腰椎化脓性脊柱炎的手术治疗

SURGICAL TREATMENT OF LUMBAR PYOGENIC SPONDYLITIS

目的探讨腰椎化脓性脊柱炎的诊断及手术疗效。方法 2005年2月-2010年6月,收治15例腰椎化脓性脊柱炎患者。其中男10例,女5例;年龄26～72岁,平均48.6岁。病变节段:L2、33例,L3、43例,L4、58例,L5、S11例。临床均表现为中度以上发热,病变局部疼痛,腰椎活动受限,10例伴有神经根性症状,8例有下肢截瘫症状。实验室检查白细胞计数、C反应蛋白、红细胞沉降率均明显增高。术前X线片及CT检查无明显骨质破坏;MRI表现为局部T1加权像低信号,T2加权像高信号,7例有局限脓肿形成。均采用病灶清除植骨内固定手术,其中前路手术13例,后路手术1例,联合前后路手术1例。术后细菌培养阳性10例,选择敏感抗生素。结果术后患者切口14例Ⅰ期愈合,1例Ⅱ期愈合。1例后路手术患者术后2周复发,经对症治疗后症状缓解;其余患者腰背部疼痛和/或下肢疼痛症状均较术前明显缓解,体温3～4 d即恢复正常,复查血常规、红细胞沉降率、C反应蛋白较术前明显降低。15例均获随访,随访时间12～70个月,平均35.4个月。术后均无排斥反应,手术切口无窦道形成,无腰椎后凸畸形,内固定物松动、断裂等并发症发生。术后4～8个月植骨均获得骨性融合。结论结合患者临床表现、实验室检查及MRI,可诊断腰椎化脓性脊柱炎,其中C反应蛋白是判断病情发展的重要指标,MRI对明确诊断有重要意义;病灶清除植骨内固定是一种安全、有效的治疗方法。

Objective To investigate the diagnosis and effectiveness of surgical treatment for lumbar pyogenic spondylitis. Methods Between February 2005 and June 2010, 15 cases of lumbar pyogenic spondylitis were treated. There were 10 males and 5 females with an average age of 48.6 years （range, 26-72 years）. Affected segments included L2, 3 in 3 cases, L3, 4 in 3 cases, L4. 5 in 8 cases, and L5, S1 in 1 case. All cases had clinical manifestations of moderate or severe fever, local pain of lesion, and limitation of the spinal movement; 10 patients had nerve root symptoms, and 8 patients had symptoms of lower limb paraplegia. Leukocyte, C-reactive protein （CRP）, and erythrocyte sedimentation rate （ESR） significantly increased in all cases. The preoperative X-ray and CT examinations showed no clear bone destruction; MRI showed decreased signal intensity on T 1WI and increased signal intensity on T2WI, 7 cases had localized abscess formation. The patients underwent focal cleaning and bone grafting and fusion combined with internal fixation, including anterior operation in 13 cases, posterior operation in 1 case, and combined anterior and posterior operation in 1 case. The results of bacterial culture were positive in 10 cases. According to the results of intraoperative bacterial cultures, sensitive antibiotics were selected. Results Healing of incision by first intention was achieved in 14 cases, healing by second intention in 1 case. After 2 weeks, 1 case recurred and symptoms was reliefed after symptomatic treatment. Back pain and （or） lower limb pain were obviously improved in the other patients; body temperature recovered to normal after 3-4 days; leukocyte, ESR, and CRP significantly decreased. All the patients were followed up 12 to 70 months with an average of 35.4 months.The patients had no rejection, no fistula formation, no lumbar kyphosis, and no fixator loosening or breakage. The bony fusion time was 4-8 months. Conclusion Combination of clinical manifestations, laboratory tests, and MRI can diagnose lumbar pyogenic spondylitis, of which CRP is an important indicator to determine progression of the disease, and MRI is important for diagnosis. Debridement combined with interbody fusion and internal fixation is a safe and effective treatment method.