脊柱结核伴截瘫外科治疗的疗效分析

 目的 探讨脊柱结核伴截瘫患者的手术指征及手术时机，并评价脊柱结核伴截瘫患者的临床疗效。方法 回顾性分析2008年3月至2012年4月治疗的78例脊柱结核伴截瘫患者的临床资料，男45例，女33例；年龄13~71岁，平均39.5岁。骨病活动型截瘫69例，41例已行抗结核治疗，发生截瘫至手术时间平均为2.3周（0~4周）行早期手术治疗；22例（合并活动肺结核6例、结核性脑膜炎5例、药物性肝炎7例、尿毒症3例、不稳定心绞痛1例）经围手术期处理后行手术治疗，发生截瘫至手术时间平均为4.5周（3~8周）；6例单纯行药物治疗。骨病治愈型截瘫9例，行常规手术治疗。结果 所有病例均获得随访，随访时间12~48 个月，平均31.4个月。术后第1天~3周，神经功能开始部分恢复；术后3个月至末次随访,完全恢复65例，部分恢复7例，无改善6例。骨病活动型截瘫患者预后相似，骨病治愈型截瘫患者初始恢复慢，且预后较差。术后及末次随访疼痛视觉模拟评分（visual analogue scale，VAS）、Cobb角明显改善，与术前比较差异均有统计学意义。随访期间病灶无复发，X线片或CT提示病灶均获骨性融合。结论 对于骨病活动型截瘫，病变较轻者可行单纯药物治疗；病变较重者（Frankel分级C级以下，后凸畸形）早期手术治疗有利于神经功能恢复；有早期手术禁忌者，合并症处理后，延期手术治疗亦可取得较好疗效。骨病治愈型截瘫的神经症状改善较骨病活动型截瘫患者差，提示初治病例（尤其是儿童结核）应强调脊柱稳定性重建。

Clinical outcomes of surgical treatment of spinal tuberculosis with paraplegia

Objective To investigate the clinical outcomes of the surgical management for spinal tuberculosis with paraplegia retrospectively. Methods From March 2008 to April 2012, we retrospectively analyzed 78 patients with spinal tuberculosis combined with paraplegia. Among them, 45 patients were male and 33 were female. The average age was 39.5(13 to 71) years. 69 patients had focus-active paraplegia. 41 patients had received chemotherapy before admissed to our hospital. They also received further standard chemotherapy for an average period of 2.3 (0 to 4) weeks after the admission. 22 patients with complex complications (6 patients with active pulmonary tuberculosis, 5 with tuberculous meningitis, 7 with drug hepatitis, 3 with kidney failure and 1 with unstable angina) received preoperative treatment for an average period of 4.5(3 to 8) weeks after the admission. 6 patients were managed with chemotherapy only. All 9 patients who had focus-healed paraplegia received surgical treatment after the admission immediately. Results All the patients were followed up clinically and radiologically for an average period of 31.4 (12 to 48) months. There was no recurrence of patients. At the final follow-up, all the patients had achieved rigid bony fusion. Both the VAS score and the Cobb angle had satisfactory improvement postoperatively and at the final follow-up. The neurological status began to improve 1-21 days after the operation. From 3 months postoperatively to the final follow-up, 65 patients achieved complete recovery, 7 partial recovery and 6 no recovery. The clinical outcomes for focus-active paraplegia were similar, while focus-healed paraplegia had slower recovery and worse outcomes. Conclusion Patients with focus-active paraplegia combined with mild destruction and relative favourable neurological status could be treated conservatively. For patients with severe bony destruction and neurologic deficits (Frankel A-C, or combined with kyphosis), surgical treatment as early as possible is crucial to improve the neurologic status. If patients had contraindications, operation could be performed after the complications had been cured. However, the neurologic status improvement in focus-healed paraplegia is worse than focus-active paraplegia, suggesting that the reconstruction of spinal stability is important for initial treatment of spinal tuberculosis and children.