成人血源性脊柱化脓性骨髓炎23例临床分析

目的 总结23例成人血源性脊柱化脓性骨髓炎(PDVO)的临床诊治经验.方法 对1999年7月至2006年10月收治的23例成人血源性PDVO患者的病史、临床表现、诊断、治疗及转归等进行回顾性分析.结果 本组23例,男15例,女8例;平均年龄55.4岁.诊治延误时间4周～11个月,平均4.4个月.其中患有或合并患有下述1种以上疾病的17例:糖尿病、泌尿系感染、酒精中毒、肝硬化、风湿性关节炎以及长期滥用糖皮质激素.全部23例实验室检查C反应蛋白和红细胞沉降率均有升高,而白细胞计数仅有9例升高.7例保守治疗;16例前路病灶清创植骨融合,其中11例脊柱不稳的选择适当的内固定,3例采用一期椎体侧前方钢板固定.7例采用二期后路融合椎弓根螺钉固定.本组23例全部获随访,随访时间6个月～7年,平均27个月.患者生活均能自理,无复发.手术治疗的患者,术后症状迅速缓解,植骨融合率达87.5%.结论 成人血源性PDVO好发于患有内科疾病的老年患者,血培养阳性有助于确诊.对于保守治疗失败的慢性PDVO的患者,手术清创植骨融合配合适当的内固定,能迅速缓解症状,安全有效.

Adult hematogenous pyogenic discitis and vertebral osteomyelitis: clinical features, diagnostic, therapeutic approaches and outcome in 23 patients

Objective In order to sum up the experience of diagnosis and treatment, the clinical information, diagnostic approach and treatment strategies from 23 patients with hematogenous pyogenic discitis and vertebral osteomyelitis (PDVO) in adults were reviewed. Methods A retrospective record review was conducted of all cases of hematogenous PDVO from July 1999 to October 2006, the diagnostic approach and the treatment strategies were discussed. Results The average age was 55.4 years. The average delayed diagnosis time was 4.4 months ( range, 4 weeks to 11 months). Of these, 17 had underlying diseases such as diabetes mellitus, chronic alcoholism, liver cirrhosis, rheumatic disease, and the use of corticosteroids. All percent had elevated erythrocyte sedimentation rates and C-reactive proteins, while white blood cell counts were less reliably elevated. Imaging studies included radiographs and MRI. Seven patients were treated with immobilization and intravenous antibiotic drugs. Because of a delay in diagnosis, 16 patients underwent operative treatment for hematogenous PDVO using staged anterior debridement and Bone grafting with iliac crest or rib strut, anterior spinal instrumentation in 3 patients, posterior instrumentation was placed in 7 patients at a second procedure 10 days to 2 weeks following initial operation. Twenty-three patients were followed-up for an average period of 27 months, with a minimum of 6 months and the longest for7 years. The patients return to their preoperative everyday activity. No patient had a recurrence of osteomyelitis. All their symptoms improved after surgery, bony fusion occurred in 87.5% of cases. Conclusions Adult hematogenous PDVO is a disease that affects mainly older patients suffering underlying medical illnesses. Positive blood cultures is valuable for the diagnosis. Hematogenous PDVO may require surgery in case of a development of biomechanical instability and/or a vertebral collapse with progressive deformity. In experienced hands, surgical debridement, interbody fusion, and anterior or posterior iustrumentation is a safe and effective treatment.