一期后路内固定前路病灶清除植骨治疗严重腰骶椎结核的临床研究

Clinical research of one-stage posterior internal fixation and anterior debridement of bone grafting in the treatment of severe lumbosacral tuberculosis

目的：探讨一期前后路联合病灶清除，后路椎弓根螺钉内固定、前路经腹直肌内侧腹膜外入路椎间植骨治疗严重腰骶椎结核的临床疗效。方法自2008年1月至2011年12月，采用后路椎弓根螺钉内固定，前路经腹直肌内侧腹膜外入路行病灶清除，取同种异体骨植骨治疗L4～S1椎体结核患者17例，术前均行X线片，CT及核磁共振成像（MRI）检查，病变累及L5～S18例，L4～56例，L4～S13例；单侧腰大肌脓肿6例，双侧腰大肌脓肿3例，其中8例椎管内受侵；5例合并有神经功能障碍， Frankel分级D级4例，C级1例。术前常规抗结核治疗2周以上，术后常规支持及抗结核治疗9～12月，定期随访（术后3、6、9、12个月，以后每半年随访1次），查红细胞沉降率、摄X线片评估结核活动情况及植骨融合情况，按照Frankel神经功能分级评定患者手术前、后神经功能变化，对比研究手术前后腰骶角的变化。结果所有患者术中均无大血管、神经损伤，1例术中出现输尿管损伤，及时修补后愈合，17例患者都得到随访，随访10～36个月，平均18个月，所有患者均达到临床愈合，无结核性腹膜炎，无勃起功能障碍，无逆行性射精等并发症，随访期间未见结核复发，内固定无松动，无断钉断棒，植骨均融合，平均融合时间7．5月，末次随访神经功能Frankel分级除1例为D级外，其余4例患者神经功能均恢复至E级。患者的腰骶角由术前的19．8°～27．8°[平均（23．8°±4．0°）]矫正为术后的25．5°～32．7°[平均（29．1°±3．6°）]，术后的腰骶角较术前明显增大（ P＜0．05）。结论一期前后路联合病灶清除，后路内固定，经腹直肌内侧腹膜外入路椎间植骨是治疗严重腰骶椎结核有效而安全的方法，可彻底清除病灶，重建腰骶段的稳定性，有效防止植骨块松动移位。

Objective To investigate the clinical efficacy of one-stage posterior internal fixation with pedicle screw and anterior debridement of bone grafting through the extraperitoneal approach the medial edge of rectus abdominis in treating severe lumbosa-cral tuberculosis .Methods 17 cases with L4-S1 tuberculosis were treated by internal fixation with pedicle screw ,anterior debride-ment through the extraperitoneal approach the medial edge of rectus abdominis ,and application of allogenic bone from January 2008 to December 2011 .All patients performed X-ray ,CT and MRI examinations before surgery .L5-S1 were involved in 8 cases ,L4-5 were involved in 6 cases ,and L4-S1 were involved in 3 cases;unilateral psoas abscess was found in 6 cases ,while bilateral psoas ab-scess was found in 3 cases ;Among the 17 cases ,8 cases had intraspinal invasion ,and 5 cases were combined with neurological dys-functions ,however ,according to Frankel grade ,4 cases were grade D ,and 1 case was grade C .Regular anti-tuberculosis treatment was given for more than 2 weeks before surgery ,and regular supportive treatment and anti-tuberculosis treatment were given for 9-12 months after surgery .As for regular follow-up（3 ,6 ,9 ,and 12 months after surgery ,and every 6 months later on） ,patients had examinations including ESR and X-ray to evaluate the tuberculosis activity and the condition of bone graft fusion ;while accord-ing to Frankel grade of nerves function ,changes in nerve function before and after surgery were evaluated in patients ,and changes of lumbosacral angle were also comparatively studied before and after surgery .Results There were no great vessel injuries and no nerve injuries except one case who had intraoperative ureteral injury which was repaired in time .The 17 patients were all followed up for 10-36 months（18 months average） ,and all reached clinical healing without complications such as tuberculous peritonitis ,e-rectile dysfunction and retrograde ejaculation .During the follow-up period ,there were no tuberculosis recurrence ,no loosening of in-ternal fixation ,and no break of rod and nail ;the grafted bones were fused in all patients with an average time of 7 .5 months ;accord-ing to Frankel grade of nerves function ,only one patient was grade D ,while the other four cases recovered to grade E .The lumbosa-cral angle of patients was corrected from 23 .8° ± 4 .0°（19 .8°-27 .8°） before surgery to 29 .1° ± 3 .6°（25 .5°-32 .7°） after surgery , and the change was statistical significance（P〈0 .05） .Conclusion The one-stage posterior internal fixation with pedicle screw and anterior debridement of bone grafting through the extraperitoneal approach inside of rectus abdominis is a safe and effective meth-od ,which can thoroughly remove the focus ,reconstruct the lumbosacral stability ,and prevent the loosening of bone grafting .