分期后路融合内固定前路病灶清除椎间植骨治疗儿童腰椎结核伴后凸畸形

Staged posterior instrumentation and anterior debridement,bone graft for lumbar tuberculosis complicated with kyphosis in children

目的:总结分期后路融合内固定前路病灶清除椎间植骨治疗儿童腰椎结核伴后凸畸形的临床疗效。方法:2006年10月至2008年6月,我院收治15例腰椎结核伴后凸畸形患儿,男10例,女5例;年龄5～10岁。入院时血沉22～65mm/h,平均42mm/h。神经功能Frankel分级:B级2例,C级5例,D级8例。术前腰椎后凸Cobb角16°～48°,平均30.3°。均采用一期后路植骨融合内固定、二期前路病灶清除椎间植骨治疗,两次手术间隔6～10d。其中6例后凸Cobb角大于40°的患儿术前行Halo-股骨髁牵引2周左右;术前均采用异烟肼、利福平、乙胺丁醇抗结核治疗3～5周,术后继续抗结核治疗12～18个月。结果:手术时间200～320min,平均240min,术中出血量260～440ml,平均320ml。2例术后发生少量胸腔积液,加强抗炎及对症支持治疗2周后吸收。切口均一期愈合。术后后凸Cobb角2°～12°,平均6.9°,较术前明显改善(P<0.05)。随访25～44个月,平均36个月,术后3个月内血沉均恢复正常,末次随访时神经功能4例恢复2级,11例恢复1级;后凸角Cobb角为3°～14°,平均8.1°,较术后无明显丢失(P>0.05)。随访期间无内固定松动、断裂,植骨均融合,无结核复发。结论:在有效抗结核药物治疗的基础上,分期后路融合内固定前路病灶清除椎间植骨治疗小儿腰椎结核伴后凸畸形可取得较好效果。

Objective：To investigate the efficacy and feasibility of surgical management for lumbar tuberculosis complicated with kyphosis in children by staged posterior instrumentation,anterior debridement and bone graft.Method：15 children with kyphotic lumbar tuberculosis undergoing staged posterior and anterior approach between October 2006 and June 2008 were reviewed retrospectively,of them 6 cases with kyphotic angle over 40° underwent preoperative Halo-femoral traction for two weeks.There were 10 males and 5 females with the age ranged from 5 to 10 years old.The kyphotic angle ranged from 16° to 48° before operation （average, 30.3° ）.Frankel grade system was used to evaluate the neurological deficits.All patients received anti-TB chemotheraphy consisiting of rifampin,isoniazid,ethambutol for 3-5 weeks before the operation and 12-18 months after the operation.Result：The mean follow-up was 36 months（range,25-44 months）.The average operative time was 240min（range,200-320min）,and the average intraoperative blood loss was 320ml（range,260440ml）.All incisions healed perfectly.No neurological complications or instrument failure was noted.Frankel grade system showed 2 grades of improvement in 4 cases,1 grade of improvement in 11 cases.The average postoperative kyphotic angle was 6.9°（range,2° to 12°）,and there was no significant loss of the correction at the latest follow up.The ESR decreased to normal 3 months after operation.Bony fusion was achieved in all cases without recurrence.Two cases had pleura rupture during surgery which was evidenced in postoperative B-ultrasound,which dissolved after routine intervention for 2 weeks.Conclusion：Staged posterior instrumentation,anterior debridement and bone graft is effective to manage kyphotic lumbar tuberculosis on the premise of routine anti-TB chemotheraphy.