不同术式治疗胸腰椎结核合并巨大脓肿71例疗效分析

目的探讨不同手术方式治疗胸腰椎结核合并巨大脓肿的临床效果。方法采用不同手术方式，包括经胸入路或胸膜外肋横突入路、肾切口入路、倒“八”字腹膜外入路或后路入路，治疗胸腰椎结核并巨大脓肿71例，其中男37例，女34例，年龄17～78岁，平均42．0岁。病程：2月一3年。多椎体脊柱结核≥2个椎体，包括跨越性病灶，病灶分布为T7～8，2例，T8-9，1例，T9-10，3例，T10～11，11例，T11～12，4例，T12-L1，3例，T12、L1—2，4例，L1-2，12例，L2～3，10例，L3—4，5例，L4～5，5例，L5～S1，3例，L1～3，2例，L2—4，3例，T12、L2～3，1例，L2～5，2例。神经功能按美国脊髓损伤学会（ASIA）的分级：B级4例，C级6例，D级9例，E级52例。术前后凸Cobb角5°-61°，平均（31．2°±9．2°）。CT和MR显示均有明显的死骨，椎旁巨大脓肿术中吸尽乳白色脓液820—3100ml，平均1370ml，3例伴脊髓受压严重者于12—48h抗痨治疗后急诊手术，其余68例术前抗痨支持治疗2—4周，术后继续抗痨12—18月。结果随访1～4年，平均16月，手术时间平均180min，术中出血量平均900ml，3例术中发生脑脊液漏行修补，术后未发生脑脊液漏。术后6例伤口不愈合，形成窦道，经抗痨局部换药治疗后治愈。4例术后再次形成椎旁脓肿，量约100—150ml，再次病灶清除后治愈。死亡2例。1例术后发生内固定物松动，未处理。术后复发4例，再次手术后末次随访均临床治愈，结核无复发。伴神经损伤者4例术前ASIAB级恢复至D级，余均恢复至E级。结论根据病灶部位、病变程度，采用不同手术方式治疗胸腰椎结核并巨大椎旁脓肿均能达到清除病灶、脊髓减压及矫正脊柱后凸畸形的良好治疗效果。

ANALYZE THE CURATIVE EFFECT OF DIFFERENT SURGERY WAY TREATING THORACOLUMBAR SPINAL TUBERCULOSIS WITH HUGE ABSCESS IN 71 CASES

Objective To investigate the clinical effect of different operation methods in treatment of thoraco- lumbar spinal tuberculosis with huge abscess. Methods Using different operation methods, including the transthoracic approach or extrapleural approach, kidney incision, anterior retroperitoneal approach and posterior approach, 71 cases （37 males and 34 females） of thoracic and lumbar spinal tuberculosis with huge abscess were treated, age range from 17 - 78, average 42 years old. The course of disease was 3 months to 3 years. The distribution of segmental（ including 2 vertebral bodies or more） spinal tuberculosis were confirmed as follows, T7 - 8 in 2 cases, T8 - 9 in 1 cases, T9 -10 in 3 cases, T10 - 11 in 11 cases, T11 -12 in g cases, T12 - L1 in 3 cases, T12L1 -2 in g cases, L1 -2 in 12 cases, L2 -3 in 10 cases, L3 -4 in5 cases, L4 -5 in5 cases,, L5S1 in3 cases, L1,2, 3, in2 cases, L2 -4 3cases, T12L2 - 3, in 1 cases, L2 - 5,2 cases. Nerve injury according to the American Spinal Injury Association （ASIA） were classified： grade B in 4 cases, grade C in 6 cases, grade D in 9 cases, grade E in 52 cases. Cobb angle 5° -61° before operation, average （31.2° -9. 2 °）. CT and MR showed obvious sequestrum and paravertebral huge abscess, plenty of milky white pus（820 ml up to 3100ml, average 1 370 ml） were found during operation. 3 cases complicated with spinal cord compression were treated with emergency operation in 12 - 48 hours, other cases were treated with chemotherapy for 2 - 4 weeks before operation, and received anti - tuberculous for 12 - 18 months after operation. Results The follow - up period was 1 years - 4 years, average 16 months, the average operation time was 180 min, average bleeding volume was 900 ml, cerebrospinal fluid leakage occurred in 3 cases, all repaired during operation, no postoperative cerebrospinal fluid leakage. Wound nonunion with postoperative sinus tract in 6 cases, all healed after anti - tuberculous treatment and dressing change, 4 cases suffered postoperative paraspinal abscess about 100 - 150 ml, were healed after debrided again, 2 cases died. Postoperative implant failure in 1 cases, which received conservative treatment. Tuberculosis relapsed in 4 cases, all healed after received reoperation. Nerve injury in 4 cases with ASIA grade B recovered to grade D, others recovered to E grade. Conclusion After debridement, decompression of the spinal cord and correction of spinal kyphosis, spine tuberculosis with huge paravertebral abscess can achieve good therapeutic effect by different operation methods according to the lesion segment and damage degree.