一期后路病灶清除减压融合内固定术治疗老年布鲁氏菌性脊柱炎的疗效观察

Observation on the efficacy of one-stage posterior focus debridement, decompression, fusion and internal fixation in the treatment of senile brucellosis spondylitis

中文关键词:  布鲁氏菌性脊柱炎  后路病灶清除减压融合内固定术  老年  疗效

英文关键词:Brucellosis spondylitis  Posterior focus debridement, decompression, fusion and internal fixation  Senile  Efficacy

中文摘要:

  【摘要】 目的：观察一期后路病灶清除减压融合内固定术治疗老年布鲁氏菌性脊柱炎的早期疗效。方法：回顾性分析2015年4月～2021年8月首都医科大学附属北京地坛医院骨科收治的19例接受一期后路病灶清除减压融合内固定术治疗的老年（≥65岁）布鲁氏菌性脊柱炎患者的临床资料，其中男14例，女5例，年龄67.9±2.4岁（65～73岁），病程10.8±2.7个月（7～16个月），14例有接触牛羊史，3例有生食牛羊肉史，2例有食用牛奶或羊奶史，均有腰背部疼痛，其中3例伴发热，16例伴下肢疼痛/麻木；根据美国脊柱损伤协会（American Spinal Injury Association，ASIA）分级C级9例，D级7例，E级3例。影像学检查病变节段为L1-2 1例，L2-3 1例，L3-4 7例，L4-5 7例，L5-S1 1例，L1-2+L5-S1 1例，L3-S1 1例；所有患者脊柱病变节段椎间隙均狭窄，其中18例有病变节段腰椎不稳，17例有椎前鸟嘴样骨刺，17例表现为“花边椎”，16例有硬膜外脓肿，3例有腰大肌脓肿。术前疼痛视觉模拟评分（visual analogue scale，VAS）7.05±0.97分，Oswestry功能障碍指数（Oswestry disability index，ODI）（42.05±2.61）％，血沉（erythrocyte sedimentation rate，ESR） 55.84±4.53mm/h、C反应蛋白（C-reactive protein，CRP） 46.47±3.25mg/L。入院时13例合并高血压，14例合并糖尿病，8例合并冠心病，16例合并低蛋白血症。围术期积极予以系统支持治疗，手术前后均应用利福平、多西环素、左氧氟沙星三联化疗方案2周以上，出院后继续口服利福平和多西环素治疗6个月。统计术后1个月、3个月、6个月、12个月的腰腿痛VAS、ODI、ESR、CRP，统计末次随访的ASIA分级及植骨融合情况，统计术中及术后并发症情况。结果：所有患者均手术顺利，手术时间192.11±35.92min（150～300min），术中出血量527.37±108.09ml（400～800ml），术后1个月、3个月、6个月、12个月随访时腰腿痛VAS、ODI、ESR和CRP较术前显著降低（P＜0.05）；所有患者在术后6个月时ESR及CRP均恢复正常，术后6个月和术后12个月时的ESR与CRP差异无统计学意义（P＞0.05）。术后随访17.53±3.15个月（12～24个月），术前9例ASIA分级C级患者末次随访时恢复到D级1例，E级8例；术前7例ASIA分级D级患者末次随访均恢复到E级。所有患者术中及术后未出现明显并发症，末次随访时均获得满意的骨性融合。结论：针对老年布鲁氏菌性脊柱炎患者，在围术期对症支持治疗及抗感染治疗的基础上，行一期后路病灶清除减压融合内固定术效果较满意，能有效促进病灶炎性修复及神经功能恢复。

英文摘要:

  【Abstract】 Objectives: To observe the preliminary effect of one-stage posterior focus debridement, decompression, fusion and internal fixation in the treatment of senile brucellosis spondylitis. Methods: A retrospective analysis was made on the clinical data of 19 senile patients(≥65 years) with brucellosis spondylitis treated in the Department of Orthopedics, Beijing Ditan Hospital affiliated to Capital Medical University from April 2015 to August 2021. There were 14 males and 5 females, aged 67.9±2.4 years(65-73 years), and the course of disease was 10.8±2.7 months(7-16 months). 14 cases had a history of contact with cattle and sheep, 3 cases had a history of eating raw beef and mutton, and 2 cases had a history of drinking milk or goat′s milk. All the patients had symptoms of low back pain, including 3 with fever and 16 with lower limb pain/numbness; according to the American Spinal Injury Association(ASIA) impairment scale, 9 cases were of grade C, 7 cases of grade D and 3 cases of grade E. Imaging examination showed that the segments involved were: L1-2 in 1 case, L2-3 in 1 case, L3-4 in 7 cases, L4-5 in 7 cases, L5-S1 in 1 case, L1-2+L5-S1 in 1 case and L3-S1 in 1 case; the segmental intervertebral space of spinal lesions was narrow in all the patients, including 18 cases of lumbar instability of diseased segments, 17 cases of prevertebral beak-like spur, 17 cases of "lace vertebra", 16 cases of epidural abscess and 3 cases of psoas muscle abscess. The visual analogue scale(VAS), Oswestry disability index(ODI), erythrocyte sedimentation rate(ESR), and C-reactive protein(CRP) before operation in the 19 patients were 7.05±0.97, (42.05±2.61)%, 55.84±4.53mm/h, and 46.47±3.25mg/L respectively. On admission, 13 cases were complicated with hypertension, 14 cases with diabetes, 8 cases with coronary heart disease and 16 cases with hypoproteinemia. Active systemic support therapy was given during the perioperative period by treating the patients with rifampicin, doxycycline and levofloxacin for more than 2 weeks before and after operation and giving oral administration of rifampicin and doxycycline for six months after discharge. The low back and leg pain VAS, lumbar ODI, ESR, and CRP at 1 month, 3 months, 6 months and 12 months postoperatively were calculated, ASIA grading, and bone graft fusion were calculated at final follow-up, intraoperative and postoperative complications were also counted. Results: All the patients underwent operation smoothly. The operation time was 192.11±35.92min(150-300min) and the intraoperative blood loss was 527.37±108.09ml(400-800ml). The low back and leg pain VAS, lumbar ODI, ESR, and CRP decreased significantly at 1 month, 3 months, 6 months and 12 months postoperatively compared with the preoperative ones(P＜0.05). The infection indexes of ESR and CRP all returned to normal at 6 months postoperatively, the differences of ESR and CRP respectively between 6 months and 12 months postoperatively were not statistically significant. The patients were followed up for 17.53±3.15 months(12-24 months) after surgery, and 9 cases of ASIA grade C before operation recovered to grade D in 1 case and grade E in 8 cases at the last follow-up; and 7 cases of ASIA grade D all recovered to grade E at the last follow-up. All the patients had no obvious complications during and after operation, and satisfactory bone fusion was obtained at the last follow-up. Conclusions: For senile patients with brucellosis spondylitis, one-stage posterior focus debridement, decompression, fusion and internal fixation has a satisfactory effect on the basis of perioperative symptomatic support treatment and anti-infective treatment, which can effectively promote focal inflammatory repair and neurological function recovery.