胸腰椎结核重度后凸畸形并截瘫的手术治疗

SURGICAL TREATMENT OF THORACIC AND LUMBAR TUBERCULOSIS COMPLICATED WITH SEVERE KYPHOTIC DEFORMITY AND PARAPLEGIA

目的探讨胸腰椎结核重度后凸畸形（后凸Cobb角≥55°）并截瘫的手术方法与疗效。方法2009年1月-2013年1月，采用一期后路全脊椎切除（posteriorvertebralcolumnresection，PVCR）联合病灶清除矫正后凸畸形、前方钛网支撑植骨、后方椎弓根螺钉固定治疗13例重度后凸畸形并截瘫的胸腰椎结核患者。男7例，女6例；年龄14～49岁，平均23．5岁。病程13～38个月，平均19个月。术前后凸Cobb角为（65．23±7．95）°，疼痛视觉模拟评分（VAS）为（7．38±0.31）分；神经功能Frankel分级为B级1例、C级7例、D级5例。病灶累及2个椎体7例，T8、91例，T11、12例，T12、L14例；3个椎体4例，T10～12 2例，T9～11 1例，T11～L1 1例；4个椎体2例，T4-7 1例，T6～9 1例。10例伴椎旁脓肿。结果术后切口均Ⅰ期愈合。术后出现3例脊髓神经损伤，2例肺部感染，均经相应处理后治愈。13例均获随访，随访时间12～48个月，平均17个月。术后3～7个月红细胞沉降率均降至正常。x线片及CT示术后10～20个月，平均14个月截骨处达骨性愈合。随访期间内固定物无松动、移位、断裂等发生：术前结核症状、体征均消失，未见结核病灶复发征象。术后1周神经功能Frankel分级为B级1例、C级10例、D级2例，末次随访时为D级1例、E级12例，均较术前显著改善（P〈0．05），末次随访与术后1周比较差异亦有统计学意义（P〈0．05）。术后1周及末次随访时脊柱后凸Cobb角分别为（22．38±1．76）°和（22．15±1．83）°，与术前比较差异均有统计学意义（P〈0．05），末次随访时与术后1周比较差异无统计学意义（P〉0．05）。术后1周及末次随访时VAS评分分别为（4．08±0．76）分和（0．62±0．14）分，与术前比较差异均有统计学意义（P〈0．05），末次随访时与术后1周比较差异亦有统计学意义（P〈0．05）。结论一期PVCR联合病灶清除矫正后凸畸形、前方钛网支撑植骨、后方椎弓根螺钉固定是一种治疗胸腰椎结核重度后凸畸形并截瘫的有效方法。

Objective To explore an method and the effectiveness of surgical treatment of thoracic and lumbar tuberculosis complicated with severe kyphotic deformity （Cobb angle ≥ 55°） and paraplegia. Methods Between January 2009 and Ianuary 2013, 13 cases of thoracic and lumbar tuberculosis complicated with severe kyphotic deformity and paraplegia were treated by one-stage posterior vertebral column resection （PVCR）, debridement, bone grafting, and instrumentation fixation. Of 13 patients, 7 were male and 6 were female with an average age of 23.5 years （range, 14-49 years）. The disease duration was 13-38 months （mean, 19 months）. The Cobb angle of kyphosis was （65.23 ± 7.95）°. The visual analogue scale score （VAS） was 7.38 ± 0.31. In 13 patients with incomplete paraplegia, 1 case was classified as Frankel grade B, 7 cases as grade C, and 5 cases as grade D. The lesion involved 2 vertebrae bodies in 7 cases （Ts.9 in 1 case, T11, 12 in 2 cases, and T12, L1 in 4 cases）, 3 vertebrae bodies in 4 cases （T10-12 in 2 cases, T9-11 in 1 case, and T11-L1 in 1 case）, and 4 vertebrae bodies in 2 cases （T4-7 in 1 case and T6-9 in 1 case）. Imaging examination showed paravertebral abscess in 10 cases. Results Healing of incision by first intention was obtained in all patients. The neurological injury and pulmonary infection occurred in 3 cases and 2 cases respectively, which were cured after symptomatic treatment. Thirteen patients were followed up 12-48 months （mean, 17 months）. The erythrocyte sedimentation rate restored to normal level in all cases at 3-7 months after operation. All the patients achieved bony fusion at 10-20 months （mean, 14 months） after operation. No fixation loosening, displacement, or fracture occurred during follow-up. Common toxic symptom of tuberculosis disappeared, and there was no recurrence of local tuberculosis. The Cobb angle of kyphosis was corrected to （22.38 ± 1.76）° at 1 week and （22.15 ± 1.83）° at last follow-up, showing significant difference when compared with preoperative one （P 〈 0.05）. There was no significant difference in Cobb angle of kyphosis between at 1 week after operation and at last follow-up （P 〉 0.05）. The Frankel grading was grade B in 1 case, grade C in 10 cases, and grade D in 2 cases at 1 weekafter operation; and it was grade D in 1 case and grade E in 12 cases at last follow-up; significant differences were found between at pre- and post-operation （P 〈 0.05）, and between at 1 week after operation and at last follow-up （P 〈 0.05）. The VAS score was 4.08 ± 0.76 at 1 week and 0.62 ± 0.14 at last follow-up, showing significant differences between at pre- and post-operation （P 〈 0.05） and between at 1 week after operation and at last follow-up （P 〈 0.05）. Conclusion One-stage PVCR, debridement, bone grafting, and instrumentation fixation is proved to be successful in treating thoracic and lumbar tuberculosis complicated with severe kyphotic deformity and paraplegia.