前方经胸骨人路治疗上胸椎结核

Anterior transsternal approach for the upper thoracic vertebral tuberculosis

目的探讨经胸骨人路治疗上胸椎（T1-4）结核的手术方法。方法采用经胸骨人路行一期病灶清除、前路减压及植骨内固定融合术治疗上胸椎结核患者16例。男9例，女7例；年龄37-72岁，平均为48．6岁。病变累及部位：T1椎体3例，T2椎体1例，T1.3，椎体4例，T3椎体2例，T3-4。椎体4例，T4椎体2例。对于T1.2。椎体病灶采用头臂干内侧间隙进入，对于T3-4。椎体病灶采用头臂干外侧间隙进入。术前按Frankel分级：A级2例，B级1例，C级2例，D级6例，E级5例。术前胸椎后凸Cobb角为15^o-40^o，平均为22．0^o±3．5^o。术后随访6-72个月。结果患者均能很好地耐受手术，术中显露清楚，病灶清除彻底。手术时间为120-150min，出血量为300-600ml，无手术并发症发生。术后胸椎后凸Cobb角10^o-25^o，平均17．0^o±2．5^o，平均矫正5^o。所有患者都得到随访，随访中结核无复发，患者的自觉症状均有好转，末次随访时11例合并有神经系统症状者，1例A级恢复到D级，1例B级恢复到C级，2例C级恢复到D级，4例D级恢复到E级，1例A级和2例D级术后无变化。无断钉及内固定失效发生。所有植骨均愈合，植骨愈合时间3-6个月，平均4．2个月。结论经胸骨人路可以清晰地暴露上胸椎，达到一期病灶清除、前路减压及植骨内固定治疗上胸椎结核目的。

Objective To study an anterior transsternal approach for treatment of the upper thoracic （T1-T4） tuberculosis. Methods 16 patients with upper thoracic tuberculosis underwent anterior decompression and fusion with sternotomy. There were 9 men and 7 women with the mean age of 48.6 years （ranged from 37 to 72 years）. The involved area included T1 in 3 patients, T2 in 1 patient, T2.3 in 4 patients, T3 in 2 patients, T3.4 in 4 patients, T4 in 2 patients. For T1 and T2 lesion, we used “inside window of brachiocephalic artery” to get the lesion site, and for T3 and T4 lesion, we used the “outside window of brachiocephalic artery”. According Frankel grade system, there were 2 patients with Grade A, 1 with Grade B, 2 with Grade C, 6 with Grade D and 5 with Grade E. The kyphosis Cobb＇s angle ranged from 15^o-40^o before operation, with the mean angle of 22^o±3.5^o. The patients were followed up for 6-72 months. Results All patients stood surgery well. The operation time was 120-150 min and the bleeding during operation was 300-600 ml. There was no postoperative complication. After surgery, pain relief was seen in all patients. The kyphosis Cobb＇s angle ranged from 10^o-25^o after operation, with the mean angle of 17^o±2.5^o. The mean correction of kyphosis angle was 5^o. 1 patient in Grade A improved to Grade B, 1 patient in Grade B improved to Grade C, 2 patients in Grade C improved to Grade D, 4 patients in Grade D improved to Grade E, without any changes in 1 case Grade A and 2 cases Grade D. During the follow-up period, all cases healed without any recurrence. There was no breakage of nails or fall of the internal fixation. Spinal bone fusion occurred after 3-6 months （median time, 4.2 months） after bone graft in all patients. Conclusion Upper thoracic vertebrae can be exposed with sternotomy. This approach can provide excellent access to the upper thoracic tuberculosis.