一期前后路手术治疗合并严重后凸畸形的胸腰椎活动性结核

One-stage combined anterior and posterior strategy in treating active tuberculosis of thoracic and lumbar spine complicated with severe kyphotic deformity

目的探讨合并严重后凸畸形（后凸角度≥45°）的活动性胸腰椎结核的合理治疗方案。方法回顾性分析2004年1月至2008年1月治疗的30例合并严重后凸畸形的活动性胸腰椎结核患者的临床资料。其中男性8例，女性22例，年龄7～60岁（平均35岁），病程3—18个月（平均8个月）。后凸角度45°～70°（平均58°）。30例均有较大的椎旁脓肿，28例合并椎管内脓肿，10例合并不完全性截瘫（Frankel分级B级2例、C级6例、D级2例）。HREZ方案化疗至少2周后手术治疗，先行后路多节段椎弓根螺钉植入（6～10枚），通过钉棒连接产生提拉力使后凸矫正；再经前入路清除脓肿、部分或全部切除病变椎体，行支撑性植骨重建。术后化疗方案为6HREZ／6～12HRE。对所有病例的后凸角度、术后矫正效果和神经功能恢复程度进行比较分析，同时观察患者的红细胞沉降率和植骨融合情况。结果手术时间4～6h（平均5．2h），出血量600～900ml（平均760ml），围手术期无严重并发症发生。后凸角纠正至0°～10°，最大纠正65°。随访1～4年（平均1．5年），术后6个月所有患者的结核病灶均治愈。术前合并瘫痪者，2例FrankelB级者恢复至D级，其余8例均恢复至E级。末次随访时未见内固定松动断裂及结核复发征象。结论一期后路多节段椎弓根螺钉固定矫形联合前路病灶清除植骨融合，是治疗合并严重后凸畸形的活动性胸腰椎结核安全、有效的方案。

Objective To explore an effective and reasonable surgical strategy for active spinal tuberculosis with severe kyphotic deformity （kyphotie angle ≥ 45°）. Methods From January 2004 to January 2008, 30 consecutive patients of active spinal tuberculosis complicated with significant angulation were enrolled in this study, including 8 male and 22 female. The average age was 35 years （range, 7-60 years） , with average angle of kyphosis of 58° （range, 45°-70°）. There were 28 patients complicated with intraspinal abscess, of which 10 patients presented with incomplete paraplegia. According to the Frankel＇s scoring system, there were 2 patients with Frankel Grade B, 6 with Grade C, 2 with Grade D. After antituberculous chemotherapy （HREZ） for at least 2 weeks, all patients underwent posterior multiple-level pedicle screw instrumentation and kyphotic correction, and then received anterior debridement, decompression and supportive bone grafting, all of which were completed in the same day. The postoperative standardized chemotherapy was 6HREZ/6-12HRE. The angle of kyphosis, curve correction after surgery, and recovery of paraplegia were analyzed. Fusion status and erythrocyte sedimentation rate were recorded to determine the presence of active disease. Results Operative time was 4 to 6 hours （ average 5.2 h）, blood loss was 600 to 900 ml （average 760 ml）. No perioperative severe complications occurred. The kyphotic angle was corrected to 0°-10°, and the maximum corrected angle was 65°. The average follow-up duration was 18 months （range, 12-48 m）. All patients showed evidence of solid fusion and healing of the active disease at 6 months follow-up. Neurologic deficits were improved： 2 patients from B to D, 6 patients from C to E, 2 patients from D to E. No recurrence of the tuberculosis infection or instrumentation failure happened at final follow-up. Conclusion Combined posterior instrumentation and anterior debridement, fusion surgery in one stage is proved to be successful in treating spinal tuberculosis, correcting the kyphosis, and providing solid fusion.