胸腰段脊柱结核伴截瘫的外科治疗

目的：探讨Ⅰ期前路病灶清除植骨融合内固定治疗胸腰段脊柱结核伴瘫痪患者的手术时机、手术指征及临床疗效。方法：对2006年3月至2008年9月应用Ⅰ期标准前路手术（经胸腹入路病灶清除、钛笼支撑、自体骨植骨、钉板或钉棒内固定）治疗的56例胸腰段结核伴截瘫患者的临床资料进行回顾性分析,其中男36例,女20例,年龄19～78岁,平均42.5岁。病程3个月～4年。病变节段为T11-L2,累及椎体数目：1个椎体6例,2个椎体42例,3个椎体7例,4个椎体1例。所有患者均有不同程度的截瘫表现,Frankel分级：A级5例,B级25例,C级21例,D级5例。术前Cobb角小于30°者30例,30°～60°者24例,大于60°者2例,平均（35.0±3.3）°。术前疼痛视觉模拟评分（VAS）为7.3±2.1。所有病例术前均进行强化化疗,时间2～3周。术后通过观察Cobb角、VAS评分、Frankel分级、骨性融合情况对疗效进行评定。结果：术后随访12～38个月,平均24个月。伤口均Ⅰ期愈合,术后即刻Cobb角（19.0±5.5）°,随访时丢失（1.8±0.7）°,术后VAS评分为1.4±0.3,末次随访时1.3±0.4。术后Cobb角、VAS评分与术前比较,差异均有统计学意义（P〈0.05）,术后与末次随访时比较无明显差异（P〉0.05）。随访1年时56例患者均获骨性融合。51例不完全性截瘫患者,经过术后1～1.5年标准化疗方案化疗及神经功能锻炼,Frankel分级全部恢复到D级以上,5例完全截瘫患者有3例恢复至C级以上,2例恢复至B级。结论：胸腰段结核伴截瘫在抗结核药物治疗的基础上,根据引起截瘫原因、部位及全身情况的不同,选择不同的手术时机,行Ⅰ期前路彻底病灶清除,椎体间自体骨植骨、内固定,能有效的解除脊髓压迫,稳定脊柱,减少脊柱后凸畸形,促进截瘫恢复。

Surgical treatment for the thoracolumbar spinal tuberculosis with paraplegia

Objectives: To explore the long-term effects, operating opportunity, indication of anterior debridement and decompression and bone graft in treating thoracolumbar tuberculosis with paraplegia. Methods: From March 2006 to September 2008, the data of 56 patients with spinal tuberculosis were retrospectively analyzed. They were 36 cases male and 20 cases female, the age in ranging from 19 to 78 years with the mean of 42.5 years;course of disease in ranging from 3 months to 4 years.The lesion level was in T₁₁-L₂, including one stage in 6 cases, two stages in 42 cases, three stages in 7 cases, four stages in 1 case.According to the Frankel grade, grade A in 5 cases, B in 25, C in 21, D in 5. Preoperative Cobb angle had 30 cases under 30°, 24 cases in 30°-60°, 2 cases more than 60°[averaged in (35.0±3. 3)°]. The mean VAS was 7.3±2.1 preoperatively. All patients had chemotherapy for 2-3 weeks. The clinical effects were evaluated by Cobb angle, VAS, condition of Frankel grade and fusion segments. Results: All patients were followed up from 12 to 38 months with an average of 24 months. All wound obtained primary healing. The Cobb angle was(19.0±5.5)° immediately after operation, and lost(1.8±0.7)°at the follow up. The mean VAS was 1.4±0.3 postoperatively and 1.3±0.4 at final follow up. The Cobb angle and VAS significant improved in postoperatively(P<0.05), and there was no statically difference between after operation and last follow up(P>0.05). At 1 year after operation, all patients obstained successful bony fusion. Among 51 cases incomeplete paraplegia recovered partially or completely(over Frankel D) through chemotherapy and rehabilitation training for 1-1.5 years;5 cases of complete paraplegia had partially recovered, 3 cases from Frankel A to C, 2 cases from Frankel A to B. Conclusion: Base on the chemotherapeutic effect, paraplegia reason and location, total body condition to select different operative opportunity can effectively relieve spinal compression, stabilize spinal column, correct kyphosis and promote recovery of paraplegia.