后路病灶清除植骨融合内固定手术治疗跳跃性脊柱结核的疗效分析

【摘要】 目的：总结跳跃性脊柱结核的临床特点,探讨一期后路病灶清除植骨融合内固定手术治疗跳跃性脊柱结核的疗效。方法：回顾性分析2016年7月~2022年5月我院手术治疗的31例跳跃性脊柱结核患者的临床资料,其中患者男18例,女13例,年龄49.5±27.5岁。其中2处病灶24例,3处病灶7例。对每例患者明确责任椎,确定手术病灶、融合节段、内固定方式,以制定个体化手术方案,随访29.7±14.7个月（15～85个月）。记录患者手术时间、术中出血量,并记录术中及术后并发症情况;术前和术后1个月、3个月、1年及末次随访的红细胞沉降（ESR）和C-反应蛋白（CRP）;术前及术后1周、1个月、3个月、1年及末次随访的疼痛视觉模拟评分（VAS）;术前及术后1周、末次随访时病灶后凸Cobb角;记录术前及末次随访时美国脊髓损伤协会（ASIA）分级;末次随访时采用Bridwell骨愈合标准分级以评估术后结核活动性、症状改善、畸形矫正及骨愈合。结果：31例患者中20例（65.4%）只有1处病灶出现临床症状,23例（74.2%）以疼痛为主诉入院,15例（48.4%）在病程中只有疼痛症状,而11例（35.5%）只有1处病灶出现疼痛症状,18例（58.1%）患者初诊时至少有1处病灶漏诊。所有患者手术顺利,手术时间280.0±52.2min（165～330min）,失血量567.7±332.0mL（150～1000mL）。术后出现脑脊液漏4例,切口感染3例,经对症处理后痊愈;所有结核病灶均治愈,未出现复发。术前及术后1个月、3个月、1年、末次随访时ESR为41.5±26.3mm/h、16.3±13.4mm/h、12.5±6.3mm/h、11.4±5.2mm/h、9.2±3.1mm/h;CRP为32.8±23.2mg/L、7.3±5.6mg/L、6.2±4.1mg/L、5.1±3.7mg/L、2.8±2.3mg/L;术前及术后1周、1个月、3个月、1年、末次随访时VAS评分为6.4±2.4分、2.4±1.7分、2.3±1.3分、1.6±0.9分、0.9±0.7分、0.4±0.3分。术后各个时间点CRP、ESR、VAS评分较术前均有显著改善（P＜0.05）。术前Cobb角25.7°±4.9°,术后1周15.4°±2.1°,末次随访时17.1°±2.3°,术后均较术前有统计学差异（P＜0.05）;10例存在术前神经功能损伤患者,末次随访时1例术前A级患者恢复至C级;4例术前B级患者1例恢复至C级,3例恢复至D级;5例术前C级患者2例恢复至D级,3例恢复至E级;术后6～12个月42处植骨病灶均获得骨融合,末次随访时34处病灶Bridwell Ⅰ级愈合,8处病灶Bridwell Ⅱ级融合。结论：对跳跃性脊柱结核患者,明确责任椎及各处病灶病变特点,一期后路病灶清除植骨融合内固定手术治疗安全且高效,能得到满意的疗效。     

经后路病灶清除RF矫形固定植骨治疗脊柱结核

目的　探讨治疗脊柱结核一期完成病灶清除、矫正脊柱后凸畸形、前后同时植骨融合的效果。方法　俯卧位 ,以病椎为中心作后正中切口 ,从病椎左右椎弓根骨膜下分离病灶 (在胸椎段 ,先切取左右肋骨后段 ) ,椎弓根短节段固定器 (RF系统 )矫正脊柱后凸畸形和椎体间高度 ,彻底清除结核病灶 ,前后同时植骨。结果　 15例患者结核病灶清除彻底 ,脊柱畸形矫正角由术前 18°～ 45°矫正到术后 3 4° ,椎体间高度由术前 62 6 %恢复到术后 98 2 % ,植骨块无移位。结论　该手术入路简捷 ,病灶清除彻底 ,畸形矫正满意 ,三柱固定植骨融合 ,后期脊柱稳定 ,缩短了卧床时间 ,减少了相应的并发症。     

一期前路病灶清除植骨内固定治疗脊柱结核

目的探讨经前路病灶清除植骨一期前路内固定术治疗脊柱结核的临床效果。方法对43例脊柱结核患者,行前路病灶彻底清除、椎间植骨、一期前路内固定术。结果脊柱结核复发2例（4.7%）,植骨不融合3例（7.0%）。植骨融合时间3～8个月。脊柱后凸畸形平均矫正70.2%±11.4%。11例截瘫患者神经功能Frankel分级术后恢复情况：术前A级3例术后恢复至B级1例、2例无恢复;B级5例恢复至C级1例、D级2例、E级1例、1例无恢复;C级3例恢复至D级1例、E级2例。结论经前路病灶清除植骨一期前路内固定术治疗脊柱结核能彻底清除结核病灶,充分减压,矫正脊柱后凸畸形,提高脊柱结核的治愈率。     

合并窦道形成的复发性复杂脊柱结核的复发原因分析和临床治疗

 目的 探讨合并窦道形成的复发性复杂脊柱结核的复发因素及临床治疗策略。方法 自1997年1月至2012年1月收治87例复杂性脊柱结核患者,对其中21例术后复发且合并窦道形成患者的相关资料进行回顾性分析。男12例,女9例;年龄22~58岁,平均38.8岁。其中15例患者结核菌培养及药敏试验提示耐药。术前排除窦道混合感染,根据脓肿的大小,一期窦道切除、病灶清除、内固定取出、前路植骨融合内固定术11例;一期病灶清除、内固定取出、植骨融合、后路植骨融合内固定术10例。结果 所有患者获得随访,平均29.7个月。术后16例获得治愈,5例再次复发,再次复发率为23.8%（5/21）,前路固定的复发率为18.2%（2/11）,后路固定的复发率为30%（3/10）。3例经保守治疗治愈,2例再次行病灶清除术后治愈。影像学检查提示术后6个月植骨融合15例,术后9个月植骨融合4例,术后12个月植骨融合2例。术后后凸畸形纠正至平均5.7°（2°~12°）。结论 复发性复杂脊柱结核合并窦道形成的临床治疗较为棘手,复发原因主要与耐药结核菌株的出现、病灶清除不彻底、脊柱稳定性重建失败、合并其他脏器结核有关。有效的化疗,彻底的病灶清除,脊柱稳定的重建是保证手术治疗成功的关键。     

一期前路病灶清除植骨内固定治疗胸腰椎结核临床观察

[目的] 探讨经前路病灶清除植骨一期前路/后路内固定术治疗胸腰椎结核的临床疗效.[方法] 对24例胸腰椎结核患者,经3～4周正规抗结核治疗,行前路病灶清除、椎间大块自体髂骨/肋骨植骨、一期前路/后路内固定术,术后继续抗结核治疗18～24个月.[结果] 1例脊柱结核复发(3%).23例植骨融合,植骨融合率为96.9%,植骨愈合时间 4～8个月(平均6个月).无窦道形成.脊柱后凸畸形平均矫正80%.[结论] 经前路病灶清除植骨一期前路/后路内固定术治疗胸腰椎结核能彻底清除结核病灶,对脊髓及神经根进行彻底减压,促进脊髓及神经功能恢复,矫正脊柱后凸畸形,同时一期建立和恢复脊柱的连续性和稳定性,促进脊柱植骨融合,提高脊柱结核的治愈率.     

前路Ⅰ期病灶清除、植骨、内固定治疗脊柱结核(附37例报告)

观察前路Ⅰ期病灶清除、植骨、内固定治疗脊柱结核的疗效。方法 :1996年 1月～ 2 0 0 2年 12月间采用该手术方法共治疗脊柱结核 37例。其中 :颈椎 3例 ,胸椎 5例 ,胸腰椎 17例 ,腰椎 12例 ;3例伴窦道形成 ;9例伴不同程度的脊髓和 (或 )神经根受压的症状 ;术前后凸成角 10°～ 72° ,平均 31°。结果 :平均随访 1.7年 ,优良率为 90 %,植骨融合率可达 95 %,后凸矫正角度 13°,术后无一例复发。结论 :前路彻底病灶清除、植骨、内固定治疗脊柱结核病灶清除彻底 ,有利于恢复脊柱的稳定性 ,提高骨融合率 ,可纠正及预防脊柱后凸畸形。     

两种术式治疗胸腰椎结核的疗效观察

目的　比较病灶清除术与前路病灶清除椎间植骨内固定术治疗胸腰椎结核的临床疗效。方法　全组 6 8例 ,平均年龄 37岁。病灶清除术组 33例 ,病灶清除植骨内固定术组 35例 ;其中胸椎结核 2 1例 ,胸腰段结核 18例 ,腰椎结核 2 9例。病灶清除术采用经胸、胸膜外或腹膜外入路 ,清除病灶后 ,骨缺损大于 5 mm者取髂骨植骨 ;小于 5 mm者不植骨。病灶清除植骨内固定术采用经胸或腹膜外入路 ,彻底清除病灶 ,髂骨或填塞自体肋骨粒的钛网椎间植骨融合 ,一期前路内固定。术后抗结核治疗 12～ 18个月。结果　平均随访 2 7个月。病灶清除术组中 5例术后结核局部复发 ,再次手术治疗。病灶清除植骨内固定术组无结核局部复发 ,脊柱后凸畸形改善 ,矫正角度 15°;无内固定器械断裂。结论　前路病灶清除植骨内固定术 ,可重建脊柱的稳定性 ,利于结核病灶的稳定与修复 ,减少结核复发 ,矫正后凸畸形 ,较病灶清除术能取得更好的临床疗效。     

腰骶椎结核治疗的方法选择(附65例分析)

[目的]探讨腰椎结核治疗的方法选择。[方法]回顾分析65例腰椎结核患者采用五种不同治疗方法的疗效：A组（14例）单纯病灶清除术;B组（15例）病灶清除并植骨融合术;C组（9例）后路病灶清除植骨融合＋内固定术;D组（12例）后路内固定＋前路病灶清除植骨融合术;E组（15例）前路病灶清除植骨融合＋前路内固定术。术前、术后常规支持和抗结核治疗,并定期随访,观察血沉变化,摄X线平片,CT三维重建评估结核活动、骨块融合和畸形矫正情况。[结果]65例腰椎结核患者术中无大血管、神经、输尿管损伤,随访12～16个月,平均13个月,结核病变无复发,植骨全部融合,愈合时间4～6个月,平均3.8个月。后凸畸形矫正角度无明显丢失,内固定无松动、断裂等并发症。[结论]有效的抗痨是治疗结核的前提,彻底清除病灶是治疗的关键,融合、内固定与否,根据结核破坏的程度、部位而定,合理的选择能提高腰椎结核的治疗效果。     

脊柱结核病灶清除单节段植骨融合内固定的适应证及疗效

【摘要】 目的：探讨病灶清除单节段植骨融合内固定治疗脊柱结核的适应证及疗效。方法：2003年6月～2009年6月共收治单运动节段脊柱结核患者41例,术前常规抗痨2～4周后行病灶清除、单节段植骨融合、器械内固定术,术后应用超短程化疗方案。随访观察患者的后凸Cobb角、血沉（ESR）及C-反应蛋白（CRP）的变化情况,结合植骨融合、Frankel分级进行综合评价。结果：随访12～78个月,平均29.2个月。术前、术后、末次随访时后凸Cobb角分别为21.7°±9.8°、9.5°±8.4°和11.3°±9.1°     

脊柱结核彻底病灶清除术后3～4.5个月超短程化疗方案的疗效观察

目的 :观察彻底病灶清除术后3~4.5个月超短程化疗方案治疗脊柱结核的疗效,探讨脊柱结核彻底病灶清除术后3~4.5个月的超短程化疗方案的可行性。方法:2003年12月~2014年12月116例彻底病灶清除术后应用3~4.5个月化疗方案治疗的脊柱结核患者,其中男60例,女56例,年龄40.98±17.09岁(3~78岁)。低热31例,盗汗47例,乏力53例,病变节段局部疼痛113例,脓肿78例,纳差、消瘦43例,神经功能障碍38例;胸腰椎后凸畸形33例,术前Cobb角28.46°±7.19°(19°~42°);病灶部位:颈椎1例,颈胸段1例,胸椎39例,胸腰段17例,腰椎48例,腰骶段9例,骶椎1例;累及单节段87例,双节段19例,3节段及以上10例。术前SHRZ四联抗结核治疗2~4周(平均3.2周)。手术均以彻底病灶清除为基础,其中前路手术37例,后前路手术70例,后路手术9例。术后化疗方案为2SHRZ/1~2.5HRZ,化疗期间全程督导化疗。术后观察临床表现、神经功能Frankel分级、病灶清除情况、植骨融合及病灶治愈情况、畸形矫正情况、血沉(ESR)、C反应蛋白(CRP)、药物不良反应情况。停药指征:(1)无脊柱结核的症状、体征,无脓肿及窦道形成;(2)ESR、CRP正常;(3)B超检查未发现与脊柱结核相关的脓肿;(4)影像学检查示病灶全部治愈,无新发病灶,植骨融合。结果:116例患者术后化疗时间3~4.5个月(3.89±0.60个月)。随访时间2~3年20例,3~5年15例,5~13年81例。停药时,116例患者无结核中毒症状,无局部疼痛及脓肿、窦道,生活及工作能力恢复,ESR、CRP均降至正常,病灶均彻底清除,植骨融合,病灶治愈。1例L4椎体结核患者术后服药4个月后治愈,于停药后6年复发,再次行前路彻底病灶清除髂骨植骨术,术后抗结核治疗24个月后治愈。33例胸腰椎后凸畸形的术后Cobb角为15.30°±5.13°(3°~25°),末次随访时为18.63°±6.06°(10°~36°),矫正率为46.2%,丢失率为11.8%,畸形矫正满意。末次随访时,神经功能Frankel分级较术前明显恢复,A级1例恢复至C级,B级1例恢复至D级,C级8例恢复至D级1例、E级7例,D级28例恢复至E级。17例出现术后化疗相关并发症。结论:在彻底病灶清除的基础上,严格把握适应证,全程督导化疗,脊柱结核术后3~4.5个月的超短程化疗方案是可行的。     

Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation

Background contextTraditional focal debridement involves clearing of cold abscesses, caseous necrosis, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Reports have demonstrated that approximately 13% to 26% of patients were not better or relapsed after traditional focal debridement; these patients required a second surgery or prolonged antituberculous therapy. The presence of retained and diseased focal tissues requiring removal remains poorly understood. The contents of these retained tuberculous foci, improvement of surgical strategies, and improvement in spinal tuberculosis success rate are key subjects for discussion.PurposeTo explain the contents of foci and explore the surgical methods and curative effect of complete debridement.Study designRetrospective study of the curative effect of treatment of thoracolumbar spinal tuberculosis by using complete debridement.Patient sampleA total of 289 patients were included.Outcome measurementThe outcomes were evaluated clinically by Frankel grading. The status of the anterior fusion was assessed according to the Moon standard. Eradication of infection was determined by the level of C-reactive protein and erythrocyte sedimentation rate. X-ray, computed tomography, and magnetic resonance imaging were used to evaluate disease localization and morphology.MethodsA total of 289 patients with spinal tuberculosis (150 male and 139 female patients, aged 18–82; average age, 41.0±1.4 years) were included in this study. Damage to the vertebrae was as follows: 86 patients had thoracic damage, 49 had thoracolumbar damage, 125 had lumbar damage, and 47 had lumbosacral segment damage. After 2 to 4 weeks of antituberculous therapy, all patients underwent anterior debridement, deformity correction, graft fusion, and internal fixation. In this study, complete debridement was defined as the clearing of any damage or disease, including psoas abscesses, granulomas, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Tuberculosis cavities, sclerotic walls, and bony bridges that had no support and that were eroded by the foci were also removed. A total of 108 patients underwent anterior fixation with the Zephir system (Medtronic Sofamor-Danek, Minneapolis, MN, USA), Z plates (Medtronic Sofamor-Danek), or Ventrifix (China Great Wall Corporation, Beijing, China). A total of 181 patients underwent fixation, posterior correction, and one or two second anterior debridements and graft fusions. Posterior fixation, including TSRH (Medtronic Sofamor-Danek), Cotrell-Dubousset (Medtronic Sofamor-Danek), General Spinal System (WeiGao Orthopaedic Devices Company, Weihai City, China), or UPASS (WeiGao Orthopaedic Devices Company), was performed. All patients underwent structural bone grafting, including autologous iliac bone (251 patients), titanium mesh (32 patients), and rib (6 patients).ResultsThe 289 patients were followed for 72.0±2.8 months, with 265 patients (91.69%) completely treated and 24 incompletely treated, including 3 who suspended chemotherapy because of liver or renal failure. Twenty-one patients (7.27%) failed to have a complete debridement, including 16 with incomplete bone debridement, 6 of whom underwent a second surgery, and 10 who received conservative therapy; 5 of this group had incomplete abscess debridement, 3 underwent a second surgery, and 2 received puncture aspiration of abscess under computed tomographic guidance; the second surgery rate was 3.81%. Twenty-two patients had surgery complications, including three with graft displacement, five with wound infection and fat liquefaction, four with pleural effusion, six with pain at the graft harvesting site, and four with incisional hernia. Bone graft healing was observed 4.3±1.2 months after surgery. The Cobb angle before and after surgery and at the final follow-up was 22.16±11.51°, 8.11±4.83°, and 9.96±3.49°, respectively, with a mean correction of 63.40% after surgery; however, a 1.85±1.34° loss was observed at the final follow-up with loss rate of 8.35%.ConclusionsSclerotic bone, multiple cavities, and bony bridges are foci in spinal tuberculosis. Clearing tuberculous foci, sclerotic bone, multiple cavities, and bony bridges to increase the curative effect is an effective treatment method.     

One-stage anterior debridement,bone grafting and posterior instrumentation vs. single posterior debridement,bone grafting,and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis

Purpose

The aim of this study was to compare single posterior debridement, interbody fusion and instrumentation with one-stage anterior debridement, interbody fusion and posterior instrumentation for treating thoracic and lumbar spinal tuberculosis.

Method

From January 2006 to January 2010, we enrolled 115 spinal tuberculosis patients with obvious surgical indications. Overall, 55 patients had vertebral body destruction, accompanied by a flow injection abscess or a unilateral abscess volume greater than 500 ml. The patients underwent one-staged anterior debridement, bone grafting and posterior instrumentation (group A) or single posterior debridement, bone grafting and instrumentation (group B). Clinical and radiographic results for the two groups were analyzed and compared.

Results

Patients were followed 12–36 months (mean 21.3 months), Fusion occurred at 4–12 months (mean 7.8 months). There were significant differences between groups regarding the post-operative kyphosis angle, angle correction and angle correction rate, especially if pathology is present in thoracolumbar and lumbar regions. Operative complications affected five patients in group A, and one patient in group B. A unilateral psoas abscess was observed in three patients 12 months postoperatively. In one of them, interbody fusion did not occur, and there was fixation loosening and interbody absorption. All of them were cured by an anterior operation.

Conclusion

Anterior debridement and bone grafting with posterior instrumentation may not be the best choice for treating patients with spinal tuberculosis. Single posterior debridement/bone grafting/instrumentation for single-segment of thoracic or lumbar spine tuberculosis produced good clinical results, except in patients who had a psoas abscess.     

One-stage posterior debridement, transforaminal lumbar interbody fusion and instrumentation in treatment of lumbar spinal tuberculosis: a retrospective case series

Purpose

The purpose of this study is to compare the clinical outcomes of surgical management by one-stage posterior debridement, transforaminal lumbar interbody fusion (TLIF) and instrumentation and combined posterior and anterior approaches for lumbar spinal tuberculosis, and determine the clinical effectiveness of the posterior only surgical treatment for lumbar spinal TB at the same time.

Methods

Thirty-seven patients who suffered lumbar tuberculosis were treated by two different surgical procedures in our center from May 2004 to June 2012. All the cases were divided into two groups: 19 cases in Group A underwent one-stage posterior debridement, TLIF and instrumentation, and 18 cases in Group B underwent posterior instrumentation, anterior debridement and bone graft in a single-stage procedure. The operation time, blood loss, lumbar kyphotic angle, recovery of neurological function and fusion time were, respectively, compared between Group A and Group B.

Results

The average follow-up period for Group A was 46.6 ± 16.7 months, and for Group B, 47.5 ± 15.0 months. It was obvious that the average operative duration and blood loss of Group A was less than those of Group B. Lumbar tuberculosis was completely cured and the grafted bones were fused in 10 months in all patients. There was no persistence or recurrence of infection and no differences in the radiological results in both groups. The kyphosis was significantly corrected after surgical management. The average pretreatment ESR was 60.7 ± 22.5 mm/h, which became normal (9.0 ± 2.8 mm/h) within 3 months in all patients.

Conclusions

Surgical management by one-stage posterior debridement, TLIF and instrumentation for lumbar tuberculosis is feasible and effective. This approach obtained better clinical outcomes than combined posterior and anterior surgeries.     

Surgical treatment of thoracic spinal tuberculosis with adjacent segments lesion via one-stage transpedicular debridement, posterior instrumentation and combined interbody and posterior fusion, a clinical study

Purpose

To investigate the clinical efficacy and feasibility of one-stage surgical treatment for thoracic spinal tuberculosis with adjacent segments lesion by internal fixation, transpedicular debridement, and combined interbody and posterior fusion via a posterior-only approach.

Materials and methods

Twenty-one patients (thirteen males, eight females) with thoracic tuberculosis whose lesions were confined to two adjacent segments were studied retrospectively. All patients were treated with one-stage surgical treatment by internal fixation, transpedicular debridement, and combined interbody and posterior fusion via a posterior-only approach. The American Spinal Injury Association (ASIA) impairment scale was used to assess neurological function. Thoracic Cobb angle was used to assess thoracic kyphosis. Operating time, blood loss, complications, neurological function, deformity correction and interbody fusion were investigated.

Results

Average mean operating time was 231.4 ± 31.9 min, and evaluated blood loss during operation was 880.2 ± 112.7 ml. All patients were followed up for 22–41 months postoperatively (average 29.8 ± 5.4 months). All patients had significant postoperative improvement in ASIA classification scores. The thoracic kyphotic angles were significantly decreased to 9°–25° postoperatively (average 16.7° ± 4.4°), and at final follow-up were 10°–27°(average 17.7° ± 4.4°). No severe complications or spinal cord injury occurred. The erythrocyte sedimentation rate recovered to normal within 3 months postoperatively in all patients. All patients got bony fusion within 6–9 months after surgery.

Conclusions

One-stage transpedicular debridement, posterior instrumentation and combined interbody and posterior fusion via a posterior-only approach can be an effective and feasible treatment method for thoracic spinal tuberculosis.     

Clinical evaluation of the stability of single-segment short pedicle screw fixation for the reconstruction of lumbar and sacral tuberculosis lesions

Introduction

The routine surgical approach to posterior reconstruction in spinal tuberculosis is short- or long-segment fixation and/or fusion. This method sacrifices movement at more than one vertebral level, limits normal movement of the spinal column, and leads to degeneration of the small joints of the adjacent levels. Surgical techniques that reduce the number of fixed vertebral levels and maximize the retention of movement of the spinal column are of current interest in the treatment of spinal tuberculosis.

Materials and methods

A total of 106 patients with lumbosacral tuberculosis were randomly divided into two groups: a single-segment fixation group and a short-segment fixation group. After posterior correction and internal fixation, all patients underwent anterior radical debridement and interbody fusion with bone grafting.

Results

The mean postoperative follow-up period was 58.09?±?17.01?months. The average bone graft healing time was 4.35?±?1.04?months in the single-segment group and 4.47?±?1.10?months in the short-segment group. In the single-segment group, correction of the Cobb angle was 14.47?±?3.76° and the loss rate was 7.22?%, and in the short-segment group, correction of the Cobb angle was 16.20?±?2.70° and the loss rate was 6.37?% (P?P?Conclusions Single-segment pedicle screw fixation and correction surgery can fix and fuse the diseased segment in lumbar and sacral tuberculosis, retain normal movement in the adjacent spinal column, and promote functional recovery of the spinal column postoperatively. It was be regarded as a cost-effective means of treatment with lumbar and sacral tuberculosis.     

后路经皮内固定联合前路病灶清除植骨融合术治疗胸腰椎结核

目的探讨后路经皮内固定联合前路病灶清除植骨融合术治疗胸腰椎结核的临床疗效。方法回顾性分析2014年9月-2017年1月收治的40例胸腰椎结核患者资料,其中15例接受后路经皮内固定联合前路病灶清除植骨融合术治疗(A组),25例接受传统后路椎弓根螺钉内固定联合前路病灶清除植骨融合术治疗(B组)。记录并比较2组手术时间、出血量、术后引流量、疼痛视觉模拟量表(VAS)评分、Oswestry功能障碍指数(ODI)、美国脊髓损伤协会(ASIA)分级、后凸Cobb角矫正情况、植骨融合情况及术后并发症等指标。结果所有手术顺利完成,所有患者随访12~30(15.3±3.2)个月;末次随访时所有患者均获得骨性融合。A组出血量及术后引流量均少于B组,术后早期VAS评分和ODI优于B组,差异均有统计学意义(P<0.05)。6例脊髓功能障碍患者术后ASIA分级获得改善。2组各有1例患者术后出现伤口感染(均为前路切口处)。2组术后3 d及末次随访时Cobb角差异无统计学意义(P>0.05);末次随访时Cobb角丢失角度及矫正率差异无统计学意义(P>0.05)。结论后路经皮内固定联合前路病灶清除植骨融合术治疗胸腰段脊柱结核安全、有效,具有出血少、创伤小等优势。     

Surgical management by one-stage posterior transforaminal lumbar debridement, interbody fusion, and posterior instrumentation for lumbo-sacral tuberculosis in the aged

Purpose

To evaluate the clinical study efficacy and feasibility of 17 aged patients with lumbo-sacral tuberculosis treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, and posterior instrumentation.

Methods

17 aged patients who suffered from lumbo-sacral tuberculosis were admitted into our hospital between March 2003 and October 2010. All of them were treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, and posterior instrumentation. Then the clinical efficacy with statistical analysis was evaluated based on the materials on the lumbo-sacral angle, neurological status that was recorded by Frankel grade system, and erythrocyte sedimentation rate (ESR), which were collected at certain time.

Results

The average follow-up period was 47.5?±?17.1?months (17?C71?months), In the 17 cases, no postoperative complications related to instrumentation occurred and neurologic function was improved in various degrees. The mean preoperative lumbo-sacral angle was 20.5°?±?1.7° (range 18.0°?C23.0°). The lumbo-sacral angle became 29.1°?±?1.5° (range 26.4°?C31.0°) postoperatively. The average pretreatment ESR was 57.4?±?16.8?mm/h (33?C95?mm/h), which got normal (9.2?±?3.1?mm/h) within 3?months in all patients. All patients got bony fusion within 6?C8?months after surgery.

Conclusions

One-stage posterior transforaminal lumbar debridement, interbody fusion, and posterior instrumentation can be an effective treatment method for the treatment of lumbo-sacral tuberculosis in the aged patients.     

Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage

Purpose

Retrospective analysis of the clinical efficacy and feasibility of patients with thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.

Method

A total of 18 patients with thoracolumbar tuberculosis (TB), between February 2007 and February 2011, underwent one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. And the clinical efficacy was evaluated based on surgery duration time, the blood loss, the postural drainage of time, neurological status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, the fate of bone graft fusion, kyphosis angle, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at certain time.

Results

The average follow-up period was 34 months (range 18–48 months). 18 patients suffered from seriously neurological deficits pre-operatively, of which 16 patients returned to normal at final follow-up. The surgery duration time was 197 ± 37.9 min, and the blood loss was 815 ± 348.5 ml. The postural drainage of time was 7.2 ± 2.7 days. The psoas abscesses disappeared in all cases, within the time range of 6–9 months (mean 7.4 ± 1.2 months). All patients of the grafted bones were thoroughly fused, with a fusion time ranging from 4 to 12 months (mean 7.8 months). Kyphosis angle was 44.32 ± 7.26° on average pre-operative and returned to 11.72 ± 2.85° at 6 weeks after operation; kyphosis angle was 13.10 ± 2.39° at final follow-up. The values of ESR and CRP were significant declined at 6 weeks post-operative, and returned to normal levels at final follow-up.

Conclusion

With standardized anti-TB chemotherapy, thoracolumbar spinal tuberculosis with psoas abscesses could be effectively treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.     

胸腰段脊柱结核伴截瘫的外科治疗

目的：探讨Ⅰ期前路病灶清除植骨融合内固定治疗胸腰段脊柱结核伴瘫痪患者的手术时机、手术指征及临床疗效。方法：对2006年3月至2008年9月应用Ⅰ期标准前路手术（经胸腹入路病灶清除、钛笼支撑、自体骨植骨、钉板或钉棒内固定）治疗的56例胸腰段结核伴截瘫患者的临床资料进行回顾性分析,其中男36例,女20例,年龄19～78岁,平均42.5岁。病程3个月～4年。病变节段为T11-L2,累及椎体数目：1个椎体6例,2个椎体42例,3个椎体7例,4个椎体1例。所有患者均有不同程度的截瘫表现,Frankel分级：A级5例,B级25例,C级21例,D级5例。术前Cobb角小于30°者30例,30°～60°者24例,大于60°者2例,平均（35.0±3.3）°。术前疼痛视觉模拟评分（VAS）为7.3±2.1。所有病例术前均进行强化化疗,时间2～3周。术后通过观察Cobb角、VAS评分、Frankel分级、骨性融合情况对疗效进行评定。结果：术后随访12～38个月,平均24个月。伤口均Ⅰ期愈合,术后即刻Cobb角（19.0±5.5）°,随访时丢失（1.8±0.7）°,术后VAS评分为1.4±0.3,末次随访时1.3±0.4。术后Cobb角、VAS评分与术前比较,差异均有统计学意义（P〈0.05）,术后与末次随访时比较无明显差异（P〉0.05）。随访1年时56例患者均获骨性融合。51例不完全性截瘫患者,经过术后1～1.5年标准化疗方案化疗及神经功能锻炼,Frankel分级全部恢复到D级以上,5例完全截瘫患者有3例恢复至C级以上,2例恢复至B级。结论：胸腰段结核伴截瘫在抗结核药物治疗的基础上,根据引起截瘫原因、部位及全身情况的不同,选择不同的手术时机,行Ⅰ期前路彻底病灶清除,椎体间自体骨植骨、内固定,能有效的解除脊髓压迫,稳定脊柱,减少脊柱后凸畸形,促进截瘫恢复。     

一期后路病灶清除植骨融合内固定治疗胸腰椎结核

目的：探讨一期后路病灶清除植骨融合内固定治疗胸腰椎结核的临床疗效。方法回顾性分析2010年1月～2012年6月本院采用一期后路病灶清除植骨融合内固定治疗的28例胸腰椎结核患者的临床资料,对比研究患者手术前后患椎后凸Cobb角、红细胞沉降率（ erythrocyte sedimentation rate, ESR）、C 反应蛋白（ C-reaction protein, CRP）、植骨融合及美国脊髓损伤协会（ American Spinal Injury Association, ASIA）分级变化情况。结果28例获得随访,平均随访1．2年,术后Cobb角无明显丢失,后凸畸形平均纠正4．12°,平均矫正率24．5％。末次随访ESR、CRP恢复正常,植骨大部分骨性融合,融合时间平均为7．8个月,原有症状大部分消失,神经功能均有不同程度恢复。结论一期后路病灶清除植骨融合内固定治疗胸腰椎结核可有效完成病灶清除、减压、矫正后凸畸形、恢复生理曲度和重建脊柱稳定性,效果满意。