采用可扩张通道下病灶清除植骨融合联合后路内固定治疗腰椎结核

Extreme lateral channel debridement and fusion combined with posterior fixation for lumbar spinal tuberculosis

目的探讨采用可扩张通道下病灶清除植骨融合联合后路内固定治疗腰椎结核的临床疗效。方法回顾分析2008年12月-2014年12月采用可扩张通道下病灶清除植骨融合联合后路内固定治疗的17例腰椎结核患者临床资料。男10例,女7例;年龄20~69岁,平均42.6岁。病程1~6个月,平均3.4个月。病变累及节段:L_(1,2)5例,L_(2,3)6例,L_(3,4)3例,L_(4,5)3例。神经功能损害按美国脊髓损伤学会(ASIA)分级,C级2例,D级13例,E级2例。采用疼痛视觉模拟评分(VAS)、日本骨科协会(JOA)评分、Barthel指数评价疗效,并计算JOA评分和Barthel指数改善率;定期随访并复查腰椎X线片、CT,评价腰椎后凸Cobb角纠正情况及植骨融合情况。结果 17例患者手术均成功,术后病理检查均提示腰椎结核感染。所有患者均获随访,随访时间24~48个月,平均35.3个月。随访复查X线片及CT显示死骨清除彻底及椎旁脓肿消失,腰椎后凸Cobb角纠正良好。17例患者术后6个月植骨均达骨性融合;随访期间未发现结核病灶复发,术后18个月结核病变均达到临床治愈。未发现内固定物松动、断裂等并发症。末次随访时,2例术前ASIA分级C级患者中1例恢复至D级,1例恢复至E级;13例术前D级患者中11例恢复至E级,2例无变化;2例术前E级患者术后无神经损害。术后2周及末次随访时VAS评分、JOA评分、Barthel指数及腰椎后凸Cobb角均较术前明显改善,手术前后各时间点间比较差异均有统计学意义(P<0.05)。末次随访时,腰椎JOA改善率为75.2%±6.2%,Barthel指数改善率为75.7%±10.8%。结论采用可扩张通道下病灶清除植骨融合联合后路内固定治疗腰椎结核临床疗效良好,是一种安全有效的治疗方法 。

Objective To investigate the effectiveness of extreme lateral channel debridement and fusion combined with posterior fixation for lumbar spinal tuberculosis. Methods A retrospective analysis was made on the clinical data of 17 patients with lumbar spinal tuberculosis undergoing extreme lateral channel debridement and fusion combined with posterior fixation between December 2008 and December 2014. There were 10 males and 7 females, aged 20-69 years （mean, 42.6 years）. The disease duration was 1-6 months （mean, 3.4 months）. The involved segments included L1, 2 in 5 patients, L2, 3 in 6 patients, L3, 4 in 3 patients, and L4, 5 in 3 patients. Based on American Spinal Injury Association （ASIA） classification, there were 2 cases of grade C, 13 cases of grade D, and 2 cases of grade E. The visual analogue scale （VAS） score, Japanese Orthopaedic Association （JOA） score, and Barthel index were used to evaluate the effectiveness, and the improvement rate of JOA score and Barthel index was calculated at the same time. Lumbar X-ray film and CT were taken regularly to evaluate lumbar kyphotic Cobb angle correction and bony fusion. Results The operation was successfully performed in 17 patients, and pathological examination showed tuberculosis. All cases were followed up 24-48 months （mean, 35.3 months）. Lumbar X-ray film and CT showed that necrotic bone and abscess were cleared completely, and lumbar kyphosis correction was satisfactorily in all cases. Bony fusion was achieved within 6 months, and clinical cure was obtained within 18 months in all cases; no recurrence was found during follow-up period. No loosening or breakage of internal fixation was observed. At last follow-up, ASIA classification was recovered to grade D and grade E from grade C in 2 cases, to grade E from grade D in 11 cases and had no change in 2 cases （grade D）. Two cases of ASIA grade E showed no neurological deficit. The VAS score, JOA score, Barthel index, and lumbar kyphotic Cobb angle were significantly improved at 2 weeks after operation and at last follow-up when compared with preoperative ones （P〈0.05）. At last follow-up, the improvement rate of JOA score was 75.2%±6.2% and the improvement rate of Barthel index was 75.7%±10.8%. Conclusion To use extreme lateral channel debridement and fusion combined with posterior fixation is an effective treatment for lumbar spinal tuberculosis.