39例胸椎结核累及胸腔的手术时机、手术方式和疗效分析

Analysis of operation timing, operation procedure and efficacy in 39 cases with thoracic vertebrae tuberculosis involved in pleural

目的探讨胸椎结核累及胸腔的围手术期处理及手术时机和手术方法，以此减少此类患者的手术并发症。方法回顾性分析2012年1月至2014年12月北京胸科医院收治的39例胸椎结核累及胸腔的手术治疗患者，根据手术时胸椎结核累及胸腔后继发胸腔积液和脓胸的病程时间分为2个组。A组：27例；胸椎结核累及胸腔前体温稳定在37．5℃以下，并且血红细胞沉降率稳定或处于下降过程，累及胸腔后继发胸腔积液或脓胸的病程短于4周者。B组：12例；胸椎结核累及胸腔继发胸腔积液或脓胸的病程大于4周，则待胸膜纤维板较厚，体温稳定在37．5℃以下，并且血红细胞沉降率稳定或处于下降过程者。39例患者均一期完成病灶清除、椎体问植骨融合、内固定术。手术方式：后侧人路胸椎病灶清除、椎体间植骨融合、椎弓根系统内固定（术式1）；后侧入路椎弓根系统内固定、前侧入路经胸腔胸膜纤维板不剥脱或部分剥脱、胸椎病灶清除、椎体间植骨融合术（术式2）；后路椎弓根系统内固定、前侧入路经胸腔胸膜纤维板完全剥脱、胸椎病灶清除、椎体间植骨融合术（术式3）；前侧入路经胸腔胸膜纤维板不剥脱或部分剥脱、胸椎病灶清除、椎体间植骨融合、前路钉板内固定术（术式4）；前侧入路经胸腔胸膜纤维板完全剥脱、胸椎病灶清除、椎体间植骨融合、前路钉板内固定术（术式5）；前侧入路胸膜外胸椎病灶清除、椎体间植骨融合、前路内固定术（术式6）；后侧入路椎弓根系统内固定、前侧入路胸膜外胸椎病灶清除、椎体间植骨融合术（术式7）。结果A组27例，手术在累及胸腔继发胸腔积液或脓胸后1～4周施行，平均（2±1．7）周；B组12例，手术在累及胸腔继发胸腔积液或脓胸后8～12周施行，平均（9±1．4）周。5例选择术式1，11例选择术式2，9例选择术式3，5例选择术式4，3例选择术式5，2例选择术式6，4例选择术式7。所有思者均无死亡及发生严重心脑血管、肺、肝、肾并发症。术后胸腔管引流时间6～33d，平均（15±10．9）d。术后切口一期愈合35例，一期愈合率（89．7％）；2例经每日伤口换药1个月内愈合，2例经每日伤口换药1个月后行清创后愈合。5例术前并发脊髓损伤，术后3个月均恢复正常。术后6个月x线摄影复查，显示椎体呈骨性融合者28例，骨性融合率达71．8％（28／39）；术后1年X线摄影复查，显示椎体骨性融合者35例，骨性融合率达89．7％（35／39）。术后随访2～3年，所有患者末次随访时均未见结核病复发迹象。所有患者受累及的胸腔均已粘连闭合，未见胸腔积液或脓胸。结论胸椎结核累及胸腔，继发胸腔积液或脓胸患者的治疗需同时兼顾胸椎结核和胸腔积液或脓胸，在有效抗结核药物治疗的基础上，选择合适的手术时机和手术方法，可以取得比较好的治疗效果。

Objective To explore the perioperative management, operation timing and operation procedure in patients with thoracic vertebrae tuberculosis involved in pleural in order to reduce the surgical complications. Methods Thirty-nine cases with thoracic vertebrae tuberculosis involved in pleural admitted and performed by operation in Beijing Chest Hospital were enrolled and divided into two groups according the time of secondary pleural effusion and empyema due to thoracic vertebrae tuberculosis involved in pleural during January 2012 to December 2014. Twenty-seven cases with the temperature below 37.5 ℃ and erythrocyte sedimentation rate （ESR） stable or declining process before the time of pleural effusion or empyema secondary thoracic vertebrae tuberculosis involved in pleural less than 4 weeks belonged to Group A. Twelve cases with the time of pleural effusion or empyema secondary thoracic vertebrae tuberculosis involved in pleural more than 4 weeks with thick pleural fibrotic, the temperature below 37.5 ℃ and ESR stable or declining process belonged to Group B. Thirty-nine cases performed focus debridement, bone graft fusion between vertebra and internal fixation in one stage. Surgical procedures： Type 1： Posterior approach for thoracic debridement, bone graft fusion between vertebra and pedicle screw fixation. Type 2： Posterior pedicle screw fixation, anterior approach via pleural fibrotic non-stripping or partial stripping, thoracic vertebrae debridement and bone graft fusion between vertebra. Type 3： Posterior pedicle screw fixation, anterior approach via pleural fibrotic stripping completely, thoracic vertebrae debridement and bone graft fusion between vertebra. Type 4： Anterior approach via pleural fibrotic non-stripping or partial stripping, thoracic vertebrae debridement, bone graft fusion between vertebra and anterior screw plate fixation. Type 5： Anterior approach via pleural fibrotic stripping completely, thoracic vertebrae debridement, bone graft fusion between vertebra and anterior screw plate fixation. Type 6： Anterior approach for extrapleural thoracic vertebrae debridement, bone graft fusion between vertebra and anterior internal fixation. Type 7： Posterior pedicle screw internal fixation, anterior approach for extrapleural thoracic debridement, bone graft fusion between vertebra. Results The average time of operation performed was （2±1.7） weeks ranged from 1 to 4 weeks in 27 cases with secondary pleural effusion or empyema in group A. The average time of operation performed was （9±1.4） weeks ranged from 8 to 12 weeks in 12 cases with secondary pleural effusion or empyema in group B. There were type I in 5 cases, type 2 in 11 cases, type 3 in 9 cases, type 4 in 5 cases, type 5 in 3 cases, type 6 in 2 cases and type 7 in 4 cases. All patients had no death and serious complications of cardiovascular and cerebrovascular diseases, lung, liver and kidney. The postoperative drainage average time was （15±10. 9） days ranged from 6 to 33 days. The rate of postoperative incision primary healing was 89.7% （35/39） in a9 cases. Wound was cured after daily dressing change for one month in 2 cases and after daily dressing change for one month and debridement in 2 cases. Spinal cord injury was recovered after operation for 3 months in 5 cases. The X-ray showed that the bony fusion was achieved in 28 cases in the 6th month after the operation and the fusion rate was 71.8% （28/39）. The X-ray showed that the bony fusion was achieved in 35 cases in the 12th months after the operation and the fusion rate was 89. 7% （35/39）. There was no recurrence case in the last follow up. The pleural involvement were adhesion and clousure without pleural or empyema in all patients. Conclusion The treatment for secondary pleural effusion or empyema patients with thoracic vertebrae involved in pleural need to treat both thoracic vertebrae tuberculosis and pleural effusion or empyema. The proper operation timing and operation procedure can achieve good treatment outcome on the basis of effective antituberculosis drug therapy.