脊柱结核病灶清除的手术入路问题

抗结核药物化疗是治疗脊柱结核和防止其复发的重要措施,相当部分患者可通过药物化疗而治愈.但单纯药物治疗并不能阻止脊柱结核畸形进展,Rajasekaran 等[1]研究发现,非手术治疗的儿童脊柱结核患者中约有39％的病例后凸继续进展,部分患者即使疾病治愈脊柱畸形仍加重.自从Hodgson和Stock在1956年报道单纯前路手术治疗脊柱结核以后,Hodgson的"香港术式"以及后来改进的前路病灶清除、支撑植骨融合、内固定术成为了治疗脊柱结核的标准术式.对于巨大死骨、脓肿,窦道形成、椎体破坏严重脊柱不稳、严重后凸畸形及截瘫患者应在有效抗结核药物治疗基础上积极手术治疗,其目的在于彻底清除结核病灶、解除脊髓神经压迫、重建脊柱稳定、预防和矫正脊柱后凸畸形.目前脊柱结核手术可选择前方入路、后方入路或前后联合入路,具体如何选择,应根据病变部位、病变累及范围、畸形情况而定.     

侧前方病灶清除人工椎体置换术治疗胸椎结核后凸畸形

目的:探讨脊柱侧前方病灶清除椎间轴套式钛合金人工椎体置换治疗胸椎结核并后凸畸形的疗效。方法:胸椎结核并后凸畸形患者19例,后凸Cobb角15°～30°,平均25°,7例患者合并脊髓压迫,Frankel分级C级3例,D级4例。手术方法为一期侧前方病灶清除椎间轴套式钛合金人工椎体置换,置换的人工椎体内置入松质骨。术后抗结核药物治疗9个月。结果:随访2～3年,平均2年4个月。切口均一期愈合,椎体无滑脱,胸椎结核全部治愈,脊髓功能损害者术后1年内完全恢复。术后后凸Cobb角平均8°,平均矫正17°,随访期间畸形矫正无明显丢失。结论:胸椎结核侧前方病灶清除人工椎体置换术治疗胸椎结核并后凸畸形效果较好,能够一期完成病灶清除、脊髓减压、脊柱稳定性重建和后凸畸形矫正。     

非病灶区截骨矫形手术治疗陈旧性脊柱结核严重角状后凸畸形1例报告

脊柱结核亦称为Pott′s病,约占全身各部位结核的2%。脊柱结核的病灶主要发生在椎体,导致多椎体破坏塌陷融合,而椎体附件基本未累及,逐渐形成脊柱角状后凸畸形,约3%~5%的患者最终可以达到60°以上角状后凸畸形。在儿童时期发生的脊柱结核,结核破坏的椎体数越多,发生脊柱角状后凸畸形的角度越大,程度更重,常导致患者心肺功能障碍以及较早出现脊髓神经功能损害、顽固性腰痛。文献报道其脊髓神经损伤的发生率可达10％～43%。目前,手术矫形是治疗陈旧性脊柱结核角状后凸畸形最有效的方法。手术治疗的目的是纠正脊柱的角状后凸外观畸形、恢复脊柱的矢状位平衡,从而解除脊髓压迫,稳定脊柱。同时通过矫正脊柱角状后凸,增加胸腔的纵径,减轻对胸腔脏器的压迫,改善心肺功能状态等。脊柱后路三柱截骨[如经椎弓根截骨（pedicle subtraction osteotomy,PSO）、全椎体截骨（vertebral column resection,VCR）]是目前最有效的矫正脊柱结核角状后凸畸形的手术方式。但截骨的部位通常选择在角状后凸顶椎区域,也就是陈旧性脊柱结核的病灶区域,虽然也能取得较好的效果,但当脊柱结核破坏的椎体多,形成的角状后凸程度严重时,难以达到满意的矫形效果;而病灶区是由于前柱多椎体破坏压缩融合成一块,其上有多个破坏椎体的椎弓根,后柱结构相对正常,逐渐形成严重的脊柱后凸畸形,常伴有椎管扭曲狭窄变形,硬膜囊粘连,脊髓严重受压,脊髓血循环不同程度受损,肋骨和脊神经挤压在角状后凸这一狭窄区域。如果再选择在病灶区截骨矫正脊柱畸形,必将进一步损伤此部位脊髓的血循环,引起脊髓损伤的几率更高。因此,需要探寻更安全的截骨部位和手术方式。我们针对这类陈旧性脊柱结核伴严重角状后凸畸形的患者,设计了非病灶区截骨、远端后移、椎管重建、脊髓重置,达到矫正脊柱后凸、恢复整体矢状位平衡、解除脊髓受压的目标,并使用该方法治疗1例陈旧性脊柱结核伴严重角状后凸畸形的病例,取得了较好效果,报道如下。     

侧前方入路病灶清除植骨内固定术治疗脊柱结核38例疗效分析

脊柱结核并发脊柱后凸畸形、脊髓损伤,致残率高,严重影响患者身心健康和生活质量.传统的单纯病灶清除植骨融合术是治疗脊柱结核的基本方法,但常会出现植骨块吸收、植骨块塌陷,假关节形成或矫正后凸畸形丢失,脊柱稳定性差,后凸畸形再复发,而出现迟发性脊髓损伤.     

球囊扩张椎体成形术治疗老年骨质疏松性椎体骨折

目的探讨经皮穿刺球囊扩张椎体后凸成形术（Percutaneous Kyphoplasty,PKP）治疗老年性骨质疏松椎体骨折并后凸畸形的临床效果。方法应用PKP治疗患者17例,28个椎体。分别在术前、术后进行止痛药使用评分和活动能力评分,在脊柱侧位X线片测量椎体高度的丢失及后凸畸形Cobb角的比较。结果本组17例未发现脊髓神经的损伤,骨水泥的渗漏,栓塞等并发症出现。术后随访4～17个月,平均13个月,患者上述四项指标均较术前有显著改善。结论 PKP是一种微创治疗办法,可以迅速、有效的缓解疼痛,恢复正常活动,矫正脊柱后凸畸形。     

病变治愈型脊柱结核脊柱后凸畸形及脊髓压迫的外科治疗

[目的]探讨胸腰段病变治愈型脊柱结核合并脊柱后凸畸形及脊髓压迫的外科治疗方法。[方法]对17例胸腰段病变治愈型脊柱结核分别采用单纯后路植骨融合3例，后路椎弓根螺丝钉固定及后路植骨融合术8例，椎体侧前方椎管减压6例，其中行单纯椎体侧方植骨融合术3例，辅以椎体侧方钢板内固定3例。[结果]术后随访时间9个月～7a6个月，平均4．2a。后路植骨平均骨融合时间为2．8个月，椎体侧方植骨平均骨性融合时间为3．3个月，椎管侧前方减压6例中1例神经根刺激症状完全消失，3例大部分改善，2例症状加重并伴单侧下肢肌力1～2级减退。[结论]胸腰段病变治愈型脊柱结核合并脊柱后凸畸形临床上有时并不合并严重的脊髓压迫症状，外科治疗目的在于防止脊柱后凸畸形进一步加重及避免继发性截瘫，而过分强调椎管完全减压及脊柱后凸畸形矫正会导致严重的脊髓功能受损。     

前路一期病变椎体切除并重建治疗胸腰椎结核并后凸畸形

目的:观察前路一期病变椎体切除、人工椎体或钛网融合器植骨替代、椎体钉板或钉棒系统内固定治疗连续两个及以上节段胸腰椎结核并后凸畸形的疗效。方法:34例病变累及连续两个及两个以上椎节的胸腰椎结核患者,术前后凸Cobb角27.8°￣65.4°(38.6°±10.3°),一期行前路病变椎体切除,椎间撬拔撑开复位,人工椎体或钛网融合器植骨替代,辅以椎体钉板或钉棒系统短节段邻近椎节内固定,重建脊柱稳定性,术后均给予短疗程化疗。观察术后局部疼痛缓解、脊髓神经功能恢复、后凸畸形矫正及脊柱稳定性情况。结果:患者术后局部疼痛缓解,术前伴有脊髓神经损伤的12例患者术后神经功能均有不同程度恢复。影像学检查示脊柱内固定物位置良好,椎体序列恢复良好,椎间高度恢复。后凸Cobb角矫正至2.1°￣14.2°(7.5°±8.3°),平均矫正31.2°±8.5°。随访18￣54个月,平均35个月。末次随访时后凸矫正度丢失4.3°±3.8°,均无结核复发。结论:连续两个及两个以上节段的胸腰椎结核采用前路一期行病变椎体切除有利于病灶彻底清除,减少复发;也有利于椎管彻底减压。前路椎体替代、植骨内固定重建脊柱稳定性可更好地纠正和预防脊柱后凸畸形。     

胸腰椎后凸畸形的后路矫形手术

<正>胸腰椎后凸俗称驼背,常见于先天椎体发育畸形、脊柱陈旧结核、脊柱陈旧创伤、强直性脊柱炎和Scheuermann病等疾病;该病病程较长,多持续进展,常因脊髓受压而引发截瘫,还可由于代偿性腰椎过度前凸而引发下腰痛;该后凸畸形同时也会给患者带来严重的心理障碍。因此,胸腰椎后凸畸形的手术治疗需要解除神经压迫并矫正畸形。脊柱截骨矫形手术是治疗胸腰椎后凸畸形的有     

脊柱椎体后部结核合并椎管内脓肿的外科治疗

典型的脊柱结核多累及2个以上的椎体前部, 易形成椎前和椎旁脓肿及脊柱后凸畸形。临床上仅局限在椎体后部的脊柱结核较少报道,因本病形成的椎管内脓肿可直接对相邻脊髓产生压迫,故可较早产生脊髓受累的并发症。1999年8月-2004年 7月我院共收治该类椎体结核患者28例,均早期采取外科手术治疗并取得较满意的疗效。     

侧前方病灶清除椎弓根内固定治疗胸椎结核后凸畸形

目的观察侧前方病灶清除椎间植骨经椎弓根内固定术治疗脊柱结核并后凸畸形的疗效。方法胸椎结核并后凸畸形患者17例,男11例,女6例;年龄23～56岁,平均36.4岁。结核病损位于下胸椎,累及两或三个椎体。后凸成角15°～34°,平均25°。5例患者合并脊髓损伤,Frankel分级为C级2例、D级3例。手术方法为一期侧前方病灶清除椎间植骨经椎弓根内固定,抗结核药物治疗9个月。结果术后随访2~4年,切口一期愈合,椎间植骨全部融合,脊柱结核全部治愈,脊髓功能损害患者术后1年内完全恢复。术后后凸成角平均为7°,平均矫正18°,随访期间畸形矫正无明显丢失。结论侧前方病灶清除椎弓根内固定术治疗脊柱结核并后凸畸形,能够一期完成病灶清除、脊髓减压、脊柱稳定性重建和后凸畸形矫正。坚强的内固定可促进病椎植骨融合,有助于缩短术后药物治疗时间和提高脊柱结核治愈率。     

Treatment of tuberculosis of the spine with neurologic complications

Neurologic complications are the most dreaded complication of spinal tuberculosis. The patients who have paraplegia develop in the active stage of tuberculosis of the spine require active treatment for spinal tuberculosis and have a better prognosis than the patients who have paraplegia develop many years after the initial disease has healed. Neurologic dysfunctions in association with active tuberculosis of the spine can be prevented by early diagnosis and prompt treatment. Prompt treatment can reverse paralysis and minimize the potential disability resulting from Pott's paraplegia. When needed, a combination of conservative therapy and surgical decompression yields successful results in most patients with tuberculosis of the spine who have neurologic complications. The vertebral body primarily is affected in tuberculosis; therefore, decompression has to be anterior. Laminectomy is advocated in patients with posterior complex disease and spinal tumor syndrome. Late onset paraplegia is best avoided by prevention of the development of severe kyphosis. Patients with tuberculosis of the spine who are likely to have severe kyphosis develop (< 60 degrees) on completion of treatment should have surgery in the active stage of disease to improve kyphus.     

人工椎体置换治疗胸腰椎结核的临床疗效观察

目的探讨人工椎体置换治疗胸腰椎结核的临床疗效。方法回顾性分析胸腰椎结核28例,其中累及1个椎体5例,2个椎体22例,3个椎体1例。对该组患者行椎体大部切除,撑开复位后行可调式中空笼状钛合金人工椎体植骨置换、前路椎体钉棒系统邻近椎节固定,观察术后局部疼痛缓解、脊柱稳定性及后凸畸形的矫治情况。结果所有患者术后疼痛缓解,切口均一期愈合,随访12～36个月,平均17个月,局部无复发,影像学检查椎体序列恢复良好,椎间高度恢复,达到骨性愈合,后凸畸形基本矫正。结论胸腰椎结核行人工椎体置换,既能彻底切除病灶防止复发,又能矫正畸形,有效重建脊柱稳定性,恢复脊柱支撑功能。     

Kyphosis secondary to infectious disease

Infections of the spine usually involve the vertebral body and therefore by definition produce a kyphosis. Non-tuberculous infection usually staphylococcal and in the lumbar spine, is often diagnosed late and can involve the cord. Open exploration and stabilization with graft should therefore be considered. The destruction is usually less extensive and therefore the kyphosis less severe than in late neglected tuberculous infections. Tuberculous spinal infection accounts for 59% of all orthopedic tuberculosis. It invariably involves vertebral bodies and is progressive. Destruction of the bodies is by infection and avascular necrosis, kyphosis is inevitable and cord compression a common threat. While L-1 is the most commonly affected body T-10 is statistically the most commonly associated with cord compression. The treatment of spinal tuberculosis should be aimed at correcting 5 basic defects associated with the disease and the deformity: mechanical instability; chronic smoldering infection; spinal cord and nerve root compression; disturbance of spinal growth; depressed lung function. The cornerstone to effective treatment for spinal tuberculosis is drug therapy and the anterior fusion operation. For the established tuberculous kyphosis, which is always a fixed deformity, multiple staged operations and gradual correction used the Halo-pelvic apparatus is the best treatment available at present.     

Natural history of Pott’s kyphosis

The natural history of Pott’s kyphosis is different from that of other spinal deformities. After healing of the spinal infection, the post-tubercular kyphosis in adults is static but in children variable progression of the kyphosis is seen. The changes occurring in the spine of children, after the healing of the tubercular lesion, are more significant than the changes that occur during the active stage of infection. During growth, there is a decrease in deformity in 44 % of the children, an increase in deformity in 39 % of the children and no change in deformity in 17 % of the children. The critical factor leading to the progress of the deformity is dislocation of the facets. This can be identified on radiographs by the “Spine-at-risk” signs. Dislocation of facets at more than two levels can lead to the “Buckling collapse” of the spine, which is characteristically seen only in severe tubercular kyphosis in children. Age below 10 years, vertebral body loss of more than 1–1.5 pre-treatment deformity angle of greater than 30° and involvement of cervicothoracic or thoracolumbar junction are the other risk factors for deformity progression. In children, the kyphosis can progress even after healing of the spinal infection and hence children with spinal tuberculosis must be followed-up till skeletal maturity.

     

Spinal tuberculosis: a review

Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a 'cold' abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.     

儿童脊柱结核的MRI随访观察

目的：探讨MRI在儿童脊柱结核随访中的应用价值.方法：对2004年2月至2013年4月的21例经临床或手术诊断为脊柱结核的儿童患者MRI表现进行回顾性分析,其中男11例,女10例;年龄2～14岁,平均9.4岁.18例保守治疗,3倒手术治疗,病程2个月～3年,所有病例行2次或2次以上MRI检查.比较初次和复查结果,主要观察椎体及椎间隙信号变化、椎旁脓肿及后凸角的变化.结果：21例脊柱结核患者共累及85个椎体,其中颈椎、胸椎及腰骶椎发生率分别为10.6％（9/85）,49.4％ （42/85）及40％（34/85）.初诊及随访时相仿,15例出现椎体变扁或楔形变,10例可见椎间盘受累,而椎间隙可见不同程度变窄或融合.初诊13例后凸角＞0°,位于胸段7例,胸腰段2例,腰段3例,颈段1例.18例保守治疗患儿中,8例初诊及治疗过程中（2～9个月）后凸角均为0°;1例轻度后凸患儿（＜10°）,治疗12个月时后凸角稍增加;5例中度后凸患儿（10°～30°）,治疗过程中（3～12个月）多次随访均无明显改变;4例重度后凸患儿（＞30°）,保守治疗过程中及治疗后（3～28个月）多次随访后凸畸形均有不同程度加重,其中1例保守治疗失败后行手术治疗后凸角减小.结论：儿童脊柱结核运用MRI随访具有重要意义,能够清晰显示治疗后椎体及椎间隙信号变化、椎旁脓肿及后凸角的变化,为临床治疗及评估预后提供参考.     

Conservative treatment of tuberculosis of the lumbar and lumbosacral spine

Fifty-six adults (average age, 38 years) with active tuberculosis of the lumbar and lumbosacral spine were treated conservatively with triple chemotherapy for 12 to 18 months. The minimum followup was 3 years. Three methods of assessments of the chronologic changes of sagittal spinal deformity were used on lateral radiographs of the lumbar spine obtained with the patient standing: deformity, kyphos angles, and total lumbar lordosis. The lumbosacral joint angle was measured for tuberculosis of the lumbosacral joint. The disease healed in all patients with a minimum increase of kyphosis, although in 23 patients there was minimal new involvement of the adjacent vertebral bodies within 6 months of treatment. The pattern of the involved vertebral body collapse in tuberculosis of the lumbar and lumbosacral joints was vertical (telescoping), along a longitudinal axis that minimized the progression of kyphosis. The outcome was judged on the basis of residual kyphosis (British Medical Research Council criteria) and found to be favorable in 96.4% (54 patients). Triple chemotherapy for lumbar and lumbosacral tuberculosis is effective in curing the disease and in minimizing the residual kyphosis through early diagnosis and immediate initiation of chemotherapy. The pattern of vertebral body collapse is the telescoping type, which is the determining factor in minimizing residual spinal deformity.     

Spinal tuberculosis: A review

Abstract

Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a ‘cold’ abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.     

Instrumented stabilization in spinal tuberculosis

Spinal tuberculosis (TB) produces neurological complications and grotesque spinal deformity, which in children increases even with treatment and after achieving healing. Long-standing, severe deformity leads to painful costo-pelvic impingement, respiratory distress, risk of developing late-onset paraplegia and consequent reduction in quality and longevity of life. The treatment objective is to avoid the sequelae of neural complications and achieve the healed status with a near-normal spine. In TB, the spine may become unstable if all three columns are diseased. Pathological fracture/dislocation of a diseased vertebral body may occur secondary to mechanical insult. Surgical decompression adds further instability, as part of the diseased vertebral body is excised. The insertion of a metallic implant is to provide mechanical stability and the use of an implant in tubercular infection is safe. Indications for instrumented stabilisation can be categorised as: (a) pan vertebral disease, in which all three columns are diseased; (b) long-segment disease, in which after surgical decompression a bone graft >5 cm is inserted with instrumentation to prevent graft-related complications and consequent progression of kyphosis and neural complications and (c) when surgical correction of a kyphosis is performed when both anterior decompression and posterior column shortening is required. The implant choice should be individualised according to the case. Pedicle screw fixation in kyphus correction in healed disease is a most suitable implant. Hartshill sublaminar wiring stabilisation in active disease is a suitable implant to stabilise the spine, taking purchase against healthy posterior complex of the vertebral body to save a segment.     

Tuberculosis of the spine

Pott's spine, commonly known as spinal tuberculosis (TB), is an extrapulmonary form of TB caused by Mycobacterium TB. Pott's paraplegia occurs when the spine is involved. Spinal TB is usually caused by the hematogenous spread of infection from a central focus, which can be in the lungs or another location. Spinal TB is distinguished by intervertebral disc involvement caused by the same segmental arterial supply, which can result in severe morbidity even after years of approved therapy. Neurological impairments and spine deformities are caused by progressive damage to the anterior vertebral body. The clinical, radiographic, microbiological, and histological data are used to make the diagnosis of spinal TB. In Pott's spine, combination multidrug antitubercular therapy is the basis of treatment. The recent appearance of multidrug-resistant/extremely drug-resistant TB and the growth of human immunodeficiency virus infection have presented significant challenges in the battle against TB infection. Patients who come with significant kyphosis or neurological impairments are the only ones who require surgical care. Debridement, fusion stabilization, and correction of spinal deformity are the cornerstones of surgical treatment. Clinical results for the treatment of spinal TB are generally quite good with adequate and prompt care.