复治的脊柱结核外科治疗加短程化疗的临床研究

目的:探讨复治的脊柱结核外科治疗加短程化疗的临床疗效.方法:总结2005年3月至2008年3月外科治疗加短程化疗的46例复治脊柱结核,其中男29例,女17例;年龄27～61岁,平均43.7岁.46例脊柱结核病灶均处于活跃期,血沉和CRP水平均高于正常值.结核灶位于胸椎17例、胸腰段13例、腰骶椎16例;其中5例合并结核窦道,7例有下肢瘫痪.手术方法为Ⅰ期病灶清除、植骨融合与坚强内固定.根据围手术期抗结核疗效和药敏试验结果确定化疗方案,对于异烟肼(INH)、利副平(RFP)、吡嗪酰胺(PZA)等抗结核疗效敏感或结核杆菌培养阴性者,化疗持续9～12个月(3HRZ/6～9HRE方案).术后动态观察结核症状、化验指标和放射影像的变化.结果:术前化疗4～6周时46例患者结核症状均有不同程度改善,血沉和CRP平均值显著下降.术后2～3个月结核症状明显缓解,结核窦道消失,其中有37例血沉和CRP恢复正常水平.术后6～12个月X线片未见内固定松动或矫形丢失,7例合并下肢瘫痪者有6例恢复正常,有1例从C级改善至D级.本组有44例患者化疗9～12个月结核病灶治愈(3HRZ/6～9HRE方案),有2例(对RFP+INH耐药)化疗15个月治愈,化疗药物为力克肺疾、左氧氟沙星、乙胺丁醇和链霉素等.结论:复治的脊柱结核通过清除无血运病灶,能提高化疗效果和缩短化疗时间.

Clinical study of short-course chemotherapy combined with radical operation in retreating spinal tuberculosis

Objective: To investigate clinical outcome of short-course chemotherapy in retreating spinal tuberculosis after radical operation. Methods: Forty-six retreating patients with spinal tuberculosis were included in this series,29 males,17 females with the age from 27 to 61 years(average of 43.7 years). All patients were treated with radical operation and short-course anti-tuberculous chemotherapy from March 2005 to March 2008. The tuberculous focus located thoracic spine in 17 cases,thoracic-lumbar in 13 and lumbosacral vertebrae in 16 cases. Of them,5 cases had sinuses of tuberculosis and 7 cases had incomplete palsy in lower limbs(Frankel C-D). CT or MRI showed obvious sequestra,cold abscess within spinal focus. Surgical procedures including debridement,auto-bone grafting,and one-stage internal fixation,was performed at the 4 to 6 weeks after chemotherapy. Chemotherapy regimes were 3HRZ/6-9HRE in majority of patients. Clinical effect and focus healing were evaluated at follow-up period. Results: Tuberculous symptoms and local pain of vertebral volume were obvious in all patients before chemotherapy,with average ESR 65.3 mm/h and average CRP 37.4 mg/L. After 4-6 weeks chemotherapy,tuberculosis symptoms and vertebral pain improved in all patients,and the average ESR decreased to 38.3 mm/1h,the average CRP decreased to 17.2 mg/L. Two to three months after operation,tuberculous symptoms and local pain relived in all patients,ESR and CRP became normal in 37 cases. Six to twelve months after operation,bonegraft complex in each patient became stable and there were no instrument loosening or deformity correction loss. Six patients with incomplete palsy recovered and 1 case improved from Frankel C to D grade. Focus healing was achieved in 44 cases(95.7%) after short-course chemotherapy(3HRZ/6-9HRE),and there were no resurgence in 2 to 4 years follow-up period. Drug fast 2 cases for RFP+INH cured at the 15 months after chemotherapy. Conclusions: Removed tubercular focus for the treatment of retreating spinal tuberculosis can improve clinical effect and shorten chemotherapy course.