一期后路保留部分关节突开窗病灶清除短节段椎弓根螺钉内固定治疗腰骶椎结核

ONE-STAGE POSTERIOR RETAINING PART FACET JOINT IN LAMINECTOMY AND DEBRIDEMENT COMBINED WITH SHORT SEGMENTAL PEDICLE SCREW FIXATION FOR LUMBOSACRAL SPINAL TUBERCULOSIS

目的探讨一期后路保留部分关节突开窗、病灶清除、植骨融合、短节段椎弓根螺钉内固定治疗腰骶椎结核的可行性及疗效。方法 2010年1月-2014年12月对符合选择标准的32例腰骶椎（L4～S1）脊柱结核患者,采用一期后路保留部分关节突开窗、病灶清除、植骨融合、短节段椎弓根螺钉内固定治疗。男20例,女12例;年龄17～62岁,平均43岁。病程12～48个月,平均18个月。病灶累及节段：L5、S1 19例,L4、5 13例。临床效果采用Oswestry功能障碍指数（ODI）及影像学指标（手术前后腰骶角矫正情况及术后X线片骨融合Bridwell分级和CT骨融合标准）评价。结果患者均顺利完成手术,手术时间平均180 min,术中出血量平均400 m L。32例均获随访,随访时间12～67个月,平均15.6个月。末次随访时患者结核中毒症状均消失,无内固定物松动、断裂发生;7例神经症状患者神经功能均恢复正常,美国脊柱损伤协会（ASIA）分级由术前C级2例、D组5例均恢复至E级。术后1年及末次随访时ODI评分均较术前显著改善（P〈0.05）,术后1年及末次随访间比较差异无统计学意义（P〉0.05）。术后7 d、1年及末次随访时腰骶角均较术前显著增加（P〈0.05）,术后各时间点间比较差异无统计学意义（P〉0.05）。术后植骨融合时间为9～24个月,平均12个月。术后1年和末次随访时X线片Bridwill骨融合率分别为87.50%（28/32）和93.75%（30/32）,CT总融合率分别为87.50%（28/32）和90.63%（29/32）,两个时间点间植骨融合情况比较差异有统计学意义（P〈0.05）。4例出现耐药,经调整抗结核方案1年后3例呈BridwillⅢ级融合,1例呈Ⅳ级融合。结论一期后路保留部分关节突开窗能有效清除病灶,椎体及附件间植骨、短节段椎弓根螺钉内固定能维持术后脊柱可靠的稳定性并获得较满意的植骨融合率,是治疗腰骶椎结核的有效方法。

Objective To evaluate the feasibility and effectiveness of one-stage posterior retaining part facet joint in laminectomy, bone graft and debridement combined with short segmental pedicle screw fixation for lumbosacral spinal tuberculosis. Methods Between January 2010 and December 2014, 32 cases of lumbosacral spinal tuberculosis（L4-S1） were treated by one-stage posterior retaining part facet joint in laminectomy, bone graft and debridement combined with short segmental pedicle screw fixation. There were 20 males and 12 females, aged 17-62 years（mean, 43 years）. The disease duration was 12-48 months（mean, 18 months）. The involved segments included L5, S1 level in 19 cases and L4, 5level in 13 cases. The effectiveness was evaluated by Oswestry disability index（ODI） and imaging parameters（lumbarsacral angle correction and Bridwell classification and CT fusion criteria） after operation. Results The operation was successfully completed in all patients; the average operation time was 180 minutes, and the average intraoperative blood loss was 400 m L. All cases were followed up 12 to 67 months（mean, 15.6 months）. At last follow-up, common toxic symptom of tuberculosis disappeared, and no internal fixation failure occurred. Neurological function was recovered to normal in 7 patients with neurological symptoms, and American Spinal Injury Association（ASIA） scale was improved to grade E from grade C（2 cases） and grade D（5 cases） before operation. At 1 year and last follow-up, the ODI scores were significantly improved when compared with preoperative score（P〈0.05）, but no significant difference was found between at 1 year and last follow-up（P〈0.05）. The lumbarsacral angle was significantly increased at 7 days, 1 year and last followup when compared with preoperative one（P〈0.05）, but there was no significant difference between different time points after operation（P〈0.05）. The bone graft fusion time was 9-24 months（mean, 12 months）. At 1 year after operation and last follow-up, X-ray Bridwill bone fusion rates were 87.50%（28/32） and 93.75%（30/32） respectively, and CT fusion rates were 87.50%（28/32） and 90.63%（29/32） respectively; and there was significant difference in interbody fusion between at 1 year and last follow-up（P〈0.05）. Drug resistance was observed in 4 cases; Bridwill grade III and grade IV fusion was shown in 3 cases and 1 case after adjusting the anti-tuberculosis scheme after 1 year. Conclusion One-stage posterior retaining part facet joint in laminectomy and debridement can effectively clear the tuberculose focus, intervertebral bone graft combined with short segment pedicle screw fixation can maintain postoperative spinal reliable stability and get satisfactory bone fusion rate, so it is an effective method for the treatment of lumbosacral tuberculosis.