胸腰椎结核的前路手术治疗探讨

Clinical evaluation of anterior operation for treatment of thoracic or lumbar tuberculosis

[目的]探讨一期前路病灶清除植骨内固定治疗胸腰椎结核的可行性及临床疗效。[方法]自1999年7月～2006年7月对37例胸腰椎结核患者进行一期前路病灶清除植骨内固定。男性21例，女性16例；年龄21～67岁，平均39．6岁。病变节段：T4-10例；T11～L1 11例；L3-5 16例。术前融合节段后凸角（21．5±4．5）°，20例存在脊髓压迫，Frankel B级4例，C级6例，D级10例。术前静脉强化抗痨治疗1～2周，术中根据相应节段选择不同治疗方法，术中彻底清除病灶，21例采用钛网植骨，16例单独应用肋骨或三面皮质髂骨植骨后行前路内固定。术后根据药敏做规则抗痨治疗1年。[结果]全部病例随访0．5～3．5年，平均1．5年，除1例术后第2d死亡，切口均甲级愈合。术后3个月ESR均正常，术后融合节段后凸角为（7．2±3．5）°，终末随访时钛网内固定组丢失（4．2±1．6）°，单纯植骨组丢失，神经功能均有不同程度恢复。[结论]一期前路病灶清除植骨内固定治疗胸腰椎结核时要进行充分有效的药物抗痨治疗，术中清除病灶要彻底，遗留过多的椎间缺损可以通过钛网或人工椎体的植入来弥补单纯植骨的缺陷。

[ Objective] To analyze the feasibility and clinical effect of treating thoracic or lumbar tuberculosis by onestage anterior radical debridement, bone graft and internal fixation. [ Method ] Thirty-seven patients with thoracic or lumbar tuberculosis were treated by one-stage anterior radical debridement, bone graft and internal fixation from July 1999 to July 2006. There were twenty-one males and sixteen females with an average age of 39. 6 years （range 21 - 67 years）. The location of lesions were T4- 10 in 10, T11- L1 in 11, L3-5 in 16. The preoperative kyphosis angle was （21.5 ± 4. 5）°. 20 cases of the patients had spinal compression, Frankel grade was that 4 cases with grade B, 6 cases with grade C, 10 cases with grade D. After intensive anti-tuberculosis medication in vein for 1 - 2 weeks before operation, then underwent radical debridement thoroughly, to select the different methods of treatment corresponding to different segments. 20 patients were reconstructed with Ti-Mesh bone fusion, sixteens were reconstructed with costal or tri-face os integumentale flank bone and anterior internal fixation. After operation, the anti-tubereulosis medication was continued for one year on the basis of the test of medicamentous sensitive. [ Result] All the patients were followed up for 0. 5 to 3.5 years postoperatively, with the average of 1.5 years. All the wounds healed in the first stage except that a patient died in the second day after operation. The postoperative ESR became normal 3 months later, the postoperative kyphosis angle was （7.2 ± 3.5 ） o. The loss angle of kyphosis correction of the team of Ti-Mesh bone fusion and intenal fixation was （4. 2 ± 1.6） °, which of the team of the simple bone graft was （5. 6 ± 2. 1 ）° at lastest follow up, the neural symptoms were all improved in different degree. [ Conclusion ] Radical debridement and sufficient anti-tuberculosis medication are essential for anterior approach operation of thoracic or lumbar tuberculosis. To much defect of vertebra can be implanted by Ti-mesh or artifical vertebra, which can overcome the shortcoming of simple bone graft.