耐多药脊柱结核的原因分析及处理对策

Cause analysis and treatment strategy of spinal mulfidrug-resistance tuberculosis

目的探讨耐多药脊柱结核的产生原因及临床处理对策。方法回顾性分析2007年6月至2012年9月收治的16例耐多药脊柱结核患者的相关资料，男12例，女4例；年龄10～49岁，平均26．6岁；累及椎体44个，平均2．75个。胸椎9例，腰椎2例，胸腰段1例，腰骶椎3例，1例累及跳跃节段（T8．9，T12L1）。合并肺结核5例，结核性胸膜炎4例，结核性脓胸3例，颈部淋巴结核1例，胸骨结核1例，胸壁结核1例；肾病综合征1例。根据药敏试验制订个体化抗结核治疗方案，分析手术次数与过程，经过长期随访判断治疗效果，并分析耐多药产生原因。结果16例患者中接受1次外科手术者6例；2次外科手术者7例；3次手术者2例，其中1例第3次手术为一期后路内固定、前路再次病灶清除植骨术；4次外科手术者1例，第4次为窦道切除术。随访时间10～60个月，平均28～4个月。通过术后药敏试验结果及时调整化疗方案，末次抗结核治疗时间为24个月。2例患者分别在术后22个月和46个月复发并再次手术。截止末次随访，所有患者均处于结核稳定状态。16例患者中2例为初始耐药，14例为获得性耐药，原因为反复多器官结核致数次抗结核治疗失败；经历多次失败手术未调整化疗方案；出现严重药物不良反应而被迫中断化疗等。结论早期进行结核菌培养并获取药敏试验结果，制定个体化的化疗方案并严密监测药物不良反应，选择合适的时机进行外科手术是防止和治愈耐多药脊柱结核的关键。

Objective To investigate the causes and treatment strategies of spinal multidrug-resistance tuberculosis. Methods Data of 16 patients with spinal multidrug-resistance tuberculosis from Jane 2007 to September 2012 were retrospec- tively analyzed. There were 12 males and 4 females, with an average age of 26.6 years （range, 10-49 years）. The 16 patients in- volved 44 vertebrae, with an average of 2.75 vertebrae. The involved segments included： 9 thoracic segments, 1 thoracic-lumbar segment, 2 lumbar segments and 3 lumbar-sacral segments. 1 patient involved jumping segments including Ts.9, T12L1. Among them, 5 suffered from pulmonary tuberculosis, 4 tuberculous pleurisy, 3 tuberculous empyema, 1 tuberculosis of cervical lymph nodes, 1 tuberculosis of sternum, 1 tuberculosis of chest wall and 1 nephrotic syndrome. We analyzed the reasons of muhidrng-re- sistance. All patients received individualized chemotherapy based on drug sensitivity test. The operation process and time were al- so collected. The treatment effects were determined by long-term follow-up. Results Among all the 16 patients, 6 received 1 op- eration; 7 received 2 operations; 2 received 3 operations and the last operation was one-stage posterior instrumentation and anteri- or debridement, bone grafting which conducted in our hospital; 1 received 4 operations and the last of which was excision of sinus in our hospital. All patients were followed up for 10 to 60 months （average, 28.4 months）. The time of chemotherapy which accord- ed to the drug sensitivity test was 24 months. 2 cases recurred after 22 months and 46 months of the 1st surgery and received oper- ation again. At the last follow-up, all patients were in a stable state of tuberculosis. In 16 patients, 2 were initial drug resistance and 14 were acquired drug resistance. The causes of acquired drug resistance were multiple organs tuberculosis caused by failure chemotherapy, times of failed surgeries without adjusted schedules, suspension of the anti-tuberculosis chemotherapy due to seri- ous adverse drug reactions and so on. Conclusion It is very important to carry through the culture of tubercle bacillus and ac- quire the results of drug sensitive test earlier. The key to prevent and cure multidrug-resistant tuberculosis of spine are formulating individualized anti-tuberculosis chemotherapy program, monitoring closely the adverse drug reactions and selecting the appropri- ate time for surgery.