腰骶段脊柱结核患者的手术方案分析

Surgical treatment for patients with lumbosacral spinal tuberculosis

目的探讨腰骶段脊柱结核不同手术方案的临床效果。方法回顾性分析该院2007年1月-2011年12月收治的146例腰骶段脊柱结核患者的临床资料及随访结果,根据手术入路分为后路组(n=48)、前路组(n=43)及后路+前路组(n=55),3组分别采取经后路清除病灶+植骨内固定术,经前路清除病灶+植骨内固定术,后路内固定+前路清除病灶及植骨融合术。比较3组患者的手术时间、手术出血量、术后并发症以及临床治疗效果。结果后路组、前路组及后路+前路组的手术时间和手术出血量分别为(160±23)、(150±20)和(180±21)min及(450±42)、(430±53)和(710±34)ml,后路+前路组的手术时间和手术出血量明显高于后路组及前路组,差异有统计学意义(P<0.05),而后路组和前路组比较,差异无统计学意义(P>0.05)。所有患者在术中均未发生神经及输尿管损伤等严重的并发症,3组的术后并发症发生率分别为4.2%、7.0%和7.3%,3组比较差异均无统计学意义(P>0.05)。术后临床症状均有明显改善,血沉(ESR)和C反应蛋白(CRP)均在术后3个月恢复正常。3组的优良率分别为93.8%、93.0%和98.2%,三者比较差异无统计学意义(P>0.05)。3组骨性融合率及平均骨性融合时间比较差异无统计学意义(P>0.05)。3组的腰骶角均显著高于术前(P<0.05),且3组患者术前及末次随访时的腰骶角比较,差异均无统计学意义(P>0.05)。3组患者的神经功能不全的患者比例明显低于术前(P<0.05),且3组患者术前及末次随访时的神经功能不全的患者比较,差异均无统计学意义(P>0.05)。结论对于腰骶段脊柱结核,3种手术均是安全有效的治疗选择,应根据病灶位置及椎体破坏情况选择合适的手术入路,尽可能彻底清除病灶,选择有效的内固定和植骨的方式,均有望获得满意的疗效。

[ Objective ] To investigate the clinical effect of different operation procedures on patients with lum- bosacral spinal tuberculosis. [ Methods ] The clinical data and follow-up results of 146 patients with lumbosaeral tu- berculosis from January 2007 to December 2011 were retrospectively analyzed. According to the operative approach, 146 cases were divided into posterior group （n = 48） which underwent posterior pedicle screw instrumentation plus debridement and allograft, anterior group （n = 43） which underwent anterolateral debridement plus allograft and in- ternal fixation, and posterior-anterior group （n = 55） which experienced posterior pedicle screw instrumentation and anterior debridement and allograft. The operative time, operative blood loss, postoperative complications and clinical effect were compared among three groups. [ Results ] The operative time and operative blood loss in posterior group, anterior group and posterior-anterior group were respectively （160±23） min, （150±20） min, （180±21） min and （450±42） ml, （430±53） ml, （710±34） ml. The operative time in posterior-anterior group was significantly longer and the operative blood loss in posterior-anterior group was significantly higher than posterior group and anterior group （P 〈 0.05）, and there was no significant difference in them between posterior group and anterior group （P 〉 0.05）. All cas- es had no serious complication such as nerve and ureteral injury. The rates of postoperative complication in three groups were 4.2%, 7.0%, and 7.3%, in which there was no significant difference （P 〉 0.05）. The clinical symptoms of all cases were significantly improved after operation. The erythrocyte sedimentation rate （ESR） and C-reaction pro- tein （CRP） were recovered to normal after three months. The excellent plus good rates of three groups were 93.7%, 93.0% and 98.2%, in which there was no significant difference （P 〉 0.05）. There was no significant difference in the rate of bony fusion and average bony fusion time among three groups （P 〉 0.05）. The lumbosacral angle at the end of follow-up in three groups were all significantly higher than those before operation （P 〈 0.05）, and there were no sig- nificant differences in the lumbosacral angle before operation and at the end of follow-up among three groups （P 〉 0.05）. The proportion of patients with nerve dysfunction at the end of follow-up in three groups were all significantly lower than those before operation （P 〈 0.05）, and there were no significant differences in the proportion of patients with nerve dysfunction before operation and at the end of follow-up among three groups （P 〉 0.05）. [ Conclusions ] For lumbosaeral spinal tuberculosis, three surgical methods are all safe and effective treatment options. We should select appropriate surgical approach according to the location of disease and vertebral destruction, then remove the afflicted region thoroughly as far as possible, choose effective internal fixation and bone grafting method, which was expected to acquire the satisfied curative effect.