脊柱结核再次手术原因分析及治疗方案选择

目的 回顾性分析脊柱结核再次手术的原因,并对个体化手术结果进行随访观察.方法 对三个脊柱外科中心24例再次手术的脊柱结核患者进行原因分析,并针对不同原因采用个体化治疗.再次手术方式:单纯病灶清除术14例,病灶清除、窦道切除术5例,一期病灶清除、植骨融合内固定4例,二期病灶清除植骨融合、前后路联合固定1例.术后加强抗结核药物治疗12～18个月,定期观察红细胞降率、X线片、CT三维重建,评估结核活动及植骨融合情况.结果 再次手术为多因素作用的结果,主要原因有病灶清除不彻底、化疗方案不合理、全身营养不良、脓腔处理不当、内植物选择不当等.再次手术中无大血管、神经、输尿管损伤.再次手术后随访12～36个月,平均20个月,结核病变无复发.根据Bridwell标准,17例椎间植骨内固定患者植骨均融合,另7例患者椎间骨桥形成.结论 脊柱结核再次手术原因复杂,为多因素共同作用的结果,治疗难度大.术前应详细分析其复发的主要原因,加强营养支持治疗,强调个体化的药物治疗和手术治疗.

The reasons and methods of resurgery for spinal tuberculosis- a retrospective multicenter study

Objective To analyze the reasons of resurgery for spinal tuberculosis retrospectively and investigate the clinical outcomes in patients underwent individual surgery. Methods From June 2003 to June 2006, 24 spinal tuberculosis patients in 3 spine centers underwent resurgery, which included 11 males and 13 females, with the mean age of 27.3 years ( range 8-60 years). The reasons of resurgery were anal-ysed. Individual surgery was performed according to the major reason: 14 cases with debridement, 5 with de-bridement and sinus resection, 4 with single stage debridement, interbody fusion, and anterior inernal fixa-tion, 1 with double stage debridement, interbody fusion, combined anterior and posterior inernal fixation. All patients were followed regularly,and treated by antituberculous chemotherapy for 12-18 months. The ESR, roentgenogram and 3D-CT were concerned to estimate the progress of tuberculosis and evaluate bony fusion. Results The complicated reasons included: inadequate debridement, unreasonable antituberculosis regi-mens, malnutrition, improper management of abscess cavity, misuse of internal implant. There was no injury of blood vessel, ureter or cauda eguina during the resurgery. The mean follow-up period was 20 months (range 12-36 months), and there was no recurrence in any of these patients. According to Bridwell criteria, bony fusion was obtained in 17 patients with bone graft and internal instrumentation, the other 7 patients were observed with bone bridge between the adjacent vertebraes. Conclusion The resurgery reasons are complicated and muhifactorial. Reasons analysis and detailed surgical plan should be performed preopera-tively, and comprehensive managements include intensified nutrition support, individual antituberculosis therapy and surgery are recommended.