陈旧性胸腰椎结核后凸畸形继发截瘫的危险因素分析

Risk factors of paraplegia secondary to post-tubercular thoracic or thoracolumbar kyphosis

目的总结陈旧结核性胸腰椎后凸畸形患者的病例特点，分析其继发截瘫的危险因素。方法以自1995年3月至2006年12月确诊陈旧结核性胸腰椎后凸畸形并住院手术治疗者为研究对象，回顾性总结其病例资料，对比分析截瘫与未截瘫组的性别、胸腰椎结核发病年龄、病程、病变导致塌陷并融合的椎体数、后凸顶点所在节段、后凸角度、既往病灶清除手术史等因素的差异。结果22例均于胸腰椎结核发病后半年至2年出现胸腰椎后凸畸形，后凸畸形缓慢进行性加重，后凸角度（Cobb法）平均90．7°（48°-130°），15例继发不全截瘫，7例无脊髓功能异常。15例不全截瘫者中，男9例，女6例，确诊胸腰椎结核年龄平均8．4岁（1-33岁），病程平均24．4年（4-52年），术前后凸角度平均86．8°（48°-120°），7例曾行病灶清除术。7例未截瘫者中，男3例，女4例，确诊胸腰椎结核年龄平均6．4岁（1-22岁），病程平均13．4年（7-26年），术前后凸角度平均97．6°（73°-130°），4例曾行病灶清除术。按其后凸顶点所在节段分组，上胸椎（T1-4）后凸者100％继发截瘫（5／5例），中胸椎（T5-8）后凸者80％继发截瘫（4／5例），胸腰段（T11-L1）后凸者50％继发截瘫（6／12例）。统计学分析结果显示两组的结核病程、后凸顶点所在节段、塌陷椎体数差异有统计学意义（P〈0．05），两组的后凸角度差异无统计学意义（P〉0．05）。结论对于45°以上的重度陈旧结核性胸腰椎后凸畸形，尤其是青少和中、上胸椎后凸者，建议尽早手术治疗；对于重度陈旧结核性胸腰椎后凸畸形而言，其后凸顶点所在节段越靠近头端，塌陷椎体数越少，继发截瘫的危险性越高。

Objective To investigate the characteristics of the patients with post-tubercular kyphosis, and analyze the risk factors related to the late onset paraplegia. Methods Retrospectively summarize the characteristics of the patients who were diagnosed as post-tubercular kyphotic deformity （n=22）, and group the patients according to paraplegia or not, then analyze the differences of sex, tubercular age, duration, number of the collapsed vertebral bodies, kyphotic apex, kyphotic angle, and radical debridement operation history. Results Most patients＇ kyphotic deformity appeared during the period from half a year to two years after the spinal tuberculosis occured, and gradually progressing during the duration. The kyphotic angel before operation was 90.7 averagely. 15 of the 22 patients had late onset paraplegia, and the other 7 cases were still normal in spinal cord function. 22 cases were grouped according the kyphotic apex, and 100% （5/5） suffered paraplegia when the apex was in upper thoracic spine （T1-4）, while 80% （4/5） in midthoracic spine （T5-8） and 50% （6/12） in lower thoracolumbar spine （T11-L1）. The spinal tubercular duration, kyphotic apex, the number of collapsed vertebral bodies were remarkably different between the two groups with or without paraplegia （P〈 0.05）, while the kyphotic angle wes not remarkably different （P 〉0.05）. Conclusion Severe thoracic or thoracolumbar kyphotic deformity whose Cobb angle is bigger than 45°should be operated as early as possible, especially for the adolescent cases and those cases whose kyphosis apex locates in the upper thorax spine; For the severe kyphosis, more upper the kyphotic apex is, and less collapsed vertebral bodies are, more probably the late onset paraplegia will happen.