前路病灶清除植骨内固定结合局部灌洗化疗治疗下颈椎结核伴巨大脓肿

Anterior debridement,autograft and internal fixation combined with postoperative local chemotherapy for lower cervical tuberculosis with huge abscesses

目的：评价前路病灶清除植骨内固定结合术后异娴肼生理盐水持续灌洗局部化疗治疗下颈椎结核伴巨大脓肿的临床疗效。方法：2001年6月-2010年6月收治下颈椎结核伴巨大脓肿患者13例，男8例，女5例：年龄28-62岁，平均44岁。病变累及部位：C3-C42例，C4-C53例，C5-C64例，C52例，C62例；脓肿累及节段：C3-C65例，C3-C73例，C4-C74例，C4-T11例。患者均存在颈部疼痛和不同程度的吞咽及呼吸困难．术前颈部疼痛VAS评分7-10分（8．1±1.3分）。10例出现神经功能障碍，JOA评分5-12分（8．3±1．7分）。术前血沉78±12mm／h，C反应蛋白65±17mg／L。均在全身抗结核药物治疗下采用颈前路结核病灶清除、钛网填充白体髂骨植骨内固定，术后异炯肼生理盐水持续局部灌洗化疗，并继续全身抗结核治疗12-18个月。随访观察患者临床症状改善、脓肿清除和植骨融合情况。结果：手术均顺利完成，所有患者无术中及术后并发症，术后异炯肼生理盐水持续灌洗14-26d，平均18d。未出现窦道、瘘管和脑脊膜感染。随访24-72个月，平均42个月，血沉和C反应蛋白在术后3个月内均恢复正常，手术节段在3-7个月（平均5．8个月）均得到骨性融合。颈部疼痛VAS评分末次随访时为0-3分（1．5±0．7分），与术前比较有显著性差异（P〈0．05）。末次随访时JOA评分为12-17分（14．6±1．5分），与术前比较有显著性差异（P〈0．05）。末次随访复查MRI均未见结核复发。结论：在全身规范抗结核药物治疗的前提下，采用前路病灶清除植骨内同定结合术后持续局部灌洗化疗治疗下颈椎结核伴巨大脓肿安全有效，临床效果满意。

Objectives： To evaluate the efficiency of anterior debridement, autografl, internal fixation com- bined with postoperative irrigation, drainage and local chemotherapy with isoniazid for cervical tuberculosis with huge tuberculous abscesses. Methods： From June 2001 to June 2010, 13 inpatients（8 males and 5 fe- males, aged 28-62 years, mean of 44 years） suffering from cervical tuberculosis with huge tuberculous ab- scesses were reviewed retrospectively. The vertebral tuberculosis sites included C3-C4 in two patients, C4-C5 in three patients, C5-C6 in four patients, C5 in two patients and C6 in two patients. Segments of the tuber- culosis abscess were C3-C6 in five cases, C3-C7 in three eases, C4-C7 in four cases and C4-T1 in one case. All patients presented with neck pain and varying degrees of swallowing and breathing difficulties. The average neck visual analogue scales（VAS） score was 8.1±1.3（range, 7-10） preoperatively. 10 cases had neuro- logical deficit, with the preoperative average JOA score of 8.3±1.7（range, 5-12）. The preoperative ESR and CRP was 78±12mm/h and 65±17mm/h respectively. Under systemic and routine antituberculosis chemotherapy, all patients received anterior debridement, autograft and internal fixation. Postoperative persistent irrigation, drainage and local chemotherapy with isoniazid were performed. Systemic antituberculosis therapy continued for 12-18 months. The clinical symptoms, abscess clearance and bone fusion were followed up. Results： The op- erations were all successfully completed with no perioperative complications such as sinus, fistula andmeningeal infection. Postoperative persistent irrigation, drainage and local chemotherapy lasted for 14 to 26 days（average, 18 days）. The mean follow-up was 42 months（range, 24-72 months）. The postoperative ESR and CRP returned to normal within three months in all patients. Bone fusion was achieved within 3-7 months（av- erage, 5.8 months）. Final follow-up VAS scores were from 0 to 3（average, 1.5±0.7） and were significantly low- er than the preoperative ones（P〈0.05）. Final follow-up JOA scores were from 12 to 17（average, 14.6±1.5） and were significantly higher than the preoperative ones （P〈0.05）. There was no recurrence of tuberculosis under MRI at final follow-up. Conclusions： Under systemic and routine antituberculosis chemotherapy, anterior de- bridement, autograft, internal fixation combined with postoperative irrigation, drainage and local chemotherapy with isoniazid is effective and feasible for cervical tuberculosis with huge mbereulous abscesses.