脊柱结核合并脊髓损伤患者的手术治疗

目的探讨在化疗基础上，一期手术病灶清除、植骨、内固定治疗脊柱结核伴脊髓损伤的临床疗效。方法回顾性分析2003年4月至2011年4月，我科收治的脊柱结核并脊髓损伤患者42例。根据脊髓损伤神经学国际标准（americanspinalinjuryassociation，ASIA）神经功能评分进行ASIA残损分级，B级14例，C级19例，D级9例。在标准化疗基础上根据脊髓损伤发展情况，24例化疗后3～4周手术，18例化疗未达2周，但脊髓损伤症状进行性加重或脓肿较多而进行手术。采用一期病灶清除、植骨、内固定手术治疗，术后严格强化四联抗结核治疗，术后3个月改三联化疗9～15个月。神经功能障碍改善情况采用ASIA神经功能评价，对其神经功能恢复、病灶愈合及内固定情况等进行分析研究。结果所有患者随访18～40个月，平均24个月。经X线、CT或MRI检查，病灶无残留，后凸角度矫正满意，随访无明显丢失；所有病例ASIA神经功能评价最终随访均得到明显好转，术前感觉评分（90.93±35.59），运动评分（51.04±11.86）；末次随访感觉评分（185.58±30.41），运动评分（85.21±11.48），和术前比较差异有统计学意义（P＜0.01）；所有病灶治愈，骨性愈合，无1例结核复发；无断钉、断棒及内固定松动、窦道形成等相关并发症。结论脊柱结核伴神经压迫多缓慢产生，症状持续时间越长、瘫痪越重，预后越差，应在标准化疗基础上尽早手术，一期病灶清除、植骨、内固定治疗，效果满意。

Surgical treatment of spinal tuberculosis with spinal cord injury

Objective To investigate the clinical results of one-stage radical debridement, bone graft and internal fixation for spinal tuberculosis combined with nerve injuries on the basis of chemotherapy. Methods 42 patients with spinal tuberculosis combined with nerve injuries were adopted from April 2003 to April 2011, whose data were retrospectively analyzed. According to the damage classiifcation of neurological severity scores of American Spinal Injury Association （ ASIA ）, there were 14 cases of grade B, 19 cases of grade C and 9 cases of grade D. Based on the standard chemotherapy and the severity of nerve injuries, 24 patients underwent the operation after receiving chemotherapy for 3 to 4 weeks. And while, 18 patients underwent the operation after receiving chemotherapy less than 2 weeks due to the progressively aggravated spinal cord injuries or increased abscess. One-stage radical debridement, bone graft and internal fixation were performed, with quadruple anti-tuberculosis treatment strictly strengthened postoperatively. And 3 months later, the triple chemotherapy was performed for 9 to 15 months. The improvement of neurological dysfunction was evaluated according to the ASIA neurological function evaluation, and the recovery of neurological function, lesions healing and internal fixation were analyzed. Results All patients were followed up for an average period of 24 months （ range;18-40 months ）. Through the examinations of X-ray, CT or MRI, no residual lesions were found and no notable follow-up data were lost, with satisfactory correction of the kyphotic angle. According to the ASIA neurological function evaluation, signiifcant improvement was achieved in all patients in the latest follow-up. The preoperative sensory score was （ 90.93±35.59 ） and motor score was （ 51.04±11.86 ）, and while the sensory score and motor score were （ 185.58±30.41 ） and （ 85.21±11.48 ） in the latest follow-up. Statistically signiifcant differences existed between them （ P〈0.01 ）. All lesions were healed with bony union, and no recurrence of tuberculosis was found. No related complications occurred, such as broken nails, broken rods, internal ifxation loosening, sinus formation and so on. Conclusions Most spinal tuberculosis combined with nerve compression occurs slowly. If the duration of symptoms becomes longer, the paralysis will be more severe and the prognosis will be worse. The operation should be performed as soon as possible based on the standard chemotherapy, including one-stage radical debridement, bone graft and internal ifxation, and satisfactory results will be achieved.