腰椎布氏杆菌性脊柱炎患者的一期经后路手术治疗

One-stage posterior surgery in the treatment of lumbar Brucella spondylitis

目的：探讨一期经后路腰椎病灶清除、自体髂骨取骨植骨融合、腰椎椎弓根螺钉内固定手术治疗腰椎布氏杆菌性脊柱炎的疗效。方法回顾性分析2011年3月至2013年12月，我院采用一期经后路腰椎病灶清除、自体髂骨取骨植骨、腰椎内固定融合治疗的12例布氏杆菌性脊柱炎患者，其中男8例，女4例；年龄22～62岁，平均（43.8±11.1）岁。术前追溯均有羊接触史或食用史。C 反应蛋白、血沉、MRI、CT、虎红平板凝集试验（ rose bengal plate agglutination test，RBPT ）及试管凝集试验（ standard tube agglutination test，SAT ）检查诊断明确，应用链霉素＋多西环素＋利福平联合抗感染治疗后2周，采用经后路腰椎病灶清除、自体髂骨取骨植骨融合、腰椎椎弓根螺钉内固定手术治疗，术后继续抗布病用药3个月，动态复查相关感染监测指标，直至布氏杆菌 SAT 阴性后继续应用2周。采用疼痛视觉模拟评分（ visual analogue scale，VAS ）评估腰痛及下肢痛缓解程度，根据美国脊髓损伤协会（ American spinal injury association，ASIA ）分级评定脊髓功能恢复情况。结果手术时间150～220 min，平均（179.3±22.6） min，出血200～450 ml，平均（288.3±79.9） ml。术中均无大血管及脊髓损伤，术后伤口甲级愈合。术后随访15～36个月，平均（24.5±7.8）个月，所有患者布氏杆菌感染中毒症状消失，术后3个月复查血沉等感染指标正常，术后4～8个月 X 线片复查提示椎间植骨均获得骨性愈合。术后3个月、6个月、末次随访时的 VAS 评分分别为（2.92±0.76）分、（1.33±0.47）分和（0.33±0.62）分，较术前（6.58±0.76）分均明显降低，差异有统计学意义（ P＜0.05），而 ASIA 脊髓功能分级较术前均明显好转（ P＜0.05）。结论经后路腰椎布氏杆菌病灶清除手术可彻底清除椎管内脓肿或肉芽组织，充分行神经根及椎管减压。经后路椎弓根手术可获得腰椎即刻稳定，可恢复并维持正常的腰椎生理曲度，防止术后腰椎失稳。一期后路手术联合长期抗生素用药，是治疗腰椎布氏杆菌性脊柱炎的有效方案。

Objective To investigate the curative effect of one-stage posterior debridement, interbody fusion with iliac autograft and pedicle screw internal ifxation in the treatment of lumbar Brucella spondylitis.Methods Twelve patients with lumbar Brucella spondylitis adopted from March 2011 to December 2013 were treated with one-stage posterior debridement, interbody fusion with iliac autograft and pedicle screw internal ifxation, whose clinical data were analyzed retrospectively. There were 8 males and 4 females, whose mean age was （ 43.8 ± 11.1 ） years （ range： 22 - 62 years ）. All the patients had contact history with sick sheep or had eaten them. C-reactive protein （ CRP ）, erythrocyte sedimentation rate （ ESR ）, MRI, CT, rose bengal plate agglutination test （ RBPT ） and standard tube agglutination test （ SAT ） examinations were performed for diagnosis preoperatively. At 2 weeks after combined chemotherapy comprised of streptomycin, doxycycline and rifampicin, the patients were treated with posterior debridement, interbody fusion with iliac autograft and pedicle screw internal fixation, followed by continuous chemotherapy for 3 months. Infectious indicators were reviewed dynamically until negative results were noticed by SAT, which still continued for 2 weeks. The visual analogue scale （ VAS ） was used to evaluate relief of low back pain and lower limb pain, and the American spinal injury association （ ASIA ） classiifcation was performed to assess nerve function recovery.Results The operation time was 150 - 220 min （ mean 179.3 ± 22.6 min ）, and the amount of bleeding was 200 - 450 ml （ mean 288.3 ± 79.9 ml ）. No large blood vessel or spinal cord injuries were found during theoperation, and all the wounds healed in grade A. During the follow-up of 15 - 36 months （ mean 24.5 ± 7.8 months ）, all the infectious symptoms disappeared in all the patients. Infectious indicators such as ESR returned to normal at 3 months after the operation, and bone union was achieved at 4-8 months after the operation based on the X-ray iflms. The postoperative VAS pain scores were （ 2.92 ± 0.76 ） points, （ 1.33 ± 0.47 ） points and （ 0.33 ± 0.62 ） points respectively at 3 months and 6 months after the operation and at the ifnal follow-up, which were signiifcantly decreased when compared with the preoperative score of （ 6.58 ± 0.76 ） points （P 〈 0.05 ）. The ASIA classification was signiifcantly improved when compared with the preoperative value, and the differences were statistically signiifcant （P 〈 0.05 ）.Conclusions Radical debridement of intraspinal abscesses and granulomas and full never root and spinal canal decompression could be achieved by posterior approach. Pedicle screw internal ifxation facilitates instant lumbar stability and normal physiological curvature, and postoperative lumbar instability could be avoided. One-stage posterior lumbar surgery combined long-term chemotherapy are effective in the treatment of lumbar Brucella spondylitis.