21例耐多药脊柱结核手术联合个体化化疗的临床分析

目的 回顾性分析手术联合药敏试验指导下的个体化抗结核化疗对耐多药脊柱结核的临床疗效。 方法 收集2006年2月至2010年6月解放军第三○九医院全军骨科中心收治、且符合纳入标准的21例耐多药脊柱结核。包括初治结核6例，复治结核15例。21例患者入院后根据病灶特点接受不同方式手术治疗，术后参照既往抗结核化疗史及药敏试验结果，制定个体化化疗方案并定期随访。分析其临床特征与耐药表型，回顾术后1、3、6个月及之后每6个月随访时的临床表现，X线片、CT及三维重建、MRI等影像学变化及实验室指标，评价植骨融合情况及疾病转归。 结果 复治结核既往化疗平均持续（19.3±15.8）个月(7～49个月)。19例接受了开放手术治疗，其中1例于术后5个月内固定失效，有4例术后局部复发；2例接受的是CT引导下置管灌洗术。术后个体化化疗平均持续18.3(18～20)个月，末次随访时11例术前伴神经功能障碍者均有不同程度改善，9例伴后凸畸形者术后均得到良好矫正，但其中1例伴后凸畸形者因术后内固定失效，末次随访时后凸矫正明显丢失。18例最终临床治愈，3例仍在接受化疗。 结论 基于药敏试验的化疗联合手术的个体化治疗方案有利于尽早治愈耐多药脊柱结核，解决严重并发症，并避免耐多药菌株的播散及获得性耐药的产生。

Retrospective study of surgery combined with individualized chemotherapy for patients with multi-drug resistant spinal tuberculosis

Objective To investigate the clinical outcomes of the management with combination of surgery and individualized chemotherapy for the multi-drug resistant tuberculosis spondylitis. Methods From February 2006 to June 2010, we retrospectively analyzed 21 cases of multi-drug resistant tuberculosis spondylitis admitted in the General Hospital of the General Staff Department of PLA. Among them, 6 were initial treatment cases, and 15 were retreatment cases. After admission, 21 patients received open operation or CT guided percutaneous drainage according to characteristics of the focus. Individualized chemotherapy regimens were tailored for each patient according to the drug resistance spectrum and previous history of anti-tuberculosis treatment after surgery and drug susceptibility testing. All patients were followed up clinically and radiologically for at least 18 months. Results Retreatment cases had undergone previous chemotherapy for an average of（19.30±15.80）（7-49） months. 19 cases received open operation and the other 2 received CT guided percutaneous drainage. Instrumentation failure was observed in one case and local recurrence was observed in 4 patients. Patients received individualized chemotherapy with an average of 18.3（18-20） months postoperatively. At the final follow-up, all of the 11 patients with paraplegia had a slight or remarkable recovery, and 9 patients with kyphosis had significant correction. 18 patients had treatment cure and the other 3 cases were still undergoing chemotherapy. Conclusion Management with combination of surgery and individualized chemotherapy is feasible in the treatment of severe complications and prevention dissemination of multi-drug resistant strains and development of acquired drug resistant spinal tuberculosis.