脊柱结核外科治疗的探讨

The clinical evaluation of surgical treatment for spinal tuberculosis

目的总结采用彻底清除病灶和植骨消灭死腔,通过坚强内固定矫正畸形和重建脊柱稳定性治疗脊柱结核的疗效.方法自1996年10月至2002年7月共手术治疗脊柱结核152例,结核病灶位于颈椎15例、胸椎67例、胸腰段17例、腰椎53例,病灶范围1～3个椎体,无跳跃病灶.手术方法:(1)前路一期病灶清除植骨、钢板内固定;(2)经肋横突切除入路行病灶清除植骨、经椎弓根内固定;(3)后方入路行病灶清除、植骨融合和椎弓根内固定;(4)前路病灶清除植骨、后路椎弓根固定.术后配戴支具3～5个月,抗结核药物治疗6～9个月.定期进行实验室检查和影像学观察.结果(1)手术时间和出血量:前后路联合手术平均术时4.5 h,术中平均出血650ml;前路一期病灶清除植骨内固定,平均术时3.5 h,术中平均出血450 ml;其余两种手术平均术时3.0 h,术中平均出血350 ml.(2)手术创伤和并发症:前后路联合手术创伤较大,前路一期病灶清除植骨内固定术次之.手术并发症有大血管破裂1例,暂时性窦道形成5例,内固定器松动和断裂3例.(3)临床疗效:患者术后1～2周症状基本缓解并下床行走,术后6～8周日常生活基本自理,术后6个月X线片显示植骨融合.患者结核病灶全部治愈.结论有效应用抗结核药物是脊柱结核手术成功的前提,坚强内固定有利于矫正后凸畸形、重建脊柱稳定性、促进植骨融合.抗结核药物和病灶彻底清除是内固定安全植入的前提.脊柱结核的外科治疗应该是病灶清除、减压矫形、植骨融合和坚强固定.

Objective To evaluate the clinical efficacy and the surgical treatment of spinal tuber-culosis by debridement, fusion and internal fixation to restore stability of the spine. Methods One hundred and fifty-two patients with spinal tuberculosis were treated surgically between 1996 and 2002. There were 15 in cervical spine, 67 in thoracic spine, 17 in thoracolumbar spine and 53 in lumbar spine. The lesion was of 1-3 levels without jumping lesions. The surgical procedures included: 1) anterior debridement, fusion with autograft and internal fixation with plate. 2) lateral debridement with posterior fusion and pedicle screw fix-ation. 3) posterior debridement, fusion and pedicle screw fixation. 4) anterior debridement and posterior fu-sion and fixation. All patients wore a brace for 3-5 months and chemotherapy was given for 6-9 months postoperatively. The blood test and imaging evaluation were undergone. All patients were followed for 3 to 5 years postoperatively. Results 1) The average operation time and blood loss was 4.5 hours and 650 ml for combined anterior and posterior procedure, 3.5 hours and 450 ml for anterior procedure and 3 hours and 350 ml for the other two procedures. 2) In regard to complications: major blood vessel injury in one case, temporary sinus formation in 5 and loosening and breaking of the instrumentation in 3. 3) All patients had relief of the symptoms and ambulation 1-2 weeks postoperatively. Normal daily function was recovered at 6-8 weeks and solid fusion was observed in 4-6 months postoperatively. All patients were cured of tubercu-losis lesions in spinal column or on other region, and there was no recurrence. Conclusion Effective chemotherapy and radical debridement of the lesion are the basis of success of surgical treatment of spinal tuberculosis. Fusion and internal fixation were the keys for restoration of the stability of spinal column, solid fusion and correction of the kyphotic deformity.