一期前后路联合手术治疗胸椎多节段结核

One-stage combined anterior and posterior approaches in the treatment of multiple-level thoracic spinal tuberculosis

目的:评价一期前后路联合手术治疗胸椎多节段结核的疗效。方法:1998年5月至2005年11月共收治28例多节段胸椎结核患者,病变累及3个椎体9例,4个椎体8例,5个椎体7例,6个及6个以上椎体4例。患者均有低热、盗汗等结核中毒症状,体重减轻19例,胸背部显著疼痛25例,腰骶部疼痛3例。血沉58～126mm/h,平均73.7mm/h,合并椎旁脓肿19例,术前胸椎后凸Cobb角27°～108°,平均61.5°,伴有脊髓神经功能损伤27例,Frankel分级A级9例,B级7例,C级8例,D级3例,均采用一期后路钉棒或钩棒系统内固定联合前路病灶清除、自体髂骨植骨或钛网植骨融合术治疗,随访观察患者胸椎后凸改善和神经功能恢复情况。结果:平均手术时间5.6±0.7h,平均出血890±130ml。术中1例由于T4椎弓根较小无法置钉而改用钩棒系统固定。1例发生胸膜撕破,行术中缝合,术后无并发症发生;1例术后出现乳糜漏,行纵隔引流14d后愈合;1例左下肢回流不畅,给予抬高患肢,被动肢体活动,2周后好转;2例患者腹部皮肤出现麻木疼痛,给予非甾体类镇痛消炎药物西乐葆口服后症状消失;1例术后早期出现呼吸功能衰竭,给予呼吸机辅助通气7d后脱机好转,肺功能正常。无大血管、神经损伤,无死亡病例,无伤口深部感染或窦道形成。伤口均一期愈合。术后2周所有患者低热、盗汗等结核中毒症状消失;24例胸背部疼痛及3例腰骶部疼痛者症状消失,1例背部疼痛患者半年后自行缓解。随访11～22个月,平均17.3个月。1～2个月后血沉均恢复正常,末次随访时未见结核复发,均获得骨性愈合。术后1周时后凸Cobb角21°～33°,平均24.7°,末次随访时为24°～35°,平均26.3°,无1例出现椎旁脓肿复发。神经功能除A级2例、B级1例无变化外,其余患者神经功能均有不同程度恢复。结论:对于多节段胸椎结核患者一期行前后路联合手术效果好,能同时解决病灶清除、减压、稳定、融合等问题。

Objective：To evaluate the curative effect of one-stage combined anterior and posterior approaches in the treatment of multiple-level thoracic spinal tuberculosis.Method：From May 1998 to November 2005,28 patients with consecutive multiple-level thoracic spinal tuberculosis were treated with one-stage combined anterior and posterior approaches.The segments of thoracic vertebrae were involved from three to six（median：4.3 segments） ,including three segments in 9 cases,four segments in 8 cases,five segments in 7 cases,six or more than six segments in 4 cases.All patients had moderate fever,night-sweat,fatigue,19 cases had weight loss,25 cases had back pain,3 cases suffered lumbosacral area pain,and erythrocyte sedimentation rate（ESR） ranged from 58 to 126mm/h （median：73.7mm/h）,19 cases had paravertebral abscess,the preoperative Cobb angle of kyphotic deformity ranged from 27° to 108°（median：61.5° ）.27 cases had neurological deficits （9 cases in Frankel A,7 cases in Frankel B,8 cases in Frankel C,and 3 cases in Frankel D）.All the cases underwent one-stage combined anterior debridement with iliac bony fusion or titanium net bony fusion,and posterior pediele screw-rod or hook-rod fixation.To observe the improvement of thoracic spinal kyphotic deformity and recovery of neurological deficits.Result：The operative time was 5.6±0.7h on an average,and the average blood loss was 890±130ml.In one case,the diameter in the 4th thoracic pedicles was too small to place the pedicle screws,so hook-rod system was used instead.However,chyle leakage happened postoperatively in 1 case,and healed after mediastinum drainage in 2 weeks.1 case had pleural membrane laceration,it was sutured during operation and no complication occurred after operation.1 case had edema of left limb,the symptoms subsided in 2 weeks by raising limb effectively and passive motion of the limb.2 patients felt pain and numbness in abdominal skin,which were relieved by medication with NSAIDs-Celecoxib Capsiles 1 case had respiratory function failure at the early stage of postoperation,the pulmonary, function became normal in seven days by breathing machine assisted breath.There were no injuries of large blood vessels and nerves,no death case,no case with deep infection of incision and sinus.The symptoms of moderate fever,night-sweat,fatigue vanished in 2 weeks,24 cases with back pain and 1 case with lumbosacral area pain got better,1 case with back pain was relieved in 6 months without any treatment.Time of follow-up ranged from 11 to 22 months（median：17.3 months ）.All of the incisions healed and ESR became normal after 1 or 2 months.The bony fusion occured in a year,and the Cobb＇s angle ranged from 21° to 33°（median：24.7°） in a week of postoperation,and the angle was from 24° to 35°（median：26.3°） at the final follow-up.There was no palindromia sign of paraverte- bral abscess for all cases.Except for 2 cases in grade A,1 case in grade B,the neurological function of other cases had recovered to some extent.Conclusion：To the multiple-level thoracic spinal tuberculosis,especially with paravertebral abscess,the combined anterior and posterior approaches in one-stage is an effective method. It can complete debridement,decompression,stabilization and fusion simultaneously.