脊柱结核的外科治疗与术后疗效评估

目的 采用一期病灶清除植骨、坚强内固定术治疗脊柱结核,术后对多项疗效指标进行观察和评估.方法 74例脊柱结核选自2003年10月至2006年10月手术的患者,其中有17例合并脊髓功能障碍,Frankel分级D级12例,C级5例.结核病灶位于颈椎12例、胸椎37例、腰椎25例.CT或MRI显示病灶有明显的死骨和脓肿,并有不同程度的后凸畸形.术前给予4周以上的抗结核化疗,术后动态观察结核中毒症状和脊髓功能的改善情况、畸形矫正和病灶愈合情况.结果 入院时红细胞沉降率平均为81.5 mm/1 h,C反应蛋白平均为41.6 mg/L,其中51例(68.9%)脊柱结核处于活动期.抗结核化疗4周后红细胞沉降率降至43.8 mm/1 h,C反应蛋白降至27.4 mg/L,结核中毒症状明显改善.术后第8～12周红细胞沉降率和CRP检测结果正常,结核症状及病椎疼痛消失.病椎植骨单节段融合时间平均4.3个月,双节段融合时间平均6.7个月,后凸畸形平均矫正74.9%,结核病灶治愈率为97.3%.术后12个月有3例患者仍扶拐行走(Frankel D级),其余患者脊髓功能恢复正常.结论 脊柱结核的外科治疗旨在彻底清除病灶和重建脊柱稳定性,进而提高治疗效果和缩短化疗时间.规范的抗结核化疗与充分的术前准备是手术成功和病灶治愈的重要保障.动态观察和全面评估疗效指标,对于判断手术疗效和病灶预后具有重要意义.

Surgical treatment of spinal tuberculosis and clinical outcome evaluation postoperatively

Objective To investigate the surgical treatment and clinical outcome evaluation postop- eratively of spinal tuberculosis in patients who underwent one-stage focus debridement, auto-bone grafting and internal fixation combined with anti-tuberculosis chemotherapy. Methods Seventy-four adult patients with spinal tuberculosis were diagnosed clinically, histologically and bacteriologically. Seventeen patients suffered neurological deficit, including 12 cases for Frankel D,5 cases for Frankel C. The tuberculosis focus were located either in cervical spine, thoracic spine or in lumbar spine. CT or MR shew obvious dad bone, cold abseess,and kyphosis deformity. Surgical procedures included anterior debridement and auto-bone grafting, one-stage anterior or posterior instrumentation. All patients underwent 10 to12 months chemothera- py before and after operation. Clinical effect, deformity correction and focus heeling were evaluated at fol- low-up period. Results The average ESR was 81.5 mm/1h,average CRP was 41.6 mg/L, and 51 patients have active spinal tuberculosis in this series before chemotherapy. After four weeks anti-tuberculosis chemotherapy, the average ESR decreased to 43.8 mm/1h,the average CRP decreased to 27.4 mg/L.Tuber- culosis symptoms and local pain relived in all patients, and ESR or CRP became normal two months postop- eratively. Average fusion times was about 4.3 months for one-segment and 6.7 months for two-segment,the deformity was corrected to mean 74.9%, and focus healing was achieved in 97.3% patients. There are 3 pa- tients walked with crutch, the others in this group walked normally 12 months postoperatively. Conclusions Surgical strategies of spinal tuberculosis are of radical focus debridement, neurological decompression, spinal stabilization, improving outcome and shortening chemotherapy course. Rational chemotherapy is essential for spinal tuberculosis treatment, and adequate preparation before surgery is precondition of success. The evalu- ation of outcome parameters is of significance in focus prognosis,