Postoperative lumbar discitis

Summary We analysed 13 cases of lumbar disc infection following surgical discectomy. Two groups of patients were identified. The six patients in group A reported that the initial symptoms of discitis had appeared a mean of 15 days after surgery; on average, antibiotic treatment was started 31 days following operation and continued for 62 days, and symptoms regressed after 3.9 months. Four patients showed moderate changes, while two had extensive osteolytic lesions of one or both vertebral bodies adjacent to the involved disc. In the 7 cases in group B, discitis was suspected a mean of 5 days and antibiotics were initiated a mean of 8 days following surgery; on average, symptoms regressed 1.8 months after operation. Only four patients showed vertebral radiographic changes and none had marked destructive lesions. In both groups erythrocyte sedimentation rate exceeded 70 mm/h in cases in which discitis was suspected. Tomograms and magnetic resonance studies were the most diagnostic imaging studies in the initial stages of the disease. All patients obtained satisfactory clinical results at the last follow-up. Careful observation of the early postoperative clinical course usually allows detection of disc space infection. Early and adequately prolonged antibiotic treatment may shorten the course of the disease and avoid extensive osteolytic vertebral lesions.     

腰椎间盘术后椎间盘炎的诊断与治疗方法探讨

目的探讨腰椎间盘术后椎间盘炎的临床特征,诊断与治疗方法。方法自1994年7月-2004年7月共收治9例腰椎间盘术后椎间盘炎患者,平均年龄48岁,近期内均接受过腰椎间盘手术,其中2例使用椎间盘手术。全组患者血沉均升高（40-110mm/h),均经MRI检查确诊,6例症状典型,疼痛较重的患者行前路病灶清除植骨融合术,3例症状不典型,疼痛较轻患者予非手术治疗。结果 行前路病灶清除植骨融合术患者,疗效较好,症状缓解明显,保守治疗病程较长,病精常有反复,但一般预后良好。结论结合患者的临床特性,经MRI检查可以作出诊断。根据患者病情的具体情况,选择手术治疗或非手术治疗。     

原发性腰椎间隙感染的诊断和治疗

目的:探讨原发性腰椎间隙感染的诊断及治疗.方法:2004年8月～2008年12月收治10例原发性腰椎间隙感染患者,男6例,女4例,年龄26～79岁,平均52岁.轻度腰痛3例,腰痛伴下肢放射痛2例,仅有腰部剧痛5例,体温37.8℃～41.0℃,平均38.3℃.有糖尿病史4例,发病前前列腺有创检查2例、尿路感染2例.血白细胞计数正常6例,增高4例;均有血沉(ESR)和C-反应蛋白(CRP)增高;术前血液和尿液细菌培养阳性各1例,分别为金黄色葡萄球菌和大肠埃希杆菌.病变节段L2/3和L3/4 1例,LA/5 5例,L5/S1 4例.CT检查发现相邻椎体边缘不规则骨质破坏9例(其中1例L5椎弓根破坏),MRI T1像示病变椎间盘呈不均匀低信号影、MRI T2像为均匀的高信号影9例,椎间盘信号异常伴椎管内占位1例.5例诊断为原发性腰椎间隙感染,予绝对卧床和抗生素治疗,其中3例年轻患者保守治疗有效而未行手术,2例保守治疗无效而行手术治疗;3例诊为结核,2例诊为肿瘤,均行手术;7例手术患者术后均行病理检查及抗生素治疗.结果:7例术后病理检查均提示感染.随访8～24个月,平均18个月.3例保守治疗1周后腰痛缓解,6周后ESR和CRP恢复正常,治愈后12个月随访时腰椎X线片检查提示病变节段无脊柱不稳.7例手术治疗患者术后2～5d腰痛减轻,2周左右消失,2～3周后体温、ESR和CRP恢复正常;植骨均骨性融合,平均融合时间为3-4个月(3～5个月),无内固定松动和断裂.1例术后6个月邻近椎间隙出现感染,其余均在术后5个月恢复正常生活和工作.结论:原发性腰椎间隙感染临床症状缺乏特异性,早期易误诊.对年轻患者,可行保守治疗.对保守治疗效果不佳或症状较重者,手术治疗是安全有效的治疗方法.     

Postoperative discitis following single-level lumbar discectomy: Our experience of 17 cases

Background:

The established protocols of treatment of postoperative lumbar discitis have not been validated till date. We report a retrospective analysis of a series of patients with discitis following single level lumbar discectomy. We analyzed the outcome of conservative treatment of postoperative discitis with the objective to define when and what surgery was required when the conservative treatment failed.

Materials and Methods:

A total of 17 cases of postoperative discitis treated from 2002 to 2009 were followed up and evaluated clinically, radiologically and by laboratory investigations. All the patients were treated initially conservatively with rest and antibiotic therapy after diagnosis and those who did not respond to conservative treatment of at least 4 weeks were treated surgically. The cases were followed up with serial C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), X-ray, computed tomography (CT) scan and magnetic resonance imaging (MRI) for at least 1 year.

Results:

The mean followup was 40.38 months (range 12-86 months). Four cases failed to respond to conservative therapy and were treated surgically. In three of these four cases, open debridement, transpedicular fixation and posterolateral fusion was performed, and in the fourth case percutaneous transpedicular fixation was done. In the former group, one case was diagnosed to be tubercular, in another case Staphylococcus aureus was cultured where as the third case culture was sterile. All operated patients showed evidence of interbody fusion at 1 year followup.

Conclusions:

Early detection and aggressive treatment are paramount in managing postoperative discitis and the majority do well with conservative treatment. Surgical management in the form of transpedicular fixation and debridement, when required, gives excellent results.     

Do Augmentin or cefuroxime reach effective levels in lumbar vertebral discs when used prophylactically for discectomy?

Summary The incidence of discitis following discectomy is reported at between 0.75% and 3.0%. We believe this rate could be reduced if an antibiotic that penetrated the disc tissue with an appropriate spectrum were to be given prophylactically to cover surgery. A prospective study of 20 patients undergoing routine lumbar discectomy was performed. Ten patients received Augmentin 1 2 g and ten received cefuroxime 1.5 g pre-operatively. In eight patients sequestrated disc fragments were analysed, and the majority were found to have drug levels higher than in the attached disc material; the reasons for this are discussed. We conclude that Augmentin penetrates damaged disc material to a limited extent, but cefuroxime achieves levels effective against the most commonly implicated pathogens in discitis tissue and is a rational choice of antibiotic for prophylaxis during lumbar discectomy.     

椎间盘镜辅助 X-Tube下椎体间融合术治疗退变性腰椎间盘疾病

 目的 探讨椎间盘镜辅助 X-Tube下腰椎后路椎体间融合术(posterior lumbar interbody fusion, PLIF)和经椎间孔腰椎椎体间融合术(transforaminal lumbar interbody fusion, TLIF)治疗退变性椎间盘疾病的临床疗效。方法 2007年 11月至 2008年 4月, 采用椎间盘镜辅助 X-Tube下 TLIF和 PLIF治疗退变性椎间盘疾病 32例: PLIF 13例, TLIF 19例。单节段腰椎间盘突出症伴相应节段腰椎不稳定 21例, 腰椎滑脱症 11例(玉度 6例, 域度 5例)。病变节段: L3-4 2例, L4-5 18例, L5S1 12例。年龄 38~72岁, 平均 51.2岁;男 19例, 女 13例。术后进行定期随访和影像学检查, 并进行 Oswestry功能障碍指数评定以评价术后康复情况。结果手术时间 90~180 min, 平均 120 min;手术出血量 100~400 ml, 平均 190 ml。切口均为甲级愈合, 未见切口及椎管、椎间隙感染、内固定失败等并发症发生。所以患者均获随访, 随访时间 13~41个月, 平均 21个月。 Oswestry功能障碍指数由术前 40.1%±4.1%下降到术后 3个月的 9.5%±3.7%。疗效评价: 优 19例, 良 10例, 可 3例;优良率为 90.6豫。骨融合均取得成功。结论椎间盘镜辅助 X-Tube下 TLIF和 PLIF治疗退变性椎间盘疾病具有切口小, 创伤小, 术后恢复快等优点。     

The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis.

STUDY DESIGN: A Cochrane review of randomized controlled trials. OBJECTIVES: To collate the scientific evidence on surgical management for lumbar-disc prolapse and degenerative lumbar spondylosis. SUMMARY OF BACKGROUND DATA: Surgical investigations and interventions account for as much as one third of the health care costs for spinal disorders, but the scientific evidence for most procedures still is unclear. METHODS: A highly sensitive search strategy identified all published randomized controlled trials. Cochrane methodology was used for meta-analysis of the results. RESULTS: Twenty-six randomized controlled trials of surgery for lumbar disc prolapse and 14 trials of surgery for degenerative lumbar spondylosis were identified. Methodologic weaknesses were found in many of the trials. Only one trial directly compared discectomy and conservative management. Meta-analyses showed that surgical discectomy produces better clinical outcomes than chemonucleolysis, which is better than placebo. Three trials showed no difference in clinical outcomes between microdiscectomy and standard discectomy, but in three other studies, both produced better results than percutaneous discectomy. Three trials showed that inserting an interposition membrane after discectomy does not significantly reduce scar formation or alter clinical outcomes. Five heterogeneous trials on spinal stenosis and degenerative spondylolisthesis permit very limited conclusions. There were nine trials of instrumented versus noninstrumented fusion: Meta-analysis showed that instrumentation may facilitate fusion but does not improve clinical outcomes. CONCLUSIONS: There is now strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is considerable evidence on the clinical effectiveness of discectomy for carefully selected patients with sciatica caused by lumbar disc prolapse that fails to resolve with conservative management. There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management. The Cochrane reviews will be updated continuously as other trials become available.     

单侧椎弓根螺钉内固定椎间融合术治疗腰椎间盘突出症

目的 探讨单侧神经减压椎间融合椎弓根螺钉固定治疗腰椎间盘突出症的应用价值和实际疗效.方法 对50例腰椎间盘突出患者行腰椎后路经单侧椎弓根螺钉内固定联合单枚Cage的融合手术.结果 所有患者切口均一期愈合.随访时间12-24个月,平均18个月,疗效评定按日本骨科学会(JOA)下腰痛评分评定,本组优良率为92%.结论 单侧...     

腰椎间盘突出症术后复发的临床分析

目的:探讨腰椎间盘突出症术后同节段复发的原因、诊断方法及影响二次手术疗效的因素。方法:32例有完整随访资料的椎间盘突出症术后复发病例,按治疗方式分为保守治疗组,椎板加椎间盘切除组与椎板、椎间盘切除加腰椎内固定植骨融合组。对各种治疗方法的适应证、疗效等进行总结,分析椎间盘切除术后可能的复发原因。结果:本组病例均获5个月以上随访,保守治疗组优良率100%,腰椎融合组优良率92.9%,非融合组优良率93.2%。结论:腰椎间盘突出症术后同节段复发的确切原因仍不清楚,对诊断明确并伴有神经根损伤表现的患者可行二次手术治疗,是否采用内固定加植骨融合术视患者不同情况而定。     

腰椎间盘术后椎间隙感染的治疗

目的 探讨腰椎间盘术后椎间隙感染病的治疗方法。方法 分析评价11例腰椎间盘术后椎间隙感染人的疗效。结果 9例经保守治愈,2例手术治愈,其中3例椎问未融合,伴脊柱侧弯,仍有腰部活动受限外,其余功能恢复满意,平均随访时间40±18.8个月(5个月～5年)。结论 大部分患者经保守治疗可获痊愈,对椎体破坏超过50％、有神经受损症状者可考虑手术治疗。本病重在预防。     

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: lumbar fusion for disc herniation and radiculopathy

There is no convincing medical evidence to support the routine use of lumbar fusion at the time of a primary lumbar disc excision. There is conflicting Class III medical evidence regarding the potential benefit of the addition of fusion in this circumstance. Therefore, the definite increase in cost and complications associated with the use of fusion are not justified. Patients with preoperative lumbar instability may benefit from fusion at the time of lumbar discectomy; however, the incidence of such instability appears to be very low (< 5%) in the general lumbar disc herniation population. Patients who suffer from chronic low-back pain, or are heavy laborers or athletes with axial low-back pain, in addition to radicular symptoms may also be candidates for fusion at the time of lumbar disc excision. Patients with a recurrent disc herniation have been treated successfully with both reoperative discectomy and reoperative discectomy combined with fusion. In patients with a recurrent lumbar disc herniation with associated spinal deformity, instability, or associated chronic low-back pain, consideration of fusion in addition to reoperative discectomy is recommended.     

低温等离子消融髓核成形术与保守疗法治疗腰椎间盘突出症的对比研究

目的：比较低温等离子消融髓核成形术与保守疗法治疗包容性腰椎间盘突出症的疗效。方法：69例经体格检查、CT和，或MRI检查确诊的包容性腰椎间盘突出症患者随机分为两组，髓核成形术治疗组28例，采用低温等离子消融髓核成形术治疗；保守治疗组41例，采用卧床休息、抗炎、理疗等综合保守疗法。随访1年～2年8个月，平均2．1年，采用Prolo功能评定法和VAS评分评定疗效。结果：髓核成形术治疗组和保守治疗组总体治疗成功率分别为82．1％和85.4％，差异无显著性（P〉0．05）；两组平均住院时间分别为7．6d和16．9d，差异有显著性（P〈0．05）：复发率分别为10．8％和22％，差异有显著性（P〈0．05）。髓核成形术治疗组并发椎间盘炎1例，行腰椎融合术后治愈。结论：髓核成形术和保守疗法治疗包容性腰椎间盘突出症的满意率相近，但髓核成形术治疗组复发率低，住院治疗时间短，是一种安全、有效的治疗包容性腰椎间盘突出症的微刨治疗方法。     

腰椎间盘术后椎间盘炎的诊断与治疗

目的：介绍腰椎间盘术后椎间盘炎的临床特点,讨论治疗方法。方法：对１３例术后椎间盘炎临床资料回顾,分析常见诊治失误原因。依靠临床体征、血沉、Ｃ—反应蛋白、Ｘ线、ＣＴ或ＭＲＩ建立早期诊断。非手术治疗治愈１０例,手术治疗治愈３例。结果：术后１１例随访６～３６个月。９例恢复原工作,４例遗有慢性腰痛或腰椎活动受限,２例不能胜任体力劳动。结论：早期诊断应重视术后再发剧烈腰痛的特殊体征。血沉、Ｃ—反应蛋白是提示感染或观察疗效的指标。Ｘ线、ＣＴ、ＭＲＩ有诊断价值。多数患者经严格卧床,大剂量广谱抗生素治疗效果满意。保守无效,炎症扩散出现相应临床症状者,应行病灶清除术。     

手术和保守治疗腰椎间盘术后椎间盘炎疗效的病例对照研究

目的:比较手术和保守治疗腰椎间盘术后椎间盘炎的疗效。方法:对2004年1月至2009年1月收治的41例腰椎间盘术后椎间盘炎患者进行回顾性分析,其中男17例,女24例;年龄37～68岁,平均53.6岁。其中手术治疗19例(手术组),保守治疗22例(保守组)。记录患者一般情况、临床特征、影像学资料、实验室检查结果、抗生素使用情况、住院时间、后遗症等,并进行比较分析。临床疗效采用VAS(visual analogue scales,VAS)评分系统和Oswestry功能障碍指数(Oswestry disability index,ODI)进行评定。结果:所有患者均获随访,时间25～40个月,平均31个月。影像学提示植骨融合良好,未出现椎间盘炎复发。与治疗前相比,治疗后1个月、1年及2年VAS评分及ODI指数均有明显改善(P<0.01);组间比较,1个月时手术组VAS及ODI优于保守治疗组(P<0.01),治疗后1年及2年时这2项指标间的差异无统计学意义(P>0.05)。结论:椎间盘术后并发椎间盘炎,需积极治疗,保守治疗和手术治疗均是有效的治疗方法。短期内手术疗效优于保守治疗,但长期随访显示保守治疗也可达到满意疗效。     

多间隙腰椎间盘突出症的手术治疗探讨

目的：探讨多间隙腰椎间盘突出症手术治疗的基本原则。方法：167例多间隙腰椎间盘突出症患者,87例行单纯椎板间开窗减压术,54例行半椎板切除加椎板间开窗减压术,17例行单纯全椎板切除减压术,9例行全椎板切除加内同定植骨融合术,287个“责任”椎间盘予髓核摘除,56个“非责任”椎间盘未予处理。结果：随访7个月～9年,原位椎间盘突出复发6例,术后继发椎管狭窄9例,腰椎不稳4例,内同定断裂1例。按改良Macnab法评定术后疗效,本组优93例,良44例,可29例,差1例,优良率为82％。结论：有效减压、维持脊柱的稳定性、避免并发症的发生是手术治疗多间隙腰椎间盘突出症应遵守的基本原则。     

腰椎内固定术后深部感染的原因分析及外科处理

目的：探讨腰椎内固定术后切口深部感染的原因和外科处理措施,并观察其疗效。方法：本院2009年1月～2011年1月,我院共行腰椎椎弓根内固定、腰椎融合术治疗各类腰椎疾病1774例,其中19例患者术后发生切口深部感染,男9例,女10例。年龄12—71岁,平均54．7岁。外伤7例,腰椎管狭窄5例,腰椎间盘突出症4例,滑脱3例。其中7例合并2型糖尿病,3例术前贫血（血红蛋白〈9g／dl）,3例合并四肢开放伤。对其临床资料进行回顾性分析。所有患者均行切口分泌物细菌培养,并行扩创,持续灌注冲洗引流术,对于引流液涂片阴性或者细菌培养阴性者,给予保留内固定。而行影像学检查发现内固定松动、存在引流液涂片阳性者,或者是迟发感染者则术中应去除内固定。椎间内固定物,若非存在明显的松动,感染迹象,我们不建议去除,以防感染的扩散。术后根据药敏实验结果,应用抗生素治疗。结果：本组19例切口深部感染患者,术后均获得治愈,腰痛症状明显好转,无1例发生神经症状的加重。再次术后6月复查时均获得骨性融合。所有患者腰部无明显活动受限。随访期间无1例感染复发。结论：腰椎融合内固定术后切口深部感染是一种严重的并发症,应早发现、早处理。重视术前合并病的处理,根据药敏结果使用抗生素,彻底清创,持续灌注引流术能够获得很好的临床效果。为了彻底的清创,必要时可以牺牲脊柱的即刻稳定性。     

后路减压融合术治疗复发性腰椎间盘突出症的临床疗效

目的：探讨复发性腰椎间盘突出症的原因和治疗方法.方法：手术治疗复发性腰椎间盘突出症56例,初次手术方式：椎板间开窗间盘切除38例,病变节段上下方全椎板或半椎板切除15例,内窥镜下微创间盘切除3例;再次手术采用后路减压,椎间盘切除,椎弓根螺钉内固定,横突或椎体间植骨术.随访43例,采用JOA29分法进行术前和随访时的评分.结果：56例患者手术中发现原手术部位均有不同程度的粘连,尤以椎板切除者为著.有38例为原手术节段间盘脱出,占67.9%.再次手术平均历时2.8h,术中出血平均550ml.术后住院时间平均为13.6d.患者再次手术前JOA评分平均11.6分,术后随访时JOA评分平均23.9分,平均改善率70.7%.结论：初次手术处理不当以及术后腰椎局部生物力学的改变是间盘突出复发的主要原因.对于复发性腰椎间盘突出症进行的再次手术治疗,在同时解决减压和稳定两个问题后,可获得良好的效果.     

成人原发性椎间盘炎（8例报告与文献复习）

本文报告了成人原发性椎间盘炎８例，其中男５例，女３例，年龄平均４４．５岁。病变间隙：Ｌ１～２１例，Ｌ２～３４例，Ｌ３～Ｌ４３例。入院前误诊为腰椎结核２例，椎体肿瘤３例。病因有三大学说即：细菌感染、无菌性炎症和自身免疫性反应，多数倾向于血源性细菌感染。讨论了临床特点、诊断与鉴别诊断及治疗问题。作者认为ＣＲＰ和ＥＳＲ较体温血象更敏感、更准确，可作为观察疗效的有效指标。本病应与腰椎结核、椎体肿瘤及退行性改变加以鉴别，ＭＲＩ有助于本病的诊断。保守治疗以卧床、大剂量广谱抗菌素治疗为主。经皮椎间盘镜行病灶清除及活检术有助于诊断和治疗。对椎体破坏超过５０％有神经受损症状、保守治疗无效者，手术病灶清除术同时可植骨融合，以增加脊柱稳定性。     

老年人腰椎间盘突出症的围手术期治疗

目的 探讨老年人腰椎间盘突出症的临床特点以及围手术期慎重处理的重要性。方法 回顾性分析手术治疗224例老年人腰椎间盘突出症的临床资料．结果 224例中术前检查有高血压病51例、糖尿病14例、心脏异常28例，均经相关科室的正规诊治，恢复正常或接近正常并稳定后，方可安排手术治疗。所有病人都平安渡过手术期，无一例出现严重并发症．获得完整随访资料191例，平均随访5年8个月，优良率为96．3％。结论老年人腰椎间盘突出症有其特殊性，只要围手术期处理得当，手术治疗可获得满意效果。     

Disc space infection and vertebral osteomyelitis as a complication of percutaneous lateral discectomy

Percutaneous lateral discectomy (PLD) in a 32-year-old man was followed by postoperative disc space infection and adjacent vertebral osteomyelitis caused by Staphylococcus aureus. The simplicity and decreased morbidity associated with PLD may be offset by severe infections. The small incision made in the annulus during PLD may not allow adequate drainage in the case of infection and may subsequently direct the infective process to the adjacent vertebral endplates. Meticulous aseptic technique, and possibly the use of prophylactic antibiotic therapy, is important in PLD.