老年脊柱结核患者的临床特点和术式选择

 目的 总结老年脊柱结核患者的临床特点，探讨老年脊柱结核患者手术方式的选择策略。方法 2005年10月至2010年10月采用6种手术方式治疗老年脊柱结核患者151例，69例患者纳入研究，男36例，女33例；年龄60~83岁，平均68.3岁。62例（171例次）合并有其他疾病。记录患者的临床表现、发病部位及影像学表现。统计误诊、误治的发生情况。在治疗前、术后1周及末次随访时采用疼痛视觉模拟评分(visual analog scale, VAS)进行对比分析，对伴有脊髓神经损害患者采用Frankel分级评价术后脊髓神经功能改善情况。结核临床治愈判定采用脊柱结核治愈标准。结果 所有患者均有不同程度的局部疼痛，VAS评分平均为（8.2±1.4）分，严重疼痛者（VAS评分7分以上）42例（60.9%）。72.5%的患者无明显结核中毒症状，68.1%的患者有脊髓神经损害表现，43.5%的患者无椎旁脓肿或腰大肌脓肿。腰椎结核发病率最高（78.3%，54/69），双椎体结核最常见（59.4%，41/69）。均有轻、中度的后凸畸形，Cobb角平均为20.4°±4.3°。误诊率为30.4%（21/69），误治率为13.0%（9/69）。获得平均27个月随访，结核临床治愈67例，2例窦道形成，迁延未愈。融合节段（4.1±0.6）个，骨融合时间（5.9±1.7）个月。术后后凸畸形矫正9.5°±3.6°，末次随访时矫正角度丢失7.2°±2.3°。5例伴有脊髓神经损害者术后Frankel分级至少提高了1级。术后肺部感染5例（其中死亡1例），心功能不全5例，脑梗死2例，内固定松动2例，窦道形成5例，药物性肝损害5例，药物性皮疹6例，术后神经功能损害加重1例。结论 老年脊柱结核患者起病隐匿，多合并其他疾病，易导致误诊、误治。手术方式的选择应遵循个体化及微创的原则，术中固定节段应适当延长。

The operative strategy and clinical outcomes of spinal tuberculosis in older patients

Objective To summarize clinical characteristics and explore operative strategy of elderly patients with spinal tuberculosis. Methods From December 2005 to December 2010, 151 aged patients with spinal tuberculosis were treated with six different surgical procedures. Among 69 patients were followed, including 36 males and 33 females, with the average age of 68.3 (60 to 83) years. 62 patients were complicated by other diseases. The clinical manifestations, locations and images of these patients were analyzed. The occurrence of misdiagnosis and mistreatment was counted. The visual analogue scale (VAS) scoring was applied to evaluate the local pain, and the Frankel classification was used to evaluate the improvement of neurological function. The criterion of cure of spinal tuberculosis was used to assess the clinical cure of these patients. Results All patients had different levels of local pain. The preoperative VAS was 8.2±1.4, with 42 (60.9) cases of more than 7. 72.5% patients didn't have obvious toxic symptoms and 43.5% didn’t have paravertebral or psoas abscess, while 68.1% had spinal nerve damage. Lumbar spine was the most commonly affected area and 2 vertebrae TB got the highest incidence. The Cobb’s angle was 20.4°±4.3° preoperatively. The misdiagnose rate was 30.4% (21/69) and the mistreatment rate was 13.0% (9/69). The average follow-up period was 27 months. Sixty-seven patients were clinically cured. The average union segments were 4.1±0.6 and the average time of union was 5.9±1.7 months. The correction of kyphosis was 9.5°±3.6° after surgery but lost 7.2°±2.3° at the last follow-up time. 5 patients with neurological deficits were clinically improved at least one grade after surgery, according to the Frankel grading system. One patient died from pulmonary infection. Other complications included cardiac dysfunction in 5 patients, pulmonary infection in 4 patients, cerebral infarction in 2 patients, internal fixation loosening in 2 patients, sinus formation in 5 patients, drug-induced liver dysfunction in 5 patients, drug rash in 6 patients and aggravation of neurological function in 1 patient. Conclusion Spinal tuberculosis in elderly patients usually concealed onset and combined with other diseases, which could lead to misdiagnosis and mistreatment. Surgical procedures should be chosen individually and in minimal-invasive way. The segments should be fixed longer to avoid loosening.