脊柱结核一种新分型方法的设计及可信度检验和治疗探讨

A new classification design of spinal tuberculosis, reliability analysis and treatment considerations

中文关键词:  脊柱结核  分型  可信度检验  手术治疗

英文关键词:Spinal tuberculosis  Classification  Reliability assessment  Surgical treatment

中文摘要:

  【摘要】 目的：回顾性分析多中心收治的脊柱结核患者临床资料，筛选能反映脊柱结核及临床诊疗的特征指标，提出一种新的分型方法；总结本组术后随访1年以上且资料完整的患者手术资料，评估手术疗效。方法：统计2007年1月~2022年12月间多中心诊治且资料完整的358例脊柱结核患者的临床资料，其中男性189例，女性169例，年龄35.5±28.9岁；活动性脊柱结核346例，静止型结核12例；颈椎37例，颈胸椎24例，胸椎126例，胸腰椎79例，腰椎63例，腰骶椎29例；病灶累及椎体数为1～12个（3.1±1.9个）；临床表现包括疼痛、活动受限、发热、血沉增快、椎体和椎间盘破坏吸收、寒性脓肿、死骨等。256例合并脊柱后凸畸形，66例表现为不同程度脊髓神经功能损害。采用专家组讨论和意见征询方法，筛选出能反映脊柱结核特征的指标，将脊柱后凸程度与相关指标进行相关性分析，以特征指标为基础设计一种新的脊柱结核综合分型（ASM分型）并进行可重复性评估和可信度检验。同时，收集术后随访1年以上且资料完整的117例的临床资料，采用疼痛视觉模拟量表（visual analogue scale，VAS）评分、脊髓神经功能检查，通过X线和CT检查测量脊柱后凸Cobb角和评估植骨融合情况等，评估手术疗效。结果：论证结果，脊柱结核的病理阶段、发病部位、累及的椎体数、合并的后凸畸形和脊髓神经功能损害是较为重要的特征指标，其他指标如椎体破坏程度、节段不稳、死骨的数量及大小、寒性脓肿等的特征性不强；相关性分析结果表明，更具特征性的指标脊柱后凸畸形与病程、部位、节段、有无脊髓神经损害等之间具有明显的相关性（P＜0.05）。根据论证结果，提出了一种新的脊柱结核综合指标分型：以病灶内结核活动性情况分为活动型脊柱结核（Ⅰ型）和静止型脊柱结核（Ⅱ型）两种主要类型，其中Ⅰ型又分为四种亚型：A型为早期脊柱结核；B型为进展期脊柱结核；C型和D型为特殊类型，分别为跳跃型脊柱结核和脊柱附件结核；Ⅱ型又分为畸形静止型（A型）和畸形进展型（B型）两种亚型；同时，将脊柱结核四项重要指标包括病灶部位、受累椎体数、合并的后凸畸形及程度以及有无脊髓神经功能损害作为辅助指标；可信度分析结果显示，新分型具有较好的一致性和重复性。随访1年以上资料完整的117例患者中，12例颈椎结核采用了前路手术，104例颈胸交界区及以下的脊柱结核患者均采用了单纯经后路手术，1例胸腰椎结核在后路手术同时，采用入路对侧腹部小切口行寒性脓肿清除。随访结果显示：VAS评分为1.9±0.3分（1～3分）；脊柱后凸Cobb角为15.6°±8.4°（4°～40°）；脊髓神经功能异常者，末次随访时已完全恢复至正常，上述指标与术前相比，差异均具有统计学意义（P＜0.05）。111例患者获得临床治愈、CT影像显示达到骨性融合；6例患者结核复发，其中5例因植骨不融合，出现内固定失败，再次行手术治疗。结论：新分型（ASM）能反映脊柱结核患者的病情特点，便于临床诊疗和交流。对颈胸交界区以下的脊柱结核患者采用单纯经后路手术是一种具有优势的手术选择。

英文摘要:

  【Abstract】 Objectives: To retrospectively review the clinical data from multiple centers of patients diagnosed with spinal tuberculosis, and identify key indicators that reflect the disease′s characteristics and clinical management to propose a novel classification system for spinal tuberculosis; To summarize the surgical treatment methods and outcomes of patients with complete data who were followed up for more than 1 year for surgical efficacy evaluation. Methods: The clinical data of 358 spinal tuberculosis patients diagnosed and treated at multiple centers between January 2007 and December 2022 were collected and analyzed. The patients aged 35.5±28.9 years old, and were consisted of 189 males and 169 females. There were 346 cases of active spinal tuberculosis and 12 cases of inactive tuberculosis. The distribution of lesion sites included cervical spine in 37 cases, cervicothoracic spine in 24 cases, thoracic spine in 126 cases, thoracolumbar spine in 79 cases, lumbar spine in 63 cases, and lumbosacral spine in 29 cases. The number of affected vertebrae per lesion was 3.1±1.9(ranged from 1 to 12). Clinical manifestations included pain, limited mobility, fever, elevated erythrocyte sedimentation rate, destruction and absorption of vertebrae and intervertebral discs, cold abscesses, and sequestra. Among the patients, 256 patients exhibited concomitant kyphotic deformities, and 66 patients presented with varying degrees of spinal cord or nerve dysfunction. Using expert panel discussions and opinion surveys, indicators that reflect the characteristics of spinal tuberculosis were identified and subjected to correlation analysis with the degrees of kyphosis. Based on these findings, a new comprehensive classification system(ASM classification) grounded in key indicators was designed and then re-evaluated and tested for reliability. In parallel, the clinical data of 117 patients with over one year of postoperative follow-up and complete records were collected, and the surgical efficacy was assessed according to visual analogue scale(VAS) score for pain, examination of spinal cord or nerve function, and measurement of Cobb angle of kyphosis as well as evaluation of graft fusion conditions on X-ray and CT. Results: The expert discussions confirmed that pathological stage, lesion location, number of affected vertebrae, and the presence of kyphotic deformity and spinal cord or nerve dysfunction were key indicators in the diagnosis and treatment of spinal tuberculosis; Other indicators such as the extent of vertebral destruction, segmental instability, and the number and size of sequestra and cold abscesses were found to be less specific. Correlation analysis demonstrated a significant association between kyphotic deformity and factors such as disease duration, lesion location, affected segment, and spinal cord or nerve involvement(P<0.05). Based on the validation results, a new comprehensive classification system was proposed. The spinal tuberculosis was categorized into two main types based on lesion activity, the active spinal tuberculosis(type Ⅰ) and inactive spinal tuberculosis(type Ⅱ). Type Ⅰ was further divided into four subtypes: type A - early-stage spinal tuberculosis, type B - progressive spinal tuberculosis, type C - special type including skip lesions, and type D - spinal appendage tuberculosis; Type Ⅱ was divided into two subtypes: type A - deformity-stable type, type B- deformity-progressive type. Additionally, the four key indicators-lesion location, number of affected vertebrae, presence and degree of kyphotic deformity, and spinal cord or nerve impairment were included as auxiliary indicators. Reliability analysis showed that the new classification system had good consistency and reproducibility. Among the 117 patients with over one year of postoperative follow-up and complete records, 12 with cervical tuberculosis underwent anterior approach surgery, 104 patients with lesions below the cervicothoracic junction underwent posterior-only surgery, and 1 thoracolumbar case underwent additional debridement of a cold abscess via a small contralateral abdominal incision during posterior surgery. Follow-up results revealed: VAS score was 1.9±0.3(1-3), kyphotic Cobb angle was 15.61°±8.44°(4°-40°); The patients with abnormal spinal cord nerve function were fully recovered to normal at the final follow-up, and the above-mentioned indicators were improved with statistically significant differences comparing with the preoperative values(P<0.05); 111 patients were clinically cured and bony fused on CT images; 6 patients experienced tuberculosis recurrence, among which, 5 failed in internal fixation due to graft non-fusion and underwent re-operation. Conclusions: The new classification system(ASM) effectively captures the clinical characteristics of spinal tuberculosis and facilitates diagnosis, treatment planning, and clinical communication. For patients with spinal tuberculosis below the cervicothoracic junction, a purely posterior surgical approach also represents an advantageous treatment option.