多节段胸腰椎结核的外科治疗

目的探讨多节段胸腰椎结核采取前后路联合入路病灶清除植骨内固定联合化疗的临床疗效。方法选取2007年1月至2017年12月本院收治的多节段胸腰椎结核患者28例,术前常规化疗2～4周,平均3周,手术先采用胸腰椎后入路行椎弓根螺钉固定,再行侧前方入路彻底清除病灶内脓肿、死骨、肉芽组织及坏死椎间盘在病椎上下正常椎体内行内固定,采用"钛网+自体髂骨植骨支撑,15例、自体髂骨植骨支撑10例、自体肋骨植骨支撑3例。结果28例患者均获得1～6年的随访,平均2.2年。其中合并脊髓损伤伴不全瘫者17例,按Frank分级:B级2例,C级11例,D级4例。B级2例恢复到C级;C级11例中,其中5例恢复到D级,6例恢复到E级;D级4例均恢复到E级。病灶静止、骨性融合26例,术后半年内有2例复发。1例再次手术,重新行病灶清除,去除植骨块改用钛网加髂骨植骨8个月后骨性融合;1例抗痨治疗无效,患者放弃治疗。无钢板、螺钉松动、断裂。结论术前常规化疗,术中彻底清除病灶植骨融合内固定,术后继续化疗,是外科治疗多节段胸腰椎结核获得良好效果的保证。

Surgical treatment of multisegmental thoracolumbar tuberculosis

Objective To investigate the clinical effect of anterior and posterior approach debridement with bone graft and internal fixation combined with chemotherapy in the treatment of multisegmental thoracolumbar tuberculosis. Methods From January 2007 to December 2017, 28 patients with multisegmental thoracolumbar tuberculosis underwent conventional chemotherapy for 2 to 4 weeks before surgery (mean, 3 weeks). The posterior approach of thoracolumbar vertebra was used for pedicle screw fixation, and the anterior lateral approach was used to completely remove the abscess, dead bone, granulation tissue and necrotic intervertebral disc in the lesion, and internal fixation was performed in the upper and lower normal vertebra. Among them, 15 cases were supported by titanium mesh and autogenous iliac bone graft, 10 cases were supported by autogenous iliac bone graft, and 3 cases were supported by autogenous rib bone graft. Results A total of 28 patients were followed up for 1 to 6 years, with an average of 2.2 years. There were 17 patients with paraplegia due to spinal cord injury, Two patients with Frank grade B, 11 patients with grade C, and 4 patients with grade D. 2 patients with Frank grade B recovered to grade C; among the 11 cases with grade C, 5 cases recovered to grade D and 6 cases recovered to grade E. And 4 patients with grade D all recovered to grade E. There were 26 patients with static lesion and bone fusion, and 2 patients had recurrence half a year after the surgery. One of the two patients who relapsed underwent reoperation to remove the lesion and replace the bone graft with titanium mesh and iliac crest bone graft for 8 months before bone fusion. The other case was ineffective in anti-tuberculosis treatment, and the patient gave up treatment. No steel plate, screw loose, nor fracture. Conclusion Preoperative conventional chemotherapy, intraoperative complete removal of the lesion, bone graft fusion and internal fixation, postoperative chemotherapy are the guarantee for good efficacy of surgical treatment of multisegmental thoracolumbar tuberculosis.