一期病灶清除术治疗颈椎结核

 目的 探讨Ⅰ期病灶清除术治疗不同节段颈椎结核的疗效。方法 回顾性分析1998年1月至2011年12月采用Ⅰ期病灶清除术治疗54例颈椎结核患者资料，男20例，女34例；年龄26～75岁，平均45.4岁。其中累及单节段12例（C₂ 1例、C₄ 2例、C₅ 3例、C₆ 4例、C₇ 2例）、相邻双节段36例（C_1,2 3例、C_2,3 2例、C_3,4 5例、C_4,5 6例、C_5,6 14例、C_6,7 5例、C₇T₁ 1例）、3节段5例（C_4~6 2例、C_6~7 2例、C_3,5,6 1例）、4节段1例 （C_4~7）；5例合并脊柱其他部位结核病灶，包括T₆1例、T₁₁ 3例、L_3,4 1例；1例合并颈椎后纵韧带骨化症。术前颈部VAS评分4～9分，平均5.9分；JOA评分7～12分，平均10.5分；术前病变节段Cobb角平均26.7°± 9.1°。术前行正规抗结核治疗，待红细胞沉降率< 50 mm/1 h后行手术治疗。根据病变累及节段分别采用前路病灶清除植骨融合内固定术、前路病灶清除加前后联合内固定术、经颌下入路咽后壁病灶清除术加后路枕颈融合术或后路寰枢椎融合术进行治疗。结果 术后随访时间13～52个月，平均27.3个月。术前症状均明显改善，骨性融合时间2～4个月，平均3.2个月。末次随访，颈部VAS评分平均1.1分，JOA评分平均15.6分，病变节段Cobb角平均6.8°。术后均行系统抗结核治疗18～20个月。1例上颈椎结核患者术中出现高位食道损伤，经留置胃管1周后愈合。术后无一例发生颈椎结核复发、植骨块移位及假关节形成。结论 颈椎结核在术前抗结核治疗的基础上，可根据病变累及节段及局部畸形情况，采取Ⅰ期病灶清除术治疗；术后正规的抗结核治疗是颈椎结核后期治愈的关键因素。

One-stage foci debridement for cervical tuberculosis

Objective To evaluate the effectiveness of one-stage debridement for cervical tuberculosis at different segments. Methods Clinical data of 54 patients (male 20, female 34) with cervical tuberculosis treated by one-stage debridement from Jan 1998 to Dec 2011 were reviewed retrospectively. The average age of these patients was 45.4 years (range, 26-75 years). Among them, 12 cases were involved in single level (C₂ 1 case, C₄ 2 cases, C₅ 3 cases, C₆ 4 cases, C₇2 cases); 36 cases in the adjacent two levels (C_1,2 3 cases, C_2,3 2 cases, C_3,4 5 cases, C_4,5 6 cases, C_5,6 14 cases, C_6,7 5 cases, C₇T₁ 1 case); 5 cases in three levels（C_4-6 2 cases, C_5-7 2 cases, C_3,5,6 1 case）and 1 case in four levels (C_4-7). Five cases were involved in other spinal levels (T₆ 1 case, T₁₁ 3 cases, L_3,4 1 case). Comorbidity of cervical ossification of the posterior longitudinal ligament was found in 1 case. Before surgery, the mean VAS and JOA scores were 5.9 （range, 4-9） and 10.5 （range, 7-12） respectively and the mean Cobb angle of lesion segment was 26.7°± 9.1°. All cases underwent regular anti-TB treatment preoperatively, and surgical treatment were performed when blood sedimentation (ESR) was lower than 50 mm/1 h. According to the segmental involvement, different surgical approaches were performed including anterior debridement with anterior or anterior-posterior internal fixation and fusion, submandibular approach debridement with posterior occipital cervical fusion or atlantoaxial fusion. Results Mean follow-up duration was 27.3 months (range, 13-52 months)．Symptoms were improved significantly in all cases. Mean time of union was 3.2 months (range, 2-4 months). At the last follow-up, the mean VAS and JOA scores were 5.9 （range, 4-9）and 10.5 （range, 7-12） respectively, and the mean Cobb angle of lesion segment was 6.8°. Regular anti-TB treatment was performed postoperatively for 18 to 20 months. Intraoperative esophageal injury was found in one case of upper cervical tuberculosis which was cured uneventfully after gastrointestinal tubation for 1 week. No cervical tuberculosis recurrence, graft loosening or pseudarthrosis was found in follow-up. Conclusion With preoperative anti-TB treatment, cervical tuberculosis can be treated by one-stage foci debridement according to the segmental involvement and deformity. Postoperative regular anti-TB treatment is a crucial factor for the final recovery of cervical tuberculosis.