脊柱结核手术失败的处理及危险因素分析

目的探讨脊柱结核初次手术失败的危险因素及治疗方案。方法回顾性分析2013年1月至2019年12月接受病灶清除植骨融合术的317例脊柱结核患者,男206例、女111例;年龄(53.5±16.7)岁(范围11~86岁)。随访1年以上,期间出现①~③中任意一条定义为手术失败:①同一结核病灶接受手术≥2次;②与结核病灶相关的非计划再入院次数≥1次;③结核耐药或迁延不愈,出现冷脓肿或窦道;或合并其他细菌感染,或发生内固定松动。未发生失败病例定义为治愈。收集两组患者症状、用药史、辅助检查、手术方案进行单因素分析,对手术失败的潜在危险因素行二分类变量Logistic回归分析。手术失败病例均针对病因进行治疗,穿刺引流(含置管冲洗)14例、清创10例、内固定翻修3例。术中采集脓液、坏死或肉芽组织行结核杆菌培养+药敏试验、宏基因组二代测序和实时荧光定量PCR检测。结果确定手术失败27例。脓肿或窦道形成17例,占63%(17/27);其中3例异烟肼或利福平单药耐药、2例异烟肼和利福平耐药(耐多药);经针对性抗结核治疗(17例)、穿刺引流或穿刺置管冲洗(14例)、清创缝合(3例)治愈。切口感染或愈合不良7例,占26%(7/27);其中病原菌检出5例,均未检出结核耐药;经抗感染及清创缝合治愈,其中2例取出内固定。内固定松动3例,占11%(3/27),经内固定翻修手术治愈。手术失败组与临床治愈组是否累及复合或跳跃节段、有无2型糖尿病史、有无三种以上基础疾病史、术后1周C反应蛋白、术后1周白细胞计数、首剂时间、手术时间和术中出血量的差异有统计学意义(P<0.10)。回归分析结果显示,累及复合或跳跃节段(OR=3.513,P=0.047)、术后1周C反应蛋白(OR=1.021,P=0.005)、首剂时间≥20周(OR=2.895,P=0.039)、出血量≥800 ml(OR=5.950,P=0.001)和患有三种以上基础疾病(OR=3.671,P=0.027)为手术失败的独立危险因素。结论脊柱结核,特别是耐药脊柱结核应早期诊断,并尽早开始规范抗结核治疗;脓肿穿刺引流是治疗脓肿或窦道形成的有效手段;复合或跳跃节段的脊柱结核术后失败发生率高,应强调手术病灶节段的稳定性重建。

Risk factors and interventions for surgical failure of spinal tuberculosis

Objective To investigate the risk factors and interventions for surgical failure of spinal tuberculosis(STB).Methods A total of 317 STB patients aged from 11 to 86 years with an average age of 53.5±16.7 years,who received debridement and fusion with bone grafting from January 2013 to December 2019,were retrospectively analyzed,including 206 males and 111 females.The follow-up duration was at least 1 year.During the follow-up,any one of the following 1)-3)was defined as surgical failure,namely 1)the same tubercular lesion treated by surgery more than 2 times,2)the number of unplanned readmissions related to tubercular lesion≥1,3)drug-resistant STB or delayed healing,recurrent lesion with cold abscess/sinus tract,combined with other bacterial infection,or loosening of internal fixation.The other cases were regarded as"curative"cases.Patients'symptoms,medication history,auxiliary examination and surgical plan were collected for univariate analysis.Further,the potential risk factors for surgical failure were analyzed by binary Logistic regression.Failed cases were treated with etiological intervention,such as puncture pumping pus or debridement or revision.The necrosis or granulation tissue was collected and further detected by tuberculosis culture,metagenomic next-generation sequencing(mNGS)and real-time fluorescent quantitative PCR(RT-qPCR).Results There were 27 cases with surgical failure.Abscess or sinus tract formation was developed in 17 cases,which accounted for 63%(17/27).Among these patients,there were 3 cases of resistance to isoniazid or rifampicin and 2 cases of resistance to isoniazid and rifampicin(multidrug resistance,MDR).Seventeen cases were treated by anti-tuberculosis treatment,while 14 cases by puncture drainage(or puncture catheter irrigation)and 3 cases by debridement and suturing.Seven cases with wound infection or poor healing accounted for 26%(7/27).Among them,5 kinds of pathogens were detected,none of which showed tuberculosis drug resistance.All of them were treated by anti-infection and debridement suturing,while 2 of them were treated with internal fixation removal.Three cases(11%,3/27)with internal fixation loosening were treated by revision surgery.There was statistically significant difference between the failed group and the cured group in involved multi-/jumping segment,history of type 2 diabetes,a history of more than three basic diseases,CRP at one week after surgery,WBC at one week after surgery,time of first dose,operation duration and intraoperative blood loss(P<0.10).Binary Logistic regression analysis showed that multi-/jumping segment(OR=3.513,P=0.047),CRP at one week after surgery(OR=1.021,P=0.005),first dose time≥20 weeks(OR=2.895,P=0.039),blood loss≥800 ml(OR=5.950,P=0.001)and more than three basic diseases involved(OR=3.671,P=0.027)were independent risk factors for surgical failure.Conclusion Early diagnosis,especially the diagnosis of drug-resistant STB and standardized anti-tubercular treatment,should be carried out effectively.Puncture and drainage of abscess is an effective therapy to treat the cases with abscess/sinus tract formation.Some cases involved multi-/jumping segments could be with higher risk of failure after internal fixation.Thus,they should be treated individually with emphasis on the segmental stability reconstruction.