一期后路经多裂肌和最长肌间隙入路病灶清除植骨内固定治疗成人胸腰椎化脓性脊柱炎

One-stage posterior approach via multifidus-longissimus cleavage planes for debridement combined with autogenous bone grafting and internal fixation in the treatment of thoracolumbar suppurative spondylitis in adults

中文关键词:  化脓性脊柱炎  胸椎和腰椎  肌肉间隙  病灶清除  植骨融合  内固定

英文关键词:Suppurative spondylitis  Thoracic and lumbar  Muscle interspaces  Lesion debridement  Bone grafting  Internal fixation

中文摘要:

  【摘要】 目的：探讨一期后路经多裂肌和最长肌间隙入路病灶清除植骨融合内固定治疗胸腰椎化脓性脊柱炎的临床疗效。方法：回顾性分析2019年2月～2021年2 月在西南医科大学附属医院骨科行一期后路经多裂肌和最长肌间隙入路病灶清除植骨融合内固定术且获得随访的73例胸椎或腰椎化脓性脊柱炎患者，男52例，女21例，年龄35～75岁（56.5±10.7岁）。T1～T10 15例，T11～L2 32例，L3～L5 26例。局部均有明显后凸畸形，23例伴有椎管内硬膜外脓肿形成，17例伴有椎旁或腰大肌脓肿形成，7例伴神经功能损害[美国脊髓损伤学会（American Spinal Injury Association，ASIA）神经功能分级：C级1例，D级6例]。24例合并心脑血管疾病，35例合并糖尿病，30例有术前有创操作病史。术前取静脉血做细菌培养，均采用一期后路经多裂肌和最长肌间隙入路病灶清除、植骨融合、内固定术治疗，术中取病灶组织做细菌培养，术后持续冲洗10～14d，抗感染治疗6～8周。记录患者手术时间、术中出血量、住院时间和并发症；比较术前和出院前的血沉（erythrocyte sedimentation rate，ESR）、C-反应蛋白（C-reactive protein，CRP）和降钙素原（procalcitonin，PCT）；术前、出院前和末次随访时对胸腰背部疼痛行视觉模拟量表（visual analogue scale，VAS）评分；在X线片上测量病灶节段后凸Cobb角，计算后凸畸形矫正率和末次随访矫正丢失角度；末次随访时观察脊髓神经功能恢复状况（ASIA分级）和植骨融合情况。结果：所有患者均成功完成手术，手术时间195.8±15.5min，术中出血量562.1±45.5mL，住院时间18.0±2.0d。9例患者术后出现并发症（12.3%）：2例出现谵妄综合征，口服奥氮平后逐渐消失；4例出现下肢疼痛、麻木，给予营养神经等处理后症状消失；3例出现胸腔积液，给予胸腔闭式引流，抗感染，加强肺功能锻炼后治愈。51例细菌培养阳性，金黄色葡萄球菌29例，大肠埃希菌17例，表皮葡萄球菌5例。术前ESR、CRP、PCT分别为80.9±13.9mm/h、58.4±13.5mg/L、0.8±0.2ng/mL，出院前分别为29.6±8.9mm/h、15.0±7.2mg/L、0.1±0.0ng/mL，出院前ESR、CRP、PCT均较术前显著性下降（P＜0.05）。随访12～30个月（20.1±4.0个月），术前、出院前和末次随访时的疼痛VAS评分分别为7.6±1.1分、2.2±0.6分、1.6±0.6分，出院前和末次随访时的VAS评分均较术前均显著性降低（P＜0.05）；Cobb角分别为19.6°±1.6°、6.2°±1.5°、9.4°±1.0°，矫正角度13.4°±0.6°，矫正率68.7%±5.3%，出院前较术前显著性矫正（P＜0.05）；末次随访时较出院前矫正角度丢失3.2°±0.7°，矫正角度丢失率24.0%±4.6%（P＜0.05）。末次随访时1例术前ASIA C级患者恢复至D级，6例D级恢复至E级，术前无神经损伤患者术后均无改变。末次随访时所有患者植骨均达到骨性融合。结论：在抗感染的基础上一期后路经多裂肌和最长肌间隙入路手术治疗胸椎和腰椎化脓性脊柱炎能够实现清除病灶、椎管减压、椎体间支撑植骨融合与固定，同时保护椎旁肌肉以及后方韧带复合体、减少术后慢性胸腰部疼痛。

英文摘要:

  【Abstract】 Objectives: To explore the clinical effects of one-stage posterior approach via multifidus-longissimus cleavage planes for lesion debridement, bone grafting and internal fixation in the treatment of thoracolumbar suppurative spondylitis in adults. Methods: 73 patients with thoracic or lumbar pyogenic spondylitis who underwent one-stage posterior approach via multifidus-longissimus cleavage planes for lesion removal and bone grafting and internal fixation in the Department of Orthopedics, the Affiliated Hospital of Southwest Medical University from February 2019 to February 2021 were retrospectively analyzed. There were 52 males and 21 females, aged 35-75 years(56.5±10.7 years); T1-T10 in 15 cases, T11-L2 in 32 cases, and L3-L5 in 26 cases. Obvious kyphotic deformity was found locally in all the patients. 23 cases were accompanied with intraspinal epidural abscess, and 17 cases with paravertebral or psoas major muscle abscess. 7 cases were combined with neurological impairment, and the American Spinal Injury Association(ASIA) classification of neurological function was detailed in 1 case of grade C and 6 cases of grade D. 24 cases were complicated with cardiovascular and cerebrovascular diseases, 35 cases with diabetes, and 30 cases had a history of invasive operation. The venous blood was collected for bacterial culture before operation. All the patients were treated with one-stage posterior approach via multifidus-longissimus cleavage planes for lesion removal and bone grafting and internal fixation. The lesion tissue was taken for bacterial culture during operation. The postoperative irrigation lasted for 10-14d, and the anti-infection treatment lasted for 6-8 weeks. The operative time, intraoperative blood loss, and length of hospital stays, and complications were recorded; Erythrocyte sedimentation rate(ESR), C-reactive protein(CRP) and procalcitonin(PCT) were compared preoperatively and before discharge; Visual analogue scale(VAS) scores of thoracolumbar back pain before operation and discharge and at final follow-up were compared. The Cobb angles of kyphosis of the lesion segment were measured on radiographs, and the rate of correction of kyphosis and loss angle of correction at the final follow-up were calculated; The recovery of spinal cord function(ASIA grade) and bone graft fusion at final follow-up were observed and evaluated. Results: All the patients underwent the surgery successfully. The operative time was 195.8±15.5min, the intraoperative blood loss was 562.1±45.5mL, and the length of hospital stays were 18.0±2.0d. Postoperative complications occurred in 9 patients(12.3%): 2 patients had delirium syndrome, which gradually disappeared after oral administration of olanzapine; 4 cases had lower limb pain and numbness, and the symptoms disappeared after nutritional nerve treatment; 3 cases presented with pleural effusion and were cured after administration of closed chest drainage, anti-infection and strengthening of lung function exercises. 51 cases were positive of bacterial culture, including 29 cases of Staphylococcus aureus, 17 cases of Escherichia coli and 5 cases of Staphylococcus epidermidis. Preoperative ESR, CRP and PCT were 80.9±13.9mm/h, 58.4±13.5mg/L, 0.8±0.2ng/mL, and before discharge they were 29.6±8.9mm/h, 15.0±7.2mg/L and 0.1±0.0ng/mL. ESR, CRP, and PCT were significantly decreased before discharge compared with preoperative values(P<0.05). The patients were followed up for 12-30 months(20.1±4.0 months). At preoperation, before discharge and final follow-up, the VAS scores were 7.6±1.1, 2.2±0.6 and 1.6±0.6, respectively. Before discharge and final follow-up VAS scores were significantly lower than the preoperative score(P<0.05). The Cobb angle was 19.6°±1.6°, 6.2°±1.5°, 9.4°±1.0°, and the correction angle was 13.4°±0.6°, the correction rate was 68.7%±5.3%, which was significantly corrected before discharge(P<0.05). At final follow-up, the corrected angle loss was 3.2°±0.7° relative to before discharge, and the corrected angle loss rate was 24.0%±4.6%(P<0.05). At the final follow-up, one patient of preoperative ASIA grade C recovered to grade D, and six patients of grade D recovered to grade E. There was no change in ASIA grade after operation in patients without nerve injury before operation. Bone fusion was achieved in all patients at the final follow-up. Conclusions: On the basis of anti-infection, one-stage posterior approach via multifidus-longissimus cleavage planes for the treatment of thoracolumbar suppurative spondylitis enables removal of lesion, decompression of spinal canal, and fusion and fixation of intervertebral support implants with protection of paravertebral muscles as well as the posterior ligamentous complexes, and reduces chronic thoracolumbar back pain after operation.