脊柱结核合并截瘫再手术分析（附32例报告）

The Reasons for Failure of Operation for Spinal Tuberculosis Complicated with Paraplegia： a Clinical Analysis of 32 Cases.

目的探讨脊柱结核合并截瘫手术失败的原因及再次手术方法。方法回顾性分析1993-2004年收治的手术治疗失败的脊柱结核合并截瘫病例，其中男18例，女14例；颈胸椎3例，胸椎19例，胸腰椎10例。累及椎体数1-8个，平均4．5个；第一次术前抗结核药物治疗时间0-9个月不等；由前路开胸减压手术17例。肋骨横突切除侧后方减压15例：术后22例给予抗结核治疗。其中术后16例病人截瘫有所改善（短期改善9例，3个月改善3例，6个月改善4例）。17例截瘫没有改善；2例损伤脊髓截瘫加重；另术后合并瘘管形成6例，继发肺结核1例，结核性脑膜炎1例，脊髓本身结核1例。全身结核瘫状明显伴有高热4例。结果23例选择前路开胸病清减压手术。同时给予植骨，其中9侧行钛板内固定：5例行侧后方经胸廓胸膜外减压术，2例行单纯瘘管搔刮病灶清除术，术后继续抗结核治疗。其中22倒截瘫完全恢复，6例部分恢复；另脊柱结核完全治愈。结论脊柱结核合并截瘫治疗失败的原因为：抗结核治疗不合理；合并它处结核：多椎体结核；手术时机、手术方式选择不合理；手术减压范围不够以及脊髓神经结核和脊髓受压变性等情况。成功的关键是：在有效的抗结核化疗基础上，严格掌握手术适应证，选择合理的手术时机和手术途径，彻底地减除病灶对脊髓的压迫。重建脊柱的稳定性。

Objective To explore reasons for failure of surgery for spinal tuberculosis complicated with paraplegia and reoperatire technique. Methods Total of 32 eases （18 males,14 females） with spinal tuberculosis complicated with paralegia admitted to our hospital treated with unsueeeeded operation were analyzed retrospectively. Diseased localisatiom were dorsal-thoracic （3/32）, thoracic （19/32） and thoracic-lumbar （10/32）. All patients had lesions on 1 to 8 vertebrae（average：4.5）.The course of anti-tuberculosis chemotherapy before the first operation remained 0 to 9 months, and 22 patients kept on the chemotherapy postoperatively. 17 patients received anterior approach debridement surgery while the other 15 patients received posterior approach debridement surgery. After the first operation, paraplegia was improved in 13 patients （9 were short-term improvement, 3 for 3 months,4 for 6 months）,and 17 failed,2 worsen. Besides 6 patients had sinus, 1 had secondary pulmonary tuberculosis, 1 had tuberculosis meningitis, 1 had spine cord tuberculosis, 4 had systemic poisoning symptom with high fever after the 1st surgery. Results 23 patients were treated by anterior debridement, decompression and graft placement （9 received the single-stage posterior instrumentation）. 5 patients received posterior debridement and decompression,2 patients were given sinus debridement surgery. All patients were given anti-tubereulosis chemotherapy. The paraplegia was recovery completely in 22 patients, and 6 acquired improvement. Conelasions The causes for failure of operation for spinal tuberculosis complicated with paraplegia are irregular chemotherapy, multiple vertebral body tuberculosis, combined with other organs tuberculosis and mistaken selection of operative modalities and improperly timing. The condition is also related to inadequate surgical decompression, tuberculosis or lesions of the spinal cord and certain degenerative changes. The proper selection of operative modalities and timing plus systematically anti-TB chemotherapy remains the best modality of therapy for spinal tuberculosis complicated with paraplegia. And it is also essential to choose a radical debfidement surgery and reconstruct the stability of spine.