单纯后路病灶清除内固定治疗胸腰段结核伴后凸畸形

Debridement,interbody fusion and instrumentation by single posterior approach for thoracolumbar spinal tuberculosis in adults with spinal deformity

目的：探讨单纯经后路途径病灶清除、植骨融合和椎弓根钉棒系统内固定治疗胸腰段结核的临床疗效。方法回顾性研究2010年1月至2012年1月我科收治的82例胸腰段脊柱结核伴脊柱畸形的病例，其中男性47例，女性35例；年龄19～68岁，平均（45±15）岁。均采用单纯后路途径病灶清除内固定的方法进行手术治疗。分别于术前、术后14 d、1年随访和末次随访时检测红细胞沉降率（ESR）、C反应蛋白（CRP）、病变节段Cobb′s角、Oswestry 功能障碍指数（ODI），术后1年和末次随访时采用Bridwell分级评价植骨融合情况，同时评价临床疗效。结果用SPSS 17．0进行统计分析。结果所有患者均安全度过围手术期，平均手术时间为（168±41）min ，平均失血量为（346±37）mL。ESR由术前的（57±16）mm/1 h ，末次随访时下降为（11±3）mm/1 h。术前椎体Cobb′s角平均（20±4）°，术后1年随访时和末次随访时分别改善为（2．8±2．0）°和（2．8±2．3）°。ODI评分由术前的（39±14），术后1年和末次随访时分别改善为（7±3）和（7±3）。Bridwell Ⅰ级和Ⅱ级植骨融合率于术后1年和末次随访时分别为82％和90％，无Bridw ell Ⅳ级病例。临床疗效评价于术后1年和末次随访时优良率分别为89％和94％。结论单纯后路途径手术治疗成人单节段胸腰段脊柱结核，是相对意义上的脊柱结核“微创”手术，可以满足清除病灶、脊髓减压、畸形矫正和脊柱270°融合的目的，安全有效。

Objective To investigate the efficacy of debridement ,interbody fusion and internalfixation for thoracolumbar tuberculosis with spinal deformity by posterior only approach .Methods A retrospective study was performed ,which included 82 cases of thoracolumbar tuberculosis with spinal deformity admitted to our depart-ment from January 2010 to January 2012 ,including 47 males ,35 females;aged 19 to 68 years ,an average of （45 ± 15）years old .All cases underwent debridement ,interbody fusion and internal fixation by posterior only ap-proach .ESR ,CRP ,Cobb′s angle and Oswestry Disability Index （ODI） were detected at 14th day before and after surgery ,and at the postoperative 1-year follow-up and final follow-up ,respectively .Bone graft fusion was evalua-ted with Bridwell grading criteria ,and the clinical efficacy was observed as well .Results were statistically ana-lyzed with SPSS17 .0 .Results The mean operative time was 168 ± 41 min ,and the average blood loss was （346 ± 37）mL .ESR decreased to （11 ± 3）mm/1 h at posteroperative final follow-up from preoperative （57 ± 16）mm/1 h . For the cases with spinal kyphosis ,the Cobb′s angles changed from preoperative average （20 ± 4）° to（2 .8 ± 2 .0）° and （2 .8 ± 2 .3）°at posteroperative 1-year and final follow-up ,respectively .ODI ,lumbar dysfunction index ,im-proved from preoperative （39 ± 14）to（7 ± 3） and （7 ± 3）at posteroperative 1-year and final follow-up ,respective-ly .At posteroperative 1-year follow-up ,the rate of spinal graft fusion at Bridwell Ⅰ and Bridwell Ⅱ Grade were 82% and 90% ,respectively .The clinical efficacy was evaluated at posteroperative 1-year and final follow-up ,the rate of excellence and goodness was 89% and 94% ,respectively .Conclusion Single posterior approach is in a sense a“minimally invasive surgery”for treatment of the adult thoracolumbar spinal tuberculosis with spinal defor-mity ,and can enable surgeon to remove the lesion ,decompress the spinal cord ,correct spinal deformity and a-chieve 270° spinal fusion safely and effectively.