微创方法提高病灶内药物浓度治疗脊柱结核的临床分析

Raising drug content in lesions by minimal invasive surgery to treat spinal tuberculosis: report of 210 cases

目的探讨微创方法提高病灶内药物浓度治疗脊柱结核的适应证和疗效。方法2002年1月至2007年12月间收治应用微创方法和外科方法治疗脊柱结核患者210例。分为3种治疗方法,单纯微创治疗(A)组166例(占79.05%),其中20例有脊髓神经损伤;微创手术的方法是在CT引导下,在原发病灶和流注脓肿内放置注药管和/或双腔灌注冲洗管,然后定期或者持续给药的临床治疗方法。开放手术联合微创治疗(B)组35例,其中13例有脊髓神经损伤;19例为术前经过病灶内置管冲洗引流后开放手术,另外16例为开放手术后局部置管注射药物,时间为2～3周。提高病灶内的方法为经皮穿刺病灶内放置硬膜外管,进行局部注射药物和/或经皮放置双腔管对病灶进行灌注冲洗,治疗的时间为2～4个月,局部注射的药物为异烟肼。单纯开放手术(C)组9例,其中5例有脊髓神经损伤。开放手术的方法为前路、后路或者前后路联合手术。结果A组灌注冲洗管放置顺利,无术中、术后并发症。局部化疗的时间(56±15)d;置管部位未形成窦道和交叉感染,随访时间(1.5～7.5)年,没有神经症状的患者均完全康复,有脊髓神经损伤的患者16例康复,4例改善。B组中没有脊髓神经损伤的患者完全康复,2例ASIAA级的患者没有恢复。C组中没有脊髓神经损伤的患者完全康复,1例ASIAA级的患者围手术期死亡。结论微创方法提高病灶内药物浓度是本组治疗脊柱结核的主要方法,开放手术依然是治疗严重脊柱结核的重要方法。

Objective To explore the indication and efficiency of raising drug content in the tuberculous lesions with minimal invasive surgery （ MIS） . Methods A total of 210 patients with spinal tuberculosis admitted from Jan. 2001 to Dec. 2007 and received surgical treatment were retrospectively analyzed. The patients were divided into 3 groups according to the approach they got. Group A （ 166 patients,79. 05% ） ,including 20 patients with nerve compression,received simply MIS. MIS was carried out by placing injecting tube and double lumen lavage tube in the lesions to flow abscess under CT guidance. Then clinical therapy of regular or continuous medical injection was applied. Group B included 35 patients who received combination of opened surgery and MIS,among whom there were 13 patients with nerve compression. There were 19 patients receiving open surgery after placing lavage tube into lesion,and the left 16 patients received local medical injection after open surgery,lasting 2 to 3 weeks. The method to raise drug content in the lesions was to place epidural tube through percutaneous puncture. Then local medical injection and/or lavage through double lumen tube were given,and this therapy spanned 2 to 4 months. Drugs for local injection were isoniazid,streptomycin and rifampin. Group C had 9 patients who only received open surgery,and there were 5 patients with nerve compression among them. Methods of open surgery were anterior,posterior or the combination of the 2 ways. Results In group A,all lavage tubes were placed smoothly,and no complication was discovered pre-and post-operatively. The local chemotherapy time was 56 ±15 d. There was no sinus and cross infection near tubes. During the follow-up of 1. 5 to 7. 5 years,the patients without nerve compression had recovered completely,16 cases with spinal nerve damage were fully recovered and the rest 4 cases were improved. Patients without spinal nerve damage in group B have recovered while 2 ASIA A level patients were not cured. In group C,patients without spinal nerve damage were fully recovered,and 1 ASIA A patients died in perioperative period. Conclusion Raising drug content in the tuberculous lesions by MIS is a main method in treating spinal tuberculosis,while open technique still plays important role in treating severe spinal tuberculosis.