脊柱结核内固定术后复发探讨（附23例报告）

目的 探讨脊柱结核内固定术后复发原因及处理方法。方法 回顾性分析23例脊柱结核内固定术患者的发病及治疗经过以及复发后的表现和再治疗经过。重新调整抗结核药物治疗，并且用药时间为18～30个月；19例行手术病灶清除术及重新植骨，其中2例内固定物取出1例重新行内固定手术；4例单纯行瘘管清创换药。结果 23例患者19例治愈，术后安置病灶引流管相应延长到3-14天；2例耐药术后又瘘管形成，经局部换药及调整结核药物治疗，2年后痊愈，平均用药时间增加6～12个月；2例内固定取出后绝对卧床6～8个月。结论 脊柱结核内固定术后复发是严重的并发症，它影响结核的治疗和预后以及结核的播散问题；规范抗结核治疗和正确的手术时机和方法的选择应引起高度重视；及时调整抗结核药物治疗及瘘管换药和局部结核病灶的进一步清除是治愈结核复发的关键；内固定物取出不是治愈结核的关键条件。     

超声引导下穿刺抽脓及注药治疗寒性脓肿12例

肺外结核中的浅表淋巴结结核、脊柱结核、关节结核，胸壁结核均可在体表形成寒性脓肿。较大寒性脓肿可引起局部疼痛，合并感染者疼痛加重，局部有明显红肿，全身中毒症状重，且脓肿易穿破形成结核性脓胸、肿脓食道或支气管瘘等严重并发症。较大的寒性脓肿及其病灶多需手术治疗，积极行寒性脓肿穿刺抽脓及注药可改善肺外结核的预后.[第一段]     

超声引导下穿刺抽脓及注药治疗寒性脓肿12例

肺外结核中的浅表淋巴结结核、脊柱结核、关节结核,胸壁结核均可在体表形成寒性脓肿。较大寒性脓肿可引起局部疼痛,合并感染者疼痛加重,局部有明显红肿,全身中毒症状重,且脓肿易穿破形成结核性脓胸、肿脓食道或支气管瘘等严重并发症。较大的寒性脓肿及其病灶多需手术治疗,积极行寒性脓肿穿刺抽脓及注药可改善肺外结核的预后,为外科处理创造条件。我院于2001年7月—2004年11月共收治寒性脓肿患者12例,均进行了抽脓及注药,收到了良好的效果。现报告如下。     

手术治疗脊柱结核36例分析

目的观察手术治疗脊柱结核的疗效。方法治疗脊柱结核36例,其中颈椎4例、胸椎13例、腰椎19例。均采用病灶清除椎间植骨融合内固定术。术后继续抗痨治疗12～16个月。结果术后随访1—5a,切口均一期愈合,椎间植骨融合好,脊柱结核无复发。结论采用病灶清除椎间植骨融合内固定术治疗脊柱结核,病变组织清除彻底,脊柱稳定性好,结核不易复发。     

经典病灶清除手术治疗复杂复合性脊柱结核104例临床分析

目的 探讨用经典病灶清除术治疗复杂复合性脊柱结核的外科围手术期处理及手术方法和手术时机的选择,以减少此类患者的手术并发症。 方法 回顾性分析104例复杂复合性脊柱结核患者,对其临床特点进行分析,采用经典病灶清除手术,对手术效果进行临床分析。 结果 104例患者无死亡及心、肺、肝、肾等器官的严重并发症。104例患者中90例是第一次手术,术后切口1期愈合82例,1期愈合率91.1%（82/90）,余8例经换药引流愈合,未在同一侧进行第二次手术。外院（指第三家医院）转来的14例患者中,分别在对侧行病灶清除,原刀口行窦道切除术后治愈。所有患者术后3个月复查血红细胞沉降率均恢复正常,X线检查显示：椎体呈骨性融合者65例,纤维融合者39例。随访2年,所有患者均无复发,X线复查显示椎体均呈骨性融合,达到临床治愈。 结论 谨慎对待复杂复合性脊柱结核患者的外科治疗手术时机和手术技巧,在抗结核药物治疗基础上,采用经典病灶清除手术治疗复杂复合性脊柱结核可以取得满意疗效。     

微创手术治疗胸椎结核60例疗效分析

目的 评价微创手术治疗胸椎结核的临床效果.方法 对60例胸椎结核患者采用腋下小切口技术进行胸椎结核前路病灶清除、植骨融合及内固定术,评价其疗效.结果 60例患者手术均成功,术后无并发症,术后神经功能获1～3级改善.结论 腋下小切口技术治疗胸椎结核效果确切,且较为安全.     

老年人脊柱结核术后复发的危险因素

目的探讨老年人脊柱结核术后复发的危险因素。方法回顾性分析2002²011年收治的老年脊柱结核术后复发和无复发患者共287例的临床资料,对脊柱结核术后复发的可能危险因素采用Logistic回归模型进行单因素和多因素分析。结果其中脊柱结核术后复发患者69例,单因素分析结果表明,年龄、血白蛋白水平、首次手术方式、化疗方案、病灶清除情况、术后病灶部位是否严格制动与术后复发有关。Logistic回归模型多因素分析显示病灶清除情况、化疗方案、血白蛋白水平、术后病灶部位是否严格制动是脊柱结核术后复发最重要的影响因素。结论脊柱结核手术治疗难度大,术前应详细分析病情,加强营养支持治疗,强调标准化的药物治疗和手术治疗及术后病灶部位严格制动。     

一期病灶清除植骨内固定术治疗脊柱结核83例体会

脊柱结核手术治疗从早期的单纯脓肿引流、病灶清除逐渐发展到植骨融合、内固定,脊柱稳定的重要性越来越受重视。2000年1月-2009年10月,我院行一期病灶清除内固定植骨手术治疗脊柱结核83例。现报告如下。     

局部病灶清除置管冲洗引流术治疗胸腰椎结核患者术后脓肿并发症的疗效分析

目的 探讨局部病灶清除置管冲洗引流术治疗胸腰椎结核患者术后脓肿并发症的疗效及应用价值。方法 回顾性分析2014年1月至2017年12月期间,河北省胸科医院骨科收治的术后早期未愈胸腰椎结核患者41例,男25例,女16例。其中,胸椎13例、腰椎28例,并发腰大肌脓肿23例、椎旁脓肿41例、窦道18例、皮下脓肿26例。所有患者均行局部脓肿切开病灶清除联合置管冲洗引流术,术中切开脓肿清除病灶组织后置管引流,局部置管冲洗引流术术后持续冲洗时间6~23d;定期随访,观察切口愈合、脓肿、血红细胞沉降率(ESR)、C反应蛋白(CRP)、视觉模拟量表(VAS)评分、植骨融合情况及临床症状改善情况。结果 41例患者局部病灶清除置管冲洗引流术时间20~45min,平均(30.0±13.2)min;出血量20~100ml,平均(40.0±16.3)ml,未出现重要脊髓、血管、神经损伤。术后1例拔除引流管后再次出现窦道,给予换药+引流后,愈合良好,其余切口均一期愈合,未出现切口延迟愈合及窦道;拔除引流管后无椎旁脓肿及腰大肌脓肿、皮下脓肿发生。术后3周ESR为(24.32±9.34)mm/1h,术前ESR为(40.46±19.75)mm/1h,差异有统计学意义(t=8.43, P<0.05);术后3周CRP为(13.41±6.20)mg/L,术前CRP为(20.56±10.00)mg/L,差异有统计学意义(t=7.91,P<0.05);患者术后3周VAS平均为(1.93±1.27)分,与术前的(6.68±1.95)分比较,差异有统计学意义(t=16.79,P<0.05)。所有患者均在术后6~12个月达到骨性融合。结论 局部病灶清除置管冲洗引流术对有适应证的脊柱结核术后出现脓肿的患者可以起到及时病灶清除、充分引流的效果,减少脓液的发生及病灶的进展,是治疗脊柱结核术后并发脓肿的有效方法之一。     

脊柱结核早期误用激素治疗107例分析

目的 探讨糖皮质激素的应用对脊柱结核发展及治疗影响。方法 回顾性分析我院收治的107例脊柱结核患者早期误用糖皮质激素与同期215例未用激素治疗的脊柱结核患者比较其症状、体征、治疗的结果及预后。结果 脊柱结核患者早期误用激素，造成患者发热重、脓肿大，病变部位多发及骨破坏加重，同时需延长用药时间、加大药量，术后并发症多及治愈时间延长。结论 脊柱结核患者应用糖皮质激素促使结核病情加重，影响治疗效果和预后。     

Psoas abscess: Changing patterns of diagnosis and etiology

From 1976 to 1984, 43 patients with psoas abscess were seen at the Mayo Clinic. Intestinal disease, including Crohn's disease, diverticulitis, and carcinoma, was the most frequent cause (14 patients). Eleven patients had osteomyelitis, five had postoperative complications, four had a foreign-body reaction, and three had a primary staphylococcal abscess. Two patients each had extension of a primary pancreatic and perinephric abscess. One patient had tuberculosis of the spine, and in the remaining patient, an exact cause was not determined. Definied treatment of psoas abscess includes adequate debridement, drainage of the abscess cavity, and resection of involved bowel. Read in part at the XIth Biennial Congress of the International Society of Colon and Rectal Surgeons, Dallas, Texas, May 4 to 8, 1986.     

Pyogenic psoas abscess on the dorsal side,and bacterial meningitis and spinal epidural abscess on the ventral side,both of which were induced by spontaneous discitis in a patient with diabetes mellitus: A case report

Type 2 diabetes mellitus patients are immunocompromised, particularly under poorly controlled conditions, and thereby they could develop rare inflammatory diseases, such as spontaneous discitis, pyogenic psoas abscess, spinal epidural abscess and bacterial meningitis. Herein we report a pyogenic psoas abscess on the dorsal side, and bacterial meningitis and spinal epidural abscess on the ventral side, both of which were induced by spontaneous discitis in a patient with poorly controlled type 2 diabetes mellitus. This case was very rare and interesting, because we successfully treated various infections with antibiotics over a long period of time, complicated by hyperglycemic crises, although the patient suffered severe bone destruction and required rehabilitation for a long time.     

Psoas Abscess in Inflammatory Bowel Disease

The inflammatory bowel disease (IBD) is sometimes complicated by the development of a psoas abscess. We recently encountered three patients of IBD with psoas abscess. Two patients had Crohn's ileocolitis and one with ulcerative colitis. During 1979-1984, 23 patients with psoas abscess due to a variety of underlying disease processes were seen at our institution. At the same time period, 483 cases of Crohn's disease and 283 cases of ulcerative colitis were encountered. Therefore, of 766 patients with IBD only three were complicated by psoas abscess (incidence ratio = 0.6%). Thus, psoas abscess was a very rare complication of IBD in patients seen at our institution. In our series of 23 psoas abscess patients, IBD was not a major causative factor. Additionally, to our knowledge, psoas abscess complicating ulcerative colitis has not been reported previously.     

Psoas abscess and bacterial peritonitis caused by urinary tract infection in a patient of liver cirrhosis and diabetes mellitus

Prognosis of patients with diabetes mellitus or liver cirrhosis can be worsened by the development of a variety of infectious diseases. We describe a case of psoas abscess and bacterial peritonitis in a 58-year-old woman with type C liver cirrhosis and diabetes mellitus hospitalized after having an elevated temperature caused by urinary tract infection for 2 months. The cirrhosis had not been treated and daily self-administration of insulin had been discontinued for the previous 5 months. On day 2 of hospitalization, vomiting and decreased blood pressure developed. Abdominal computed tomography scan revealed ascites, pneumoperitoneum, and psoas abscess. Laparotomy revealed psoas abscess and bacterial peritonitis without gastrointestinal perforation and psoas abscess perforation. Surgical drainage of the abscess and peritoneal cavity was performed. Immediately after the operation, upper gastrointestinal bleeding, shock, hypoglycemia, and metabolic acidosis developed, followed by hepatic failure, renal insufficiency, and cerebral dysfunction. Death occurred on postoperative day 19. Upon autopsy, bacterial peritonitis residue of psoas abscess, and urinary tract infection were confirmed. We surmise that untreated liver cirrhosis and diabetes mellitus is a risk for urinary tract infection that may spread in iliopsoas and free peritoneal space.     

Psoas abscess caused by nephrolithiasis with perirenal abscess complicated with pleural effusion]

Left pleural effusion was found in a 60-year-old woman in whom chest radiography performed during a physical check up revealed no abnormality. Abdominal CT scanning revealed an abscess in the left psoas muscle. The psoas abscess was eliminated temporarily by drainage under ultrasonographic guidance and by the administration of antibiotics, but recurred one month later. A stag-horn renal stone considered to have caused the psoas abscess by formation of a perirenal abscess was eliminated by left nephrectomy. It is suggested tentatively that the psoas abscess might have been the cause of the pleural effusion.     

脊柱结核合并截瘫再手术分析（附32例报告）

目的探讨脊柱结核合并截瘫手术失败的原因及再次手术方法。方法回顾性分析1993-2004年收治的手术治疗失败的脊柱结核合并截瘫病例，其中男18例，女14例；颈胸椎3例，胸椎19例，胸腰椎10例。累及椎体数1-8个，平均4．5个；第一次术前抗结核药物治疗时间0-9个月不等；由前路开胸减压手术17例。肋骨横突切除侧后方减压15例：术后22例给予抗结核治疗。其中术后16例病人截瘫有所改善（短期改善9例，3个月改善3例，6个月改善4例）。17例截瘫没有改善；2例损伤脊髓截瘫加重；另术后合并瘘管形成6例，继发肺结核1例，结核性脑膜炎1例，脊髓本身结核1例。全身结核瘫状明显伴有高热4例。结果23例选择前路开胸病清减压手术。同时给予植骨，其中9侧行钛板内固定：5例行侧后方经胸廓胸膜外减压术，2例行单纯瘘管搔刮病灶清除术，术后继续抗结核治疗。其中22倒截瘫完全恢复，6例部分恢复；另脊柱结核完全治愈。结论脊柱结核合并截瘫治疗失败的原因为：抗结核治疗不合理；合并它处结核：多椎体结核；手术时机、手术方式选择不合理；手术减压范围不够以及脊髓神经结核和脊髓受压变性等情况。成功的关键是：在有效的抗结核化疗基础上，严格掌握手术适应证，选择合理的手术时机和手术途径，彻底地减除病灶对脊髓的压迫。重建脊柱的稳定性。     

后路多裂肌微创入路长节段短钉固定术治疗多节段腰椎结核的疗效分析

目的 探讨前路病灶清除+取髂骨短节段植骨融合+后路经多裂肌微创入路长节段短钉内固定术在治疗多节段腰椎结核中的手术疗效。方法 选择2013年4月至2015年4月于陕西省结核病防治院行上述手术的17例多节段腰椎结核患者。采用手术前后及末次随访时的疼痛视觉模拟量表(VAS)和Oswestry 功能障碍指数(ODI)、后凸Cobb角、血红细胞沉降率(ESR)、C反应蛋白(CRP)、神经功能Frankel分级、植骨融合情况评价手术疗效。采用SPSS 21.0软件对数据进行统计学处理,计量资料采用配对t检验,以P<0.05为差异有统计学意义。结果 17例患者均顺利完成手术和获得随访,随访时间 24~33个月,平均随访时间(27.8±5.4)个月,均达到临床治愈。2例患者出院6个月时出现椎旁腰大肌脓肿形成,经腰大肌脓肿病灶清除术、调整抗结核治疗方案后愈合;其余15例患者术后随访均无异常。17 例患者术前VAS评分[(7.9±1.4)分]、ODI评分[(72.5±7.9)分]、后凸Cobb角[(22.5±7.6)°]、ESR[(47.3±11.3) mm/1h]、CRP[(32.6±9.4) mg/L]均明显高于末次随访时的(2.1±0.9)分、(30.3±6.6)分、(10.8±4.4)°、(6.1±3.2)mm/1h、(2.8±2.4)mg/L,差异均有统计学意义(t=16.61、4.18、21.24、2.44、20.11,P值均<0.001)。术前出现神经症状的7例患者,末次随访时Frankel分级均为E级。术后6个月14例患者植骨区融合达到Ⅰ级、2例为Ⅱ级、1例为Ⅲ级,融合率达到94.1%(16/17);末次随访时均达到Ⅰ级融合,椎间完全骨性融合,无复发及假关节形成。结论 前路病灶清除短节段植骨融合、后路经多裂肌微创入路长节段短钉固定术临床应用的效果良好。     

Pott's disease. A resurgent challenge to the thoracic surgeon

Nineteen patients were treated at the Los Angeles County Harbor/UCLA Medical Center between 1971 and 1986 for tuberculosis of the spine. Fourteen were immigrants, a high-risk group. A high index of suspicion is required for Pott's disease, which occurs in fewer than 1 percent of patients with tuberculosis, often presents with nonspecific symptoms, and may result in permanent deformity or neurologic impairment. CT scan, the most useful diagnostic test, showed abnormal results in 11 of 11 patients. MRI, a newer modality, may provide even more information. Eight patients required operation in addition to antimicrobial therapy. Four had lesions between T3 and T10, where the spinal canal is narrow, of whom three (75 percent had neurologic involvement. All four underwent anterior approach (thoracotomy) for decompression, debridement, and spinal fusion. Fifteen had lesions between T11 and S2. Three (20 percent) had neurologic involvement but responded to medical treatment alone. Four underwent drainage of abscess or spinal fusion for deformity. Combined surgical and medical treatment gave excellent results in this series.     

孤立性脊柱椎弓结核的临床特点及诊断治疗

目的探讨脊柱椎弓结核的临床特点及诊断与治疗。方法对１９５６～１９９６年收治的３８２５例脊椎结核中的１７例椎弓结核的临床表现及治疗进行回顾性分析。结果１７例椎弓结核中除１例为２岁儿童外，余均为青壮年，早期症状不典型，仅有局部固定性疼痛和压痛，以后有脓肿瘘管和神经系统症状出现。均经病史、体征、影像学检查及细菌学检查综合诊断，其中仅１例误诊。１７例中１例行抗结核药物化疗，１６例在抗结核药物化疗下行椎弓病灶清除术，其中４例伴有神经系统症状者同期作了椎板切除减压治疗。结果全部治愈，经随访无１例复发。结论椎弓结核早期症状较隐匿不易诊断，但限局性疼痛及Ｘ线、ＣＴ、磁共振（ＭＲＩ）等检查对该症的早期诊断极有帮助，脓肿穿刺、抗酸染色涂片检查常能明确诊断。手术是椎弓结核治疗的重要手段