老年脊柱结核伴截瘫患者的手术时机与疗效分析

Operation timing and therapeutic efficacy of thespinal tuberculosis with paraplegia in the elderly

目的探讨老年脊柱结核伴截瘫患者的手术时机并对疗效进行评价。方法回顾性分析2005年1月至2013年1月我院骨科手术治疗的64例老年脊柱结核伴截瘫患者的病历资料，男28例，女36例，年龄60--82岁，平均（69．9±6．8）岁。64例患者术前行抗结核治疗14－56d，平均（29．6±10．9）d；术前按照2000年美国脊柱损伤协会（ASIA）《脊髓损伤神经学分类标准》进行分级（简称“ASIA分级”）：B级6例、C级15例、D级43例；术前截瘫时间2～16周，平均（5．4±3．3）周；57例有合并症，分析上述因素对手术时机及疗效的影响。使用SPSS19．0统计软件分析，数据使用“-x±s”表示，计量资料使用t检验，P〈0．05为差异有统计学意义。结果64例患者均安全度过围手术期；37例出现术后并发症，与手术直接相关的并发症16例，并发症发生的主要原因为患者年龄大，及截瘫致长期卧床所致。术前疼痛视觉模拟评分（visual analogue scale，VAs）平均（7．2±1．3）分，术后VAS平均（2．2±1．2）分；术后VAS较术前平均改善（5．0±2．3）分，差异有统计学意义（t=12．270，P〈0．05）。ASIA分级患者ASIA分级术后平均改善（1．2±0．5）级，4例患者截瘫无改善，为脊髓前后方均受压迫造成脊髓器质性损伤所致；术后61例植骨融合，融合时间3～7个月，平均（4．8±1．3）个月。术前Cobb角平均为（33．4±11．3）。，术后Cobb角平均为（16．1±6．7）°；术后Cobb角较术前平均改善（17．3±3．6）°，差异有统计学意义（t=5．248，P〈0．05）。随访12-18个月，有2例结核病灶复发，复发原因为术后未规律抗结核治疗所致。结论对于老年脊柱结核伴截瘫患者，术前抗结核治疗时间≥2周、尽量缩短术前截瘫时间、合并症得到有效控制的情况下，行手术治疗是安全的；术后疼痛、ASIA分级、Cobb角较术前均有明显改善。

Objective To investigate the operation timing and therapeutic efficacy of the spinal tuberculosis with paraplegia in the elderly. Methods From January 2005 to January 2013, medical records of 64 spinal tuberculosis patients with paraplegia in the elderly were analyzed retrospectively. Among them, 28 patients were male and 36 patients were female. The average age was （69.9±6.8） （60 to 82） years old. All patients were received preo-perative chemotherapy for （29.6±10. 9） （14 to 56） days. Preoperative ASIA grades were t3 in 6 cases, C in 15 cases and D in 43 cases. The average preoperative paraplegia time was （5.4±3.3） （2 to 16） weeks. Fifty seven pa- tients had complications. All the factors above were analyzed whether operation timing and therapeutic effect were affected. All the statistical analyses were conducted with SPSS software（version 19.0）,data presented as ＂^-xs＂. A student＇s t-test was used to compared the difference of continuous measurements, and a P valve〈0.05 was considered statistically significant difference. Results Sixty-four patients survived through the preoperative period. Thirty-seven patients had postoperative complications, 16 of 37 patients with postoperative complications were related with operation directly. The reasons of the postoperative complications were the advanced age of patients and the long-term bed rest caused by paraplegia. The average score of preoperative VAS was （7.2! 1.3）, and the average score of postoperative VAS was （2.2±1.2）. The average improvement score of VAS was （5.0±2.3）. The difference was statistically significant （t- 12. 270, P〈 0.05） after operation. The average improvement of ASIA was （1.2±0. 5） grade after operation. The paraplegia did not improved in 4 cases for the spinal cord compressed before and behind. Bone grafts was fused in 61 cases. Average time of union was （4.8±1.3） （3 to 7） months. The average of preoperative Cobb angle was （33.4±11.3） degree, and the average of postoperative Cobb angle was changed to （16.1±6.7） degree. The average improvement of Cobb angle was （17.3±3.6） degree. The difference was statisticalIy significant（t= 5. 248, P〈0.05）. The average follow-up tients relapsed for taking anti-tuberculosis drugs irregularly after operation. Conclusion The operation is safety for patients with paraplegia in the elderly when preoperative chemotherapy time is ≥2 weeks, preoperative paraplegia time is shortened as possible and complications is controlled. The pain, ASIA grade and Cobb angle are improved obviously after operation.