手术治疗椎管内结核性肉芽肿的临床分析

Surgical treatment of spinal tuberculous granuloma

目的 探讨以肉芽肿包裹性压迫为特征的椎管内结核性肉芽肿的临床表现、影像学特点及外科手术治疗的方法和效果.方法 回顾性纳入15例椎管内结核性肉芽肿患者,均行病变所在节段全椎板减压术加结核性肉芽肿部分切除术,开放硬脊膜沟通椎管内外血运.术后继续应用抗结核药物≥1年.结果 15例患者手术区域共涉及l～7个节段,最高为枕颈交接部位,最低为腰1节段;肉芽肿长度3～ 16 cm.病变组织主要位于髓外蛛网膜下腔,平卧位上胸段生理弯曲低点最常见.硬脊膜与肉芽肿能够完全分离.从出现神经功能损害到手术时间最短3d,最长1个月;最短者预后相对最好,最长者预后最差.术后2周,2例肌力由Ⅰ级升至Ⅳ级,Frankel分级由C级恢复为D～E级,13例肌力由Ⅱ级升至Ⅲ级,Frankel分级由C级恢复至D级.随访1个月至3年,所有患者均有不同程度的神经功能恢复;术后2个月,MRI示11例术区肉芽肿消失,与术区临近区域肉芽肿也基本消失;术后6个月,MRI示9例术区及毗邻区域肉芽肿均完全消失.结论 手术能改善椎管内结核性肉芽肿的临床预后,出现神经功能缺损后越早手术预后越好.手术减压可明显增强临近的非手术节段的药物抗结核效果。

Objective To study the clinical,imaging characteristics,surgical treatments and results of spinal tuberculous granuloma.Methods A total of 15 cases of spinal tuberculous granuloma were retrospectively studied.Laminectomy with partial excision of tuberculous granuloma,open spinal dura mater with communication inside and outside the blood supply,and postoperative continued application of anti-TB drugs ≥ 1 year were performed.Results The surgery area covered 1-7 segment,up to the neck pillow,and down to the lumbar segments.The granuloma length was 3-16 cm.The lesions located mainly in extramedullary of subarachnoid cavity,most commonly seen in the lower point of the physiological curvature of the thoracic subarachnoid cavity.The granuloma could be entirely separated from the dura.From the appearance of neurological damage to the surgery,the shortest time was 3 days,the longest time was 1 month.The prognosis of patients with short duration was better than that of those with a long time.Two weeks after surgery,the muscle strength of 2 cases was increased from grade Ⅰ to grade Ⅳ and the Frankel classification changed from C to D-E.The muscle strength of 13 cases was increased from grade Ⅱ to grade Ⅳ,and the Frankel classification changed from C to D.The follow-up duration was from 1 month to 3 years.Varying degrees of neurological recovery were observed in all the patients.After two months,the MRI of 11 cases showed disappearance of granulomas around the surgical area.After six months,the MRI of 9 cases showed that the granulomas of surgical and non-surgical areas were completely disappeared.Conclusion Surgical decompression could improve the prognosis of spinal tuberculous granuloma.After neurological damage occurred,the sooner the surgery performed,the better the prognosis.