前方经胸骨或侧前方经肩胛下入路手术治疗上胸椎结核

Anterior transsternal or anteriorlateral transthoracic approach for upper thoracic vertebral tuberculosis

目的:探讨前方经胸骨或侧前方经肩胛下入路治疗上胸椎(T1～T4)结核的手术方法及疗效。方法:2000年6月～2008年12月收治上胸椎结核患者26例,其中16例采用经胸骨入路行一期病灶清除、前路减压、植骨融合及内固定术(A组),年龄37～72岁,平均48.6岁,术前神经功能按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′s角为15°～40°,平均22°±3.5°;10例采用侧前方经肩胛下入路行一期病灶清除、减压、植骨融合及内固定术(B组),年龄33～69岁,平均45.3岁,术前按Frankal分级A级1例,B级1例,C级1例,D级4例,E级3例,术前胸椎后凸Cobb′s角为13°～39°,平均21°±3.7°。结果:两组患者均能很好耐受手术。A组患者术中显露清楚,病灶清除彻底,手术时间为120～150min,术中出血量为300～600ml;1例患者术后出现声音嘶哑,考虑为喉返神经牵拉伤,术后2周恢复正常;术后胸椎后凸Cobb′s角为10°～25°,平均17°±2.5°;随访6～72个月,末次随访时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,余无变化。B组患者不能完全显露对侧,病灶清除不易彻底,手术时间为150～220min,术中出血量为500～900ml,1例发生胸导管损伤,经对症治疗1周后痊愈;术后胸椎后凸Cobb′s角9°～24°,平均为16°±2.3°,均有肩关节活动障碍;随访12～96个月,末次随访时4例仍有肩关节轻度障碍;1例A级恢复到C级,1例B级恢复到C级,1例C级恢复到D级,4例D级恢复到E级,其余患者神经功能无变化。两组均无结核复发,无内固定物断裂、松动等并发症。所有植骨均愈合,愈合时间为3～6个月,平均4.4个月。结论:与侧前方经肩胛下入路相比,经胸骨入路可以更清楚地显露上胸椎,创伤小,能达到一期病灶清除、前路减压及植骨内固定治疗上胸椎结核的目的。

Objective：To investigate the surgical protocol and its clinical outcome of anterior transsternal or anteriorlateral transthoracic approach for upper thoracic vertebral tubercuLosis （T1-T4）.Method：A total of 26 patients with upper thoracic tuberculosis from June 2000 to December 2008 were reviewed retrospectively.Of these,16 cases aged from 37 to 72 years old（mean,48.6 years old） underwent one-stage transsternal debridement,decompression,bone graft and instrumentation （group A）.There were 2 patients of Frankel grade A, 1 of grade B,2 of grade C,6 of grade D and 5 of grade E.The kyphosis Cobb＇s angle ranged from 15° to 40° （mean,22°±3.5°）.Another 10 cases aged from 33 to 69 years old（mean,45.3 years old） experienced debridement,decompression,bone graft and instrumentation by anteriorlateral high transthoracic approach （group B）. There were 1 patient of FrankeL grade A,1 of grade B,1 of grade C,4 of grade D and 3 of grade E.The kyphosis Cobb＇s angle ranged from 13° to 39°（mean,21°±3.7°）.Result：All patients in two groups experienced surgery successfully.For group A,good field exposure and complete Lesion clearance were ensured,the opera- tion time was 120-150min and the intraoperative blood loss was 300-600ml.One patient was complicated with recurrent laryngeal nerve injury and healed two weeks after operation.The kyphosis Cobb＇s angle after operation was 10°-25°（mean,17°±2.5°）.All patients in group A were followed up for 6-72 months,at final follow- up, 1 patient of grade A improved to grade D, 1 patient of grade B improved to grade C,2 patients of grade C improved to grade D,4 patients of grade D improved to grade E,while no change was noted in other patients.For group B,unsatisfactory contrallateral exposure and lesion clearance occurred,the operation time was 150-220rain and the blood loss was 500-900ml.One patient had injury to thoracic duct which healed two weeks postoperatively.Scapular joint malfunction was noted in all patients of group B.The mean Cobb＇s angle as for kyphosis correction was 9°-24°（mean,16°±2.3°）.The patients were followed up for 12-96 months,at final follow-up, 1 patient of grade A improved to grade C, 1 patient of grade B improved to grade C, 1 patient of grade C improved to grade D,4 patients of grade D improved to grade E,while no change was noted in other patients.During the follow-up,all cases healed without any tuberculosis recurrence,and no pull-out and breakage of screws or plates were noted.Spinal union occurred at 3-6 months（mean,4.4 months） postoperativ- ely.Conclusion：Anterior transsternal approach can provide excellent access to the upper thoracic tuberculosis and is less invasive compared with anteriorlateral high transthoracic approach.