后路病灶清除植骨融合内固定手术治疗跳跃性脊柱结核的疗效分析

Efficacy of posterior debridement, bone graft fusion and internal fixation in the treatment of noncontiguous spinal tuberculosis

中文关键词:  脊柱结核  跳跃性  个体化治疗  植骨融合内固定  手术疗效

英文关键词:Spinal tuberculosis  Noncontiguous  Individualized treatment  Bone graft fusion and internal fixation  Surgical outcomes

中文摘要:

  【摘要】 目的：总结跳跃性脊柱结核的临床特点，探讨一期后路病灶清除植骨融合内固定手术治疗跳跃性脊柱结核的疗效。方法：回顾性分析2016年7月~2022年5月我院手术治疗的31例跳跃性脊柱结核患者的临床资料，其中患者男18例，女13例，年龄49.5±27.5岁。其中2处病灶24例，3处病灶7例。对每例患者明确责任椎，确定手术病灶、融合节段、内固定方式，以制定个体化手术方案，随访29.7±14.7个月（15～85个月）。记录患者手术时间、术中出血量，并记录术中及术后并发症情况；术前和术后1个月、3个月、1年及末次随访的红细胞沉降（ESR）和C-反应蛋白（CRP）；术前及术后1周、1个月、3个月、1年及末次随访的疼痛视觉模拟评分（VAS）；术前及术后1周、末次随访时病灶后凸Cobb角；记录术前及末次随访时美国脊髓损伤协会（ASIA）分级；末次随访时采用Bridwell骨愈合标准分级以评估术后结核活动性、症状改善、畸形矫正及骨愈合。结果：31例患者中20例（65.4%）只有1处病灶出现临床症状，23例（74.2%）以疼痛为主诉入院，15例（48.4%）在病程中只有疼痛症状，而11例（35.5%）只有1处病灶出现疼痛症状，18例（58.1%）患者初诊时至少有1处病灶漏诊。所有患者手术顺利，手术时间280.0±52.2min（165～330min），失血量567.7±332.0mL（150～1000mL）。术后出现脑脊液漏4例，切口感染3例，经对症处理后痊愈；所有结核病灶均治愈，未出现复发。术前及术后1个月、3个月、1年、末次随访时ESR为41.5±26.3mm/h、16.3±13.4mm/h、12.5±6.3mm/h、11.4±5.2mm/h、9.2±3.1mm/h；CRP为32.8±23.2mg/L、7.3±5.6mg/L、6.2±4.1mg/L、5.1±3.7mg/L、2.8±2.3mg/L；术前及术后1周、1个月、3个月、1年、末次随访时VAS评分为6.4±2.4分、2.4±1.7分、2.3±1.3分、1.6±0.9分、0.9±0.7分、0.4±0.3分。术后各个时间点CRP、ESR、VAS评分较术前均有显著改善（P＜0.05）。术前Cobb角25.7°±4.9°，术后1周15.4°±2.1°，末次随访时17.1°±2.3°，术后均较术前有统计学差异（P＜0.05）；10例存在术前神经功能损伤患者，末次随访时1例术前A级患者恢复至C级；4例术前B级患者1例恢复至C级，3例恢复至D级；5例术前C级患者2例恢复至D级，3例恢复至E级；术后6～12个月42处植骨病灶均获得骨融合，末次随访时34处病灶Bridwell Ⅰ级愈合，8处病灶Bridwell Ⅱ级融合。结论：对跳跃性脊柱结核患者，明确责任椎及各处病灶病变特点，一期后路病灶清除植骨融合内固定手术治疗安全且高效，能得到满意的疗效。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical characteristics of noncontiguous spinal tuberculosis and the efficacy and prognosis of one-stage posterior debridement, bone graft fusion and internal fixation for the treatment of noncontiguous spinal tuberculosis. Methods: The clinical data of 31 patients with noncontiguous spinal tuberculosis treated in our hospital between July 2016 and May 2022 were retrospectively analyzed, including 18 males and 13 females, aged 49.5±27.5 years. There were 24 cases with 2 lesions and 7 cases with 3 lesions. Responsible vertebrae were clarified, and surgical lesions, fusion segments, and internal fixation methods were determined for each patient, so as to develop individualized surgical plans. The patients were followed up for 29.7±14.7 months(15-85 months). The operative time, intraoperative blood loss, and intraoperative and postoperative complications were recorded. Erythrocyte sedimentation rate(ESR) and C-reactive protein(CRP) were examined and recorded before operation, at 1 month, 3 months, and 1 year after operation, and at the last follow-up. Visual analogue scale(VAS) was used to evaluate the pain before operation, at 1 week, 1 month, 3 months, 1 year after operation and at the last follow-up. Cobb angle was measured before operation, at 1 week after operation, and at the last follow-up. The American Spinal Injury Association(ASIA) classification was recorded before operation and at the last follow-up. Bridwell bone healing criteria were used to evaluate postoperative tuberculosis activity, symptom improvement, deformity correction, and bone healing at the last follow-up. Results: Among the 31 patients, 20 (65.4%) had only one lesion (65.4%), 23 (74.2%) were admitted to the hospital with pain as the main complaint, 15 (48.4%) had only pain symptoms during the course of the disease, 11 cases (35.5%) had only one lesion with pain symptoms, and 18 (58.1%) patients had at least one lesion missed at the initial diagnosis. All the patients were successfully operated. The operative time was 280.0±52.2min(165-330min), and blood loss was 567.7±332.0mL(150-1000mL). There were 4 cases of cerebrospinal fluid leakage and 3 cases of incision infection after operation, which were cured after symptomatic treatment. All foci of tuberculosis were cured without recurrence or retransmission. At pre-operation, 1 month, 3 months, 1 year after surgery, and at the last follow-up, ESR was 41.5±26.3mm/h, 16.3±13.4mm/h, 12.5±6.3mm/h, 11.4±5.2mm/h, and 9.2±3.1mm/h, and the levels of CRP were 32.8±23.2mg/L, 7.3±5.6mg/L, 6.2±4.1mg/L, 5.1±3.7mg/L, 2.8±2.3mg/L, which were both significantly lower after operation than those before operation(P<0.05). The VAS score was 6.4±2.4, 2.4±1.7, 2.3±1.3, 1.6±0.9, 0.9±0.7, and 0.4±0.3 before operation, at 1 week, 1 month, 3 months, 1 year after operation, and at the last follow-up, which was significantly improved after operation when compared with that before operation(P<0.05). The Cobb angle was 25.7°±4.9° before operation, 15.4°±2.1° at 1 week after operation, and 17.1°±2.3° at the last follow-up, and there were significant differences between the postoperative angles and preoperative angles(P<0.05). Among the 10 patients with preoperative neurological impairment, 1 patient with preoperative grade A recovered to grade C at the last follow-up. Among the 4 patients with preoperative grade B, 1 patient recovered to grade C and 3 to grade D. Of the 5 patients with preoperative grade C, 2 recovered to grade D and 3 to grade E. All 42 bone graft lesions achieved bone fusion at 6-12 months after operation. At the last follow-up, 34 lesions healed in Bridwell grade Ⅰ and 8 in Bridwell grade Ⅱ. Conclusions: For patients with noncontiguous spinal tuberculosis, one-stage posterior debridement, bone graft fusion and internal fixation is safe and efficient after determining responsible vertebrae and lesion features, which can obtain satisfactory results.