一期前路病灶清除联合自体肋骨植骨融合内固定治疗胸椎结核

目的：分析一期前路病灶清除、自体肋骨椎间植骨融合前路内固定术治疗胸椎结核的临床效果。方法2003年6月～2008年5月手术治疗胸椎脊柱结核42例，男25例，女17例，均采用一期前路病灶清除、自体肋骨椎间植骨融合前路内固定术。根据术前、术后随访的X线片，分析植骨融合及脊柱后凸畸形矫正效果；采用Frankel分级、红细胞沉降率（ erythrocyte sedimentation rate， ESR）、C反应蛋白（ C-reactionprotein， CRP ）及视觉模拟量表（ visual analog scale， VAS）评分评估临床治疗效果。结果随访1～7年，平均50．8个月，42例患者均获骨性愈合，愈合时间3～7个月，平均4．5个月，无内固定松动、脱出及断裂；术前Cobb角平均19．8°，术后1周为3．7°，末次随访时为4．6°；Frankel分级，术前B级为3例，C级9例，D级20例，E级10例，末次随访时为D级6例，E级36例；VAS评分术前平均为8．2，术后1周为1．8，末次随访时为1．2。除2例患者术后出现疼痛，持续2个月后自行缓解外，无其他并发症。无复发结核感染出现。结论一期行前路病灶清除、自体肋骨椎间融合前路内固定术治疗胸椎结核，可有效矫正脊柱后凸畸形，重建脊柱稳定性，获得较好的临床效果。

One-stage anterior debridement, autogenous rib grafting and internal fixation for thoracic tuberculosis

Objective To assess the clinical efficacy of one-stage surgical management for thoracic tuberculosis by anterior radical debridement, decompression and autogenous rib grafts, and instrumentation. Methods In this retrospective study, 42 patients (25 male and 17 female; average age 47.7 years) with thoracic tuberculosis between June 2003 an May 2008 were evaluated, who underwent one-stage anterior radical debridement, decompression and autogenous rib grafts, and instrumentation. Kyphotic angle was measured to assess the severity of the thoracic tuberculosis. Neurologic outcome was evaluated using Frankel grade, infection activity using erythrocyte sedimentation rate (ESR) value and C-reactive protein (CRP) value, and pain using visual analog scale (VAS) score. Results The average follow-up period was 50.8 months (range, 24-85 months). A solid fusion was achieved in all cases. Of all 42 patients with preoperative kyphosis, the deformity was corrected from an average of 19.8° on admission to an average of 3.7° after surgery, and to an average of 4.6° at the final follow-up. No significant loss of deformity correction was noted in these patients. Three patients who had a spinal cord injury with only sensation present (Grade B) before surgery had improvement by 2 or 3 levels to Grade D or E at the final follow-up. Of the 9 patients with progressive neurologic deficits (Grade C) before surgery, 6 had complete recovery to Grade E and 3 had improvement by 1 level to Grade D. All 20 patients who had a Grade D recovered completely to normal (Grade E). The average VAS 2 score was 8.2 before operation, and decreased to 1.8. At the final follow-up, the average VAS score was 1.2. Only 2 patients had persistent pain for 2 months after surgery, and none of them needed analgesic drugs at the final follow-up. There was no other recurrence of the tuberculous infection. Conclusion The one-stage anterior autogenous rib grafts with rumentation is safe and effective method in the surgical management of thoracic tuberculosis.