一期后路病灶清除、异形钛网椎间植骨融合治疗胸、腰椎结核

One-stage posterior surgery alone for thoracic and lumbar spine tuberculosis by debridement, internal fixation, and in- terbody fusion using multiple special formed titanium meshes

目的探讨一期后路病灶清除、异形钛网椎间植骨内固定治疗胸、腰椎结核的安全性及临床疗效。方法2009年3月至2010年3月，采用一期后路病灶清除、异形钛网椎间植骨椎弓根钉一棒系统内固定治疗胸、腰椎结核28例，男17例，女11例；年龄33～68岁，平均42．7岁。病灶均为非跳跃型，且累及椎体数目（需行椎体病灶清除）均为单节段或双节段。胸椎13例，胸腰段（T11～L2）5例，腰椎10例。所有患者入院时均有胸腰背部局部疼痛，其中12例合并病变节段局部后凸畸形，9例合并神经功能障碍（ASIA分级：C级2例、D级7例）。术后每3个月门诊随访1次，评估结核治愈及钛网融合情况。结果28例均顺利完成手术，手术时间130～210min，平均150min；出血量200～1200ml，平均360ml。术中无死亡及瘫痪加重的病例。12例术前存在后凸畸形的患者，后凸Cobb角由术前平均22．3。矫正术后平均5．4°。随访39～51个月，平均43个月。术后2周患者疼痛视觉模拟评分（visualanaloguescale，VAS）由术前平均6．3分改善至2．1分。术后3个月红细胞沉降率均恢复正常。术后3～9个月（平均6个月）钛网及椎板植骨获得骨性融合。9例神经功能障碍者术后ASIA分级平均提高1级。术后并发切口浅层感染1例、脑脊液漏2例。随访期间未见结核原位复发及矫形角度丢失。结论对于单节段或双节段受累的非跳跃型胸、腰椎结核，一期后路手术是一种安全、有效的治疗方式；应用异形钛网椎间植骨融合技术，可更好地重建病椎前柱稳定性。

Objective To evaluate the safety and clinical efficacy of one-stage posterior surgery alone for thoracic and lumbar spinal tuberculosis by debridement, internal fixation, and interbody fusion using multiple special formed titanium meshes. Methods From March 2009 to March 2010, 28 patients with T/L spinal tuberculosis, including 17 males and 11 females, with an average of 42.7 years （range, 33 to 68 years）, had undergone one-stage posterior debridement, internal fixation, and interbody fu- sion using multiple special formed titanium meshes. The levels involved were less than two contiguous vertebrae： 13 in thoracic vertebrae, 5 in thoraeolumbar vertebrae and 10 in lumbar vertebrae. All patients suffered from back pain, and there were 12 pa- tients with local kyphosis, and 9 patients with neurologic deficit （2 in class C and 7 in class D according to ASIA score）. All pa- tients were followed up every 3 months after surgery. Results Twenty-eight patients underwent surgeries successfully, with aver- age blood loss of 360 ml （range, 200 to 1200 ml）, and average surgery time of 150 mins （range, 130 to 210 mins）. There was no case of death or increased paralysis intraoperatively. Kyphosis Cobb angel was corrected from 22.3° preoperatively to 5.4° postop- eratively in the 12 patients who were kyphosis. All cases were followed up for an average of 43 months （range, 39-51 months）, and there were one case with superficial infection and 2 with cerebrospinal fluid leakage. The VAS score were improved from 6.3 pre- operatively to 3.1 two weeks postoperatively. ESR returned to normal 3 months postoperatively. Titanium meshes got bone fusion within 3-9 months （mean 6 months） after surgery, with no displacement, correction loss, collapse or tuberculosis recurrence during the follow-up period. 9 patients with preoperative neurologic deficit restored by 1 grade at last follow-up. Conclusion One-stage posterior surgery alone may be a safe and effective way for thoracic and lumbar tuberculosis less than two contiguous levels in- volved, and application of multiple special formed titanium meshes can reconstruct spinal stability better.