脊柱结核致隐匿性椎管内结核15例诊疗分析

Atypical intraspinal tuberculosis diagnosis and treatment: report of 15 cases

背景:脊柱结核引起的隐匿性椎管内结核临床上较少报道。本病形成的椎管内结核肉芽肿和脓肿可直接对相邻脊髓神经等产生压迫,可较早产生神经受累的并发症。目的:探讨脊柱结核致隐匿性椎管内结核的诊断及治疗方法。方法:对2005年3月至2010年5月收治的15例脊柱结核致隐匿性椎管内结核患者术前行FSET1压脂序列强化,治疗上进行病灶清除和脊柱稳定性重建,动态观察结核中毒症状、脊髓功能的改善情况和病灶愈合情况。结果:随访时间18～24个月,平均(21±3)个月。入院时红细胞沉降率平均为69.5mm/h,C反应蛋白平均为51.6mg/L。术后红细胞沉降率降至41.8mm/h,C反应蛋白降至22.3mg/L,结核中毒症状明显改善。术后第8～12周红细胞沉降率和CRP检测结果正常;病椎椎间植骨融合时间平均4.5个月,结核病灶治愈率为95.3%。13例神经症状明显改善,2例胸椎结核术后6个月复诊时有部分改善。ODI评分术前为(35.56±9.15)分,末次随访时为(12.46±2.41)分。VAS评分术前为(9.9±1.5)分,末次随访时(4.25±1.9)分。术前与末次随访时的ODI评分和VAS评分差异有统计学意义(P<0.05)。术前Frankel分级B级2例、C级6例、D级7例,末次随访时C级2例、D级3例、10例E级。结论:脊柱结核致隐匿性椎管内结核术前MRI强化可为诊断提供有力依据;治疗上宜抗结核化疗同时进行病灶清除、椎板减压和神经松解。

Background： There have been few reports on atypical intraspinal tuberculosis. The granuloma and abscess in the infection focus can compress spinal cord and result in nerve complications. Objective： To investigate the diagnosis and surgical treatment for atypical intraspinal tuberculosis. Methods： Fifteen patients who underwent focus debridement, auto-bone grafting and internal fixation combined with anti-tuberculosis chemotherapy between March 2005 and May 2010 were enrolled in this study. Preoperative MRI was performed in all patients with Gd-DTPA injection. Clinical outcomes, ODI, VAS and focus healing were evaluated. Results： The average follow-up period was （21±3） months （range, 18-24 months）. Preoperative ESR was 69.5 mm/h and CRP was 51.6 mg/L on average. ESR decreased to 41.8 mm/h and CRP decreased to 22.3 mg/L after treatment. Tuberculosis symptoms and local pain relived in all patients. ESR or CRP became normal 8 to 12 weeks postoperatively. Average fusion time was 4.5 months, and focus healing rate was 95.3%. Neurological symptoms were improved obviously in 13 patients, and mildly improved in 2 patients 6 months postoperatively. Preoperative ODI was 35.56±9.15 and VAS was 9.9±1.5. ODI was 12.46±2.41 and VAS was 4.25±1.9 at the final follow-up. There were significant differences in VAS and ODI scores before and after surgery （P〈0.05）. There were 7 cases for Frankel D, 6 cases for Frankel C, and 2 cases for Frankel B preoperatively. At the final follow-up there were 10 cases for Frankel E, 3 cases for Frankel D, and 2 eases for Frankel C. Conclusions： MRI with Gd-DTPA injection can provide a strong basis for the diagnosis of atypical intraspinal tuberculosis. Surgical strategies included rapid focus debridement, decompression and spinal stabilization during chemotherapy course.