颈胸段脊柱结核的手术治疗

Surgical treatment of cervicothoracic spinal tuberculosis

目的探讨颈胸段脊柱结核的术式选择和临床疗效。方法总结2000年5月至2005年12月手术治疗的颈胸段脊柱结核25例。男15例，女10例；年龄23-66岁，平均47．5岁。C71例，C7T1 4例，C6-T1 2例，Cλ-T2 3例，T1.2 4例，T1-3 2例，T2.3 4例，T2-4 3例，T3-4 2例；合并截瘫17例，按Frankel分级：B级3例，C级8例，D级6例；病变节段后凸Cobb角5．0^o～65．0^o，平均32．5^o。17例行经前方入路病灶清除、椎间植骨加前路钢板固定术，其中下颈椎低位前方入路10例，下颈椎低位结合胸骨柄劈开入路7例；2例行高位经胸入路病灶清除，植骨内固定术；6例行经后路病灶清除、植骨内固定术。术后继续抗结核治疗9-18个月。结果随访时间18-84个月，平均34．8个月。1例术后出现乳糜漏，行纵隔引流10d后愈合；2例喉返神经受损，3个月后症状均缓解；1例窦道形成，经换药后4周治愈；胸膜撕裂1例，术中修补；前路钢板螺钉置入椎间隙1例，后路椎弓根螺钉松动1例。在随访期内未见复发。合并截瘫者11例完全恢复，5例部分恢复，1例D级者无恢复。术后6-12个月，23例植骨融合，2例至最终随访时骨融合不确切。术后Cobb角平均13．4^o（-8．0^o-24．0^o），随访末Cobb角平均15．2^o（-8．0^o-27．0^o）。结论颈胸段脊柱结核的术式选择应根据病灶的位置及累及范围而定，前路钢板或后路椎弓根内固定都能为颈胸段提供良好的稳定性，内固定的应用有利于彻底减压、矫正畸形，促进截瘫恢复和病灶愈合。

Objective To evaluate the surgical approach and clinical effect of operative procedures in the treatment of cervicothoracic spinal tuberculosis. Methods From May 2000 to December 2005,25 patients with cervicothoracic spinal tuberculosis were treated using different operative procedures. There were 15 men and 10 women, ranging in age from 23 to 66 years （Average age： 47.5 years）. The lession was at C7 in 1 patient, C7T1 in 4, C6-T1 in 2,C7-T2 in 3,T1.2 in 4,T1-3 in 2,T2.3 in 4,T2-4 in 3,T3.4 in 2. The average preoperative kyphotic angle was 32.5^o （range 5.0-65.0^o）. The operative procedures included supramanuhrial cervical anterior approaches in 10 cases and transmanuhrial procedures for dehridement, fusion, and plate-screw fixation in 7 cases, upper lateral transthoracic procedures for debridement, fusion, and rodscrew fixation, posterior dehridement in 2 cases, and posterolateral fusion, and transpedicular screw system fixation in 6 cases. All patients suffered anti-tuberculosis theropy for 9-18 months. Results The follow-up period ranged from 18 to 84 months （mean, 34.8 months）. All patients survived surgery. Complications included chylorrhea in l, cured after mediastinum drainage; laryngeal nerve injury in 2; sinus formation in l, recovered with appropriate treatment; pleural leakage in l, repaired during operation; loosing of screw in l; screw inserted into disc space in 1. The infection were cured in all patients. Bony fusion was achieved in 23 patients 6-12 months after operation. Unsuccessful fusion occured in 2 patients at final follow-up. The average kyphotic angle was corrected to 13.4^o （range -8.0-24.0^o） after operation and 15.2^o （range -8.0-27.0^o） at final follow-up. Among 17 cases with neurologic deficit, 11 were completely recovered, 5 were partly improved,1 with Frankel D＇s neurologic deficit was not improved. Conclusion Different operative procedures should he selected to treat cervicothoracic spinal tuberculosis according to the degree and sites of lesions. Aggressive surgical treatment was found helpful in the resolution of inflammatory process and recovery of neurological deficit, Instrumentation fixation enables accurate and lasting deformity correction and provides adequate stability to allow early mobilization.