后路椎旁肌间隙入路治疗胸、腰椎结核

Treatment of thoracic and lumbar spinal tuberculosis via posterior paraspinai muscle gap approach

目的探讨经后路椎旁肌间隙外科技术治疗胸、腰椎结核的可行性并观察其临床疗效。方法回顾性分析自2009年6月至2013年6月采用后路椎旁肌间隙外科技术治疗胸、腰椎结核29例：T8,9结核2例，T9,10结核6例，L1,2结核8例，L2，3结核10例，L4，5结核3例。男12例，女17例；年龄28～53岁，平均40．78岁。9例患者伴有后凸畸形，Cobb角平均29．67°。（19°～39°），2例患者为结核术后复发，术前Frankel分级为C级。术前所有患者均规范口服异烟肼、利福平、吡嗪酰胺、乙胺丁醇、葡醛内酯2～4周。手术方法均采用经后路椎旁肌间隙入路，一期完成前方病灶清除，后方椎弓根钉内固定。记录手术时间、术中出血量、术后引流量；术后1周及末次随访时疼痛视觉模拟评分（visual analogue scale，VAS）、Cobb角变化，术后红细胞沉降率恢复正常所需时间，神经症状改善情况和植骨融合情况。结果患者手术过程顺利，手术时间为3～4h，平均3．3h；手术出血量为300～600ml，平均434ml。手术后引流250～450ml，平均340ml。所有患者均获得随访，平均16．56个月（6～36个月）。X线及CT重建复查无内固定松动，植骨融合。患者无窦道形成及结核复发，无内固定失效及相关并发症。术后平均4．22个月红细胞沉降率恢复正常；2例结核复发患者术前Frankel分级为C级，术后1例恢复至D级，1例E级；术后Cobb角平均为10．33°（9°～12°），末次随访时为12．22°（11°～14°）。结论经后路椎旁肌间隙入路一期行胸、腰椎结核清除加内固定术是可行、有效的，临床疗效满意。

Objective To explore the feasibility and assess the efficacy of posterior paraspinal muscle gap approach in the treatment of thoracic and lumbar spinal tuberculosis. Methods From June 2009 to June 2013, a total of 29 patients were ana- lyzed retrospectively. There were 2 patients of tuberculosis T8.9, 6 of T9.10, 8 of L1.2, 10 of L2.3, and 3 of L4.5. The patients included 12 cases of male, 17 cases of female; the age ranged from 28 to 53 years, with a mean of 40.78 years. Nine patients had preoperative kyphosis deformity, and Cobb angle ranged from 19° to 39°（mean, 29.67°）. Two patients complained with paraplegia with Frankel grade C. All patients had preoperative standardized oral isoniazid, rifampicin, pyrazinamide border, ethambutol, glucuronolactone for 2-4 weeks. All patients underwent one-stage posterior paraspinal muscle gap approach fixation, rectification, debridement and autograft bone fusion. The clinical effects were observed by the time and blood loss in operation, blood loss after operation; the score of visual analogue scale （VAS） one week after operation and the last follow-up, the time erythroeyte sedimentation rate （ESR） drop to normal after operation, the change of cobb angle, the improvement of the neurological symptom, the situation of the bone fu- sion. Results Operation time was 3-4 h, with an average of 3.3 h; operative blood loss was 300-600 ml, with an average of 434 ml. Drainage volumn was 250-450 ml after surgery with an average of 340 ml. All patients were followed up for 6 to 36 months with an average of 16.56 months. There was no recurrence, sinus formation or internal fixation failure, and all patients ob- tained successful bony fusion. The mean time ESR drop to normal range after operation was 4.22 months. One patient of the two with Frankel grade C pre-operation turn to grade D, the other grade E. The Cobb angle was 10.33~ （9^-12~） immediately after oper- ation, and 12.22°（11°-14°） at the final fallow-up. Conclusion Posterior paraspinal muscle gap approach surgeries is feasible and effective in the treatment of thoracic and lumbar spinal tuberculosis.