轻型脊柱结核的早期诊断及非手术治疗

The early diagnosis of mild spinal tuberculosis and outcomes of nonoperative treatment

目的建立轻型脊柱结核诊断标准，评估标准化疗方案治疗轻型脊柱结核的疗效，为完善脊柱结核临床分型奠定基础。方法依照轻型脊柱结核诊断标准，纳入经影像学或病理学证实的轻型脊柱结核患者89例，经加强营养支持，无需卧床，采用严格标准化疗方案（异烟肼、利福平、乙胺丁醇、吡嗪酰胺）治疗18个月。化疗期间每个月监测肝功能、红细胞沉降率，于化疗后1、3、6、9、12、18、24个月门诊复查，分析治疗前后患者临床表现、疼痛视觉模拟评分（visual ana-loguescale，VAS）、病变愈合、Cobb角、神经功能、红细胞沉降率及肝功能的变化情况。结果所有患者均获得随访，随访时间18～46个月，平均（30．62±13．20）个月。85例（95．51％）获得临床治愈；4例经3个月化疗无效，红细胞沉降率增高，骨质破坏加重而行手术治疗，经药敏试验证实为耐药结核，调整化疗方案，术后化疗18个月后治愈。非手术临床治愈的85例患者，治疗前VAS评分平均为（5．6±1．6）分，后凸Cobb角平均为6．25°±3．11°；末次随访时VAS评分平均为（2．1±1．1）分，后凸Cobb角平均为12．36°±6．31°。获得临床治愈的85例中6例椎体、椎间盘恢复正常信号；79例获得邻近椎体自发融合，椎旁脓肿均吸收。69例残留无症状的轻度后凸畸形，均正常13常活动，无神经功能障碍。治疗前2例窦道形成者均愈合。结论早期诊断的轻型脊柱结核可作为脊柱结核临床分型中最轻的一型，标准化疗安全有效，非手术治疗能避免后凸畸形、脊柱失稳、神经功能障碍等并发症。

Objective To set the criteria of mild spinal tuberculosis and investigate the effect of standard chemotherapy regimen for further establishing the clinical classification of spinal tuberculosis and standardizing management. Methods Ac- cording to the criterion, a total of 89 patients with mild spinal tuberculosis were enrolled for outpatient conservative management and follow-up. Ambulant treatments were carried out in all patients, including nutrition support and standard chemotherapy regi- men. The regimen was consisting of four first-line antituberculosis drugs （rifampicin, isoniazid, ethambutol and pyrazinamide）. AU patients were followed up one month later, then every 3 months for the following 12 months, and subsequently at intervals of half a year. The clinical manifestations, kyphosis progression, neurological status, erythrocyte sedimentation rate and liver function were analyzed. Results A mean of 30.62±13,20 （range, 18-46） months＇ follow-up was achieved in 85 patients, whose tuberculosis le- sions were cured completely. Another 4 patients, who were diagnosed with drug-resistant tuberculosis later, had underwent surgery for progressive hone destruction and no response to chemotherapy. The mean visual analogue scale score and Cobb＇s angle was 5.6 ± 1.6 and 6.25 ° ± 3.11 ° before chemotherapy, and 2.1 ±1.1 and 12.36 ° ± 6.31° at the last follow - up time, respectively. Signals of vertebral body and intervertebral disc returned to normal in 6 patients, while solid bony fusion of adjacent segment was achieved in 79 patients. Asymptomatic mild kyphosis was observed in 69 patients. 2 patients with sinus before treatment all healed. No neu- rological deficit was found. Conculusion For patients early diagnosed with mild spinal tuberuclosis, standard chemotherapy regi- men could work safely and effectively for healing the tuberculous lesion, avoiding surgery as well as preventing kyphosis, vertebral instability and neurological deficit. Mild spinal tuberculosis that was early diagnosed could be considered as a subtype of spinal tu- berculosis.