸Cobb角，计算胸腰椎后凸畸形矫正率、末次随访矫正丢失角度；末次随访时脊髓神经功能恢复状况、植骨融合率和术后并发症。结果：所有患者均顺利完成手术，随访5~13年（8.4±2.1年）。A组手术时间、术中出血量、住院时间均小于B组和C组（A组分别为207.8±50.0min、570.0±309.6ml、12.5±2.5d，B组分别为249.9±47.7min、745.5±394.6ml、16.8±9.7d，C组分别为274.3±59.3min、792.0±282.8ml、17.3±3.4d，P＜0.001）。A组术前、术后1周时的ESR和CRP分别68.8±26.1mm/h、31.4±13.0mm/h和53.0±14.6mg/L、27.9±7.1mg/L；B组分别为63.7±22.4mm/h、27.9±10.0mm/h和53.4±20.3mg/L、27.6±9.4mg/L；C组分别为65.4±24.2mm/h、31.1±11.1mm/h和55.2±16.9mg/L、26.0±7.8mg/L。三组术后1周的ESR、CRP均较术前显著性下降（P＜0.001）。A组术前、术后1周和末次随访时的VAS评分为5.1±1.1分、2.5±0.8分、1.8±0.7分；B组为5.2±1.0分、2.6±1.0分、2.0±0.6分；C组为4.9±1.0分、2.5±1.1分、2.0±0.7分。三组术后1周和末次随访VAS评分均较术前显著性改善（P＜0.001）。A组术前、术后1周和末次随访时的Cobb角为27.0°±3.1°、9.8°±2.0°、13.0°±1.9°；B组为27.5°±1.9°、10.4°±0.8°、14.4°±0.9°；C组为28.3°±4.8°、10.6°±2.4°、13.9°±2.3°。三组后凸畸形均得到显著性矫正（P＜0.001）。末次随访时矫正角度丢失：A组3.2°±1.1°、B组4.0°±0.7°、C组3.3°±1.0°，B组矫正角度丢失大于A组和C组（P<0.001）。末次随访时三组未达到1级和2级融合共15例，A组10例（5.6%），B组2例（3.1%），C组3例（3.1%）（P>0.05）。24例伴有脊髓神经功能损害患者末次随访时均有明显改善。术后A组6例（3.4%）、B组6例（6.1%）、C组5例（7.8%）发生并发症（P>0.05），均经对症治疗治愈。B组1例术后2年结核复发，采用经后路Wiltse′s病灶清除椎间植骨融合内固定术治愈。结论：在抗结核药物治疗基础上三种入路手术治疗成人胸椎和腰椎结核均能够取得较满意的中远期疗效，经Wiltse′s入路组在手术时间、术中出血量、住院时间优于单纯前路组和后前路联合组，经Wiltse′s入路组和后前路联合组对后凸畸形的矫正和维持优于单纯前路组。

英文摘要:

  【Abstract】 Objectives: To compare and analyze the mid- to long-term efficacies of posterior approach(Wiltse′s approach), anterior approach, and posterior-anterior approach in the treatment of adult thorcolumbar tuberculosis. Methods: A total of 421 patients with thoracolumbar tuberculosis underwent surgical treatment in our department from January 2008 to January 2016, among which, 341 patients received mid- to long-term follow-up. There were 190 males and 151 females, aged 18 to 73 years(42.1±15.1 years). 330 patients were given standardized anti-tuberculosis therapy for at least 2 weeks before operation(isoniazid+rifampicin+pyrazinamide+ethambutol), and the other 11 patients underwent emergency surgery. T1-T10 vertebrae were involved in 82 cases, T11-L2 in 165 cases, and L3-L5 in 94 cases. 179 cases were treated with posterior debridement(Wiltse′s approach) combined with intervertebral bone grafting and internal fixation(group A), 98 cases were treated with anterior debridement combined with intervertebral bone grafting and internal fixation(group B), and 64 cases were treated with internal fixation via Wiltse′s approach + anterior debridement and intervertebral bone grafting(group C). After operation, all the patients were given standard quadruple anti-tuberculosis drugs for 1.5-2.0 years. The operation time, intraoperative blood loss, hospitalization days were collected of three groups. The erythrocyte sedimentation rate(ESR) and C-reactive protein(CRP) of all the three groups of patients were collected before surgery and at 1 week after surgery. At preoperation, 1 week after surgery, and the final follow-up, the VAS scores of thoracolumbar back pain were collected, and the Cobb angles of thoracolumbar kyphosis were measured on X-ray film to calculate the correction rate of thoracolumbar kyphosis and final follow-up correction loss angle. Besides, the recovery of neurologic function, bone graft fusion rate, and postoperative complications at the last follow-up were collected. Results: All the patients underwent operations uneventfully and were followed up for 5-13 years(8.4±2.1 years). The operation time, intraoperative blood loss and hospital stay in group A(207.8±50.0min, 570.0±309.6ml and 12.5±2.5d) were smaller than those in group B(I249.9±47.7min, 745.5±394.6ml and 16.8±9.7d) and group C(274.3±59.3min, 792.0±282.8ml and 17.3±3.4d)(P<0.001). At preoperation and 1 week after operation, the ESR was 68.8±26.1mm/h and 31.4±13.0mm/h, and CRP was 53.0±14.6mg/L and 27.9±7.1mg/L in group A; the ESR was 63.7±22.4mm/h and 27.9±10.0mm/h, and CRP was 53.4±20.3mg/L and 27.6±9.4mg/L in group B; ESR was 65.4±24.2mm/h and 31.1±11.1mm/h, and CRP was 55.2±16.9mg/L and 26.0±7.8mg/L in group C. Both ESR and CRP of all the three groups at 1 week after operation reduced significantly than those before operation, respectively(P<0.001). At preoperation, 1 week after operation, and the final follow-up, the VAS scores of group A were 5.1±1.1, 2.5±0.8, and 1.8±0.7, which of group B were 5.2±1.0, 2.6±1.0, and 2.0±0.6, and those of group C were 4.9±1.0, 2.5±1.1 and 2.0±0.7. The postoperative 1 week and final follow-up VAS scores of the three groups significantly improved than those before operation(P<0.001). At preoperation, 1 week after operation, and final follow-up, the Cobb angles of kyphosis were 27.0°±3.1°, 9.8°±2.0°, and 13.0°±1.9° in group A, 27.5°±1.9°, 10.4°±0.8°, and 14.4°±0.9° in group B, and 28.3°±4.8°, 10.6°±2.4°, and 13.9°±2.3° in group C. The kyphosis was significantly corrected in all the three groups(P<0.001). Loss of correction angle at final follow-up was 3.2°±1.1° in group A, 4.0°±0.7° in group B, and 3.3°±1.0° in group C. Loss of correction angle in group B was greater than that in group A and C(P<0.001). At the last follow-up, 15 patients failed to achieve grade 1 and grade 2 fusion, including 10 in group A(5.6%), 2 in group B(3.1%), and 3 in group C(3.1%)(P>0.05). The 24 patients with neurologic deficit improved significantly at the last follow-up. Postoperative complications occurred in 6 cases(3.4%) in group A, 6 cases(6.1%) in group B, and 5 cases(7.8%) in group C(P>0.05), all of which were cured by symptomatic treatment. In group B, one patient had tuberculosis recurrence 2 years after operation, and was cured by posterior debridement (Wiltse′s approach) combined with intervertebral bone graft fusion and internal fixation. Conclusions: All the three kinds of surgical approaches-posterior approach(Wiltse′s approach), anterior approach, and posterior-anterior approach can achieve satisfactory mid- to long-term results in treating adult thoracolumbar spinal tuberculosis on the basis of anti-tuberculosis drug treatment. The Wiltse′s approach is superior to anterior approach only and posterior combined anterior approach in operation time, blood loss, and length of hospital stay. While Wiltse′s approach and posterior combined anterior approach are superior to anterior approach only in correction and maintenance of kyphosis.