腹膜后入路腹腔镜下手术治疗腰椎结核

Retroperitoneal laparoscopic surgery for lumbar spine tuberculosis

目的：总结腹膜后入路腹腔镜下手术治疗腰椎结核的疗效。方法：2009年10月～2011年10月采用腹膜后入路腹腔镜下手术治疗腰椎结核患者16例，男11例，女5例，年龄26～62岁，平均38．2岁。L1～L22例，L2～L35例，L3－L4 4例，L2－L4 2例，L3～L5 1例，L3 1例，L4 1例；均有椎旁脓肿，单侧12例，双侧4例。12例合并腰椎后凸畸形，Cobb角5~-20。，平均11．2°±3．6°。神经功能受损2例，ASIA分级C级1例，D级1例。均采用腹膜后入路，其中4例双侧脓肿选择左侧入路，12例单侧脓肿选择脓肿侧入路。5例破坏L1或椎体破坏超过50％患者，采用传统腹腔镜技术操作，行前路单纯病灶清除及植骨，联合后路椎弓根螺钉内固定；9例病变累及2个椎体（椎体保留50％以上）者采用单孔腹腔镜技术行一期前路病灶清除、植骨及内固定；2例病变累及2个以上椎体（椎体保留50％以上）者采用改良单孔腹腔镜技术，行一期前路病灶清除、植骨及内固定。术前均用异烟肼、利福平、乙胺丁醇、链霉素四联抗结核化疗2周，术后抗结核治疗9～12个月。结果：均顺利完成手术，手术时间240～365min，平均280min；术中出血量50～400ml，平均112ml。无术中并发症。2例术前神经功能受损患者术后神经功能完全恢复正常，ASIA分级均为E级。1例右侧入路患者术后即出现植物神经功能紊乱，患侧下肢皮肤温度高于对侧．未行特殊处理，术后1周症状消失。1例L4-L5前路内固定患者术后3个月摔倒后出现L5椎体螺钉松动，予内固定拆除，行后路椎弓根螺钉固定。术后2周Cobb角-10°-5°，平均-5．10±2．70，与术前比较有统计学差异（P〈0．01）。随访3～22个月，平均12．1个月。末次随访Cobb角-10°～8°，平均-4．2°±2．1°，与术前比较有统计学差异（P〈0．01），Cobb角丢失2．6°±1．8°。末次随访植骨融合11例，融合时间6～12个月。11例完成抗结核治疗疗程者，末次随访均未见结核复发。结论：腹膜后入路腹腔镜下手术治疗腰椎结核安全．近期效果良好。

Objectives： To investigate the outcome of balloon-assisted laparoscopic retroperitoneal approach for lumbar spine tuberculosis. Methods： From October 2009 to October 2011, 16 cases of lumbar tuberculosis underwent balloon-assisted laparoscopic retroperitoneal approach. There were 5 females and 11 males with a mean age of 38.2 years（range, 26-62）. The diseased levels included L1-L2 in 2 patients, L2-L3 in 5 patients, L3-L4 in 4 patients, L2-L4 in 2 patients, L3-L5 in 1 patient, L3 in 1 patient and L4 in 1 patient. All patients presented with paraspinal abscesses, and unilateral abscesses in 12 patients and bilateral abscesses in 4 patients. Lumbar kyphosis was noted in 12 patients with a mean sagittal Cobb＇s angle of 11.2°±3.6° （50-20°） before operation. According to ASIA scale, there were 1 grade D and 1 grade C. Anterior debridement, decompression, auto bone graft and one-stage posterior instrumentation under conventional laparoendoscopic approach was performed in 5 patients. One-stage anterior debridement, bone graft and anterior single rod instrumentation for 1 level under LESS technique was performed in 9 patients. Modified LESS technique （one-stage anterior debridement, bone graft and single rod instrumentation for 2-levels） was performed in 2 patients. The standard chemotherapy including isoniazid, rifanapicin, pyrazinamide and streptomycin was admin istered for 2 weeks before operation, and continued for 2 months and followed by rifampicin/INH for 9-12 months. Results： The mean operation time was 280min（240-365min）, and the mean intraoperative blood loss was 112ml（50-400ml）. Patients were followed up for 3-22（average 12.1） months. ASIA grade revealed good recovery（ASIA E） of patients with neurological deficit. Complications included screw loosening at the L5 level, and removed 3 months after operation and presented with temporal sympathetic nerve dysfuntion. The mean sagittal Cobb＇s angle increased significantly to -5.1°±2.7°（P〈0.01） 2 weeks after operation, with the mean correction of 15.7°±5.1°. At final follow-up, the mean sagittal angle was -4.2°±2.1°（P〈0.01）, with the loss of correction of 2.6°±1.8°. 11 patients had a radiographic bony fusion in a time of 6-12 months. No tuberculosis recurrence was found at final follow-up. Conclusions： Laparoscopic retroperitoneal approach is safe and reliable for lumbar spine tuberculosis.