胸椎及胸腰段脊柱结核的外科治疗

Surgical treatment of thoracic and thoracolumbar spinal tuberculosis

目的:探讨胸椎及胸腰段脊柱结核的外科治疗原则及手术入路选择。方法:回顾分析2001年至2008年收治的胸椎及胸腰段脊柱结核病例232例,男148例,女84例;年龄20～76岁,平均37.8岁。术前后凸角度(Cobb角)<30°者65例,30°～60°者147例,>60°者20例。术前FrankelB级13例,C级12例,D级41例,E级166例。48例行单切口双入路手术,184例行经胸或经胸腹Ⅰ期前入路手术。术中清除病灶组织送病理检测和结核杆菌培养及药物敏感试验,术后根据药物敏感试验实行个体化的化疗方案治疗1～1.5年。随访内容包括复发率、植骨融合率、截瘫恢复和后凸畸形矫正状况。结果:232例患者均安全度过围手术期,2例术后伤口不愈,形成窦道,经局部换药治疗后治愈;其余患者术后伤口均Ⅰ期愈合。手术并发症包括肋间神经疼痛或麻木135例,气胸或胸腔积液13例,均无须特殊处理。232例均获随访,随访时间1.0～4.5年,平均2.6年。随访期内结核未见复发,所有出现神经损害的66例患者,神经症状得到改善或完全恢复。所有患者均显示骨性融合,术后后凸畸形平均矫正27.5°,末次随访,后凸角度平均丢失4.2°。所有病例病理检测确诊脊柱结核,107例培养出结核杆菌,阳性率46.1%,40例结核杆菌耐药,耐药率37.4%,其中8例结核杆菌耐多药,耐多药率7.5%。结论:对胸椎或胸腰段脊柱结核,首选的手术方式是经胸或经胸腹Ⅰ期前方入路病灶清除、肋骨或钛笼植骨、钢板内固定术;针对性的抗痨治疗是脊柱结核治疗的关键。

Objective：To explore the surgical measurements and principles in the treatment of thoracic and thoracolumbar spinal tuberculosis.Methods：From 2001 to 2008,232 cases of thoracic or thoracolumbar spinal tuberculosis were treated by operations in the study,including 148 males and 84 females with an average age of 37.8 years ranging from 20 to 76 years.Preoperative assessment displayed as follow：Cobb angles of kyphosis 30° in 65 cases,30° to 60° in 147 cases,60° in 20 cases;Frankel B grade in 13 cases,C in 12 cases,D in 41 cases,E in 166 cases.Among them,48 cases were performed with one stage transpedicular screw system and anterolateral debridement by single incision,184 cases with one stage anterior approach（debridement,fusion,and plate screw fixation） routinely.The tissues and liquor puris debrided from focus were sent for pathological examination,Bacillus tuberculosis detection and culture,and drug sensitivity test.The patients were given anti tuberculosis therapy according the results of drug sensitivity test for 1 to 1.5 years.The followed up included relapse rate,fusion of the bone graft,the status of neurological restoring,kyphosis correction etc.Results：All 232 cases recovered from perioperation and 230 cases got primary wound healing,only 2 cases performed with single incision one stage posterior instrumentation and anterolateral debridement got complications of wound healing problems and the sinus formation,which delayed healed by changing dressings.The complications included intercostals neuralgia in 135 cases and pneumothorax or hydrothorax in 13 cases,which needed not special handling.All the patients in this series got the followed up ranging from 1.0 to 4.5 years（means 2.6 years）.No recurrence within followed up period and bone union was found in all cases.All 66 cases with the neurological deficits recovered partially or totally.Kyphosis correction were achieved by 27.5° on average postoperatively and showed a mild loss of 4.2° on average during followed up period.All cases were confirmed with Bacillus tuberculosis infection by pathology.Bacillus tuberculosis was detected and culture successfully in 107 cases（46.1%）,40 strains（37.4%） were drug resistant and in which 8 strains（7.5%） were multi drug resistant.Conclusion：For the treatment of thoracic and thoracolumbar spinal tuberculosis,the best treatment include directional chemotherapy,one stage anterior approach with thorough debridement,auto rib or Ti mesh fusion,and plate screw fixation.