腹腔镜辅助下联合侧前方小切口腹膜后入路治疗腰椎结核

RETROPERITONEAL LAPAROSCOPIC APPROACH COMBINED WITH ANTEROLATERAL MINI-INCISION FOR LUMBAR SPINE TUBERCULOSIS

目的探讨腹腔镜辅助下联合侧前方小切口腹膜后入路治疗腰椎结核的疗效。方法回顾分析2006年6月-2012年6月,腹腔镜辅助下联合侧前方小切口腹膜后入路行腰椎结核病灶清除、植骨融合及内固定治疗的22例患者临床资料。其中男14例,女8例;年龄26－57岁,平均42.6岁。病程3－10个月,平均7.3个月。结核累及节段：单节段17例,分别为L1、2 3例,L2、3 6例,L3、4 4例,L4、5 2例,L5 2例;双节段5例,分别为L1－3 2例,L2－43例。腰椎Cobb角为5－28°,平均20°;6例有神经压迫症状及体征,神经功能按Frankel分级,C级2例,D级4例。记录手术时间、术中出血量及手术并发症。末次随访时,评估患者术后神经功能恢复情况;于腰椎侧位X线片测量Cobb角;采用Nakai评分标准进行疗效评定;根据Suk标准判断植骨融合率。结果 22例患者均顺利完成手术。手术时间110－250 min,平均140 min;术中出血量120－280 mL,平均180 mL。术后出现股神经损伤和交感神经损伤症状各1例,1－3周后均自行逐渐恢复正常;术后切口均Ⅰ期愈合。22例均获随访,随访时间16－50个月,平均21个月。随访期间未出现内固定物松动及断裂等并发症,均无结核中毒症状及病灶扩散,红细胞沉降率及C反应蛋白正常,未见结核复发。末次随访时,除1例术前神经功能Fankel C级患者恢复至D级外,余均完全恢复至E级;腰椎Cobb角为2－16°,平均7.8°;按Nakai评分标准评估,获优9例、良10例、可3例,优良率86.4%;按Suk标准评定植骨已融合或可能融合21例,融合率95.5%。结论腹腔镜辅助下联合侧前方小切口腹膜后入路治疗腰椎结核具有创伤小、并发症少的优点,是一种安全有效手术方式。

Objective To investigate the effectiveness of retroperitoneal laparoscopic approach combined with anterolateral mini-incision for lumbar spine tuberculosis. Methods A retrospective analysis was made on the clinical data of 22 patients with lumbar spine tuberculosis undergoing focus clearance, fusion, and internal fixation by retroperitoneal laparoscopic approach combined with anterolateral mini-incision between June 2006 and June 2012. There were 14 males and 8 females, with an average age of 42.6 years （range, 26-57 years） and with a mean disease duration of 7.3 months （range,3-10 months）. There were 17 patients with single-level spinal tuberculosis （L1, 2 in 3, L2, 3 in 6, L3, 4 in 4, L4, 5 in 2, and L5 in 2） and 5 patients with double-level spinal tuberculosis （L1-3 in 2 and L2-4 in 3）. The preoperative Cobb’s angle of lumbar spine was 5-28° （mean, 20°）. In 6 patients having compression symptom, 4 cases were rated as grade D and 2 as grade C according to Frankel classification. The operative time, intraoperative blood loss, and postoperative complications were recorded. At last follow-up, the neurologic function was assessed according to Frankel grade, the Cobb’s angle after operation was measured on lumbar lateral X-ray film; the efficacy was evaluated according to Nakai criteria, and the fusion was evaluated according to Suk criteria. Results All operations were successfully completed. The operation time was 110-250 minutes （mean, 140 minutes）,and intraoperative blood loss was 120-280 mL （mean, 180 mL）. The symptoms of femoral nerve injury and sympathetic nerve injury occurred in 1 case respectively and was relieved at 1-3 weeks after operation. All incisions healed by first intention. The patients were followed up 16-50 months （mean, 21 months）. During the follow-up period, no loosening or breakage of implants and no tuberculosis recurrence were found. At last follow-up, the nerve function was recovered to grade E in the others except 1 case at grade D. The Cobb’s angle was 2-16° （mean, 7.8°）. According to Nakai criteria for efficacy evaluation, the results were excellent in 9 cases, good in 10 cases, and fair in 3 cases, with an excellent and good rate of 86.4%. The bony fusion rate was 95.5% （21/22） according to Suk criteria. Conclusion Retroperitoneal laparoscopic approach combined with anterolateral mini-incision for lumbar spine tuberculosis is a safe and effective approach with minimal invasion and less complications.