经第11肋腹膜外改良小切口治疗腰椎1～2结核的疗效分析

Surgical treatment of L1 - 2 tuberculosis by llth rib extraperitoneal improved mini-incision fusion approach

目的探讨经第11肋腹膜外改良小切口治疗腰椎1～2（“L1～2”）结核的临床疗效。方法收集2010年2月至2014年12月浙江省中西医结合医院55例L1～2结核患者的临床资料。所有患者均应用一期后前路联合入路行病灶清除植骨融合内固定术，且采用随机数字表法被分为经第11肋腹膜外改良小切口组（改良组，28例）和传统。肾切口组（传统组，27例）。记录两组患者的手术时间、切口长度、术中出血量、术后住院时间、术后并发症发生率和治愈率，以及两组患者手术前后疼痛视觉模拟评分（visual analogue score，VAS）、植骨融合、脊髓功能恢复情况（Frankel分级）、脊柱病椎节段后凸Cobb角、血红细胞沉降率（ESR）及C反应蛋白（CRP）等指标。所有数据采用SPSS19．0统计软件分析，计量资料以“x^-±s”表示，组间比较采用t检验；计数资料的比较采用矿检验，均以P〈0．05为差异有统计学意义。结果所有患者随访24个月以上。改良组在手术时间[（242．21±20．87）mini、手术切口长度[（9．41±1．12）cm]、住院时间[（15．42±2．50）d]、术后1d的VAS评分[（5．63±0．58）分]及术后15d的VAS评分[（4．03±0．20）分]均优于传统组[（291．67±25．63）min、（23．32±3．21）cm、（18．78±4．51）d、（6．24±0．38）分，（4．42±0．51）分]，差异均有统计学意义（t=6．89，P=0．001；t=19．78，P=0．001；t=3．08，P=0．004；t=3．68，P=0．001；t=4．24，P=0．001）。改良组和传统组手术前、后1年组内比较，在E级（良好）脊髓功能[42．9％（12／28）、96．4％（27／28）和48．1％（13／27）、100．o％（27／27）；x^2值分别为22．29、20．77，P值均〈0．01]、病椎节段后凸Cobb角[（17．67±3．31）°、（6．29±2．03）°和（16．61±3．03）°、（7．22±2．24）°]、ESR（术前与术后2周）[（54．93±13．91）mm／1h、（33．12±7．52）mm／1h和（54．11±15．20）mm／1h、（33．21±7．64）mm／1h]、CRP（术前与术后2周）[（42．23±13．78）mg／L、（21．46±6．05）mg／L和（41．33±13．69）mg／L、（21．69±6．04）mg／L]等指标上，差异均有统计学意义（t值分别为13．93、10．93、6．47、6．38、7．30、6．82，P值均〈0．01）。结论两种手术方式对患者术后一些指标的恢复均有良好的治疗效果，但经第11肋腹膜外改良小切口病灶清除融合治疗L1～2椎体结核较传统肾切口，具有缩短手术时间及手术切口长度、改善术后疼痛、加速术后康复的优点，可以在临床推荐应用。

Objective To evaluate efficacy of modified small incision from the 11th rib extraperitoneal for treatment of the first and second lumbar vertebra （L1-2） tuberculosis. Methods The data from 55 cases with L1-2 tuberculosis admitted and performed one stage posterior-anterior approach debridement, bone graft fusion and internal fixation in the department of orthopedics of hospital of integrated traditional Chinese and western medicine in Zhejiang province during February 2010 to December 2014 were collected. According to random number table method, patients were randomly divided into two groups. Twenty eight cases （improved group） were performed with modified small incision from the llth rib extraperitoneal. Twenty seven cases （traditional group） were performed with the traditional renal incision operation in the second number group. Clinical indexes including operation time, incision length, intraoperative blood loss, postoperative hospital stay, postoperative complications, preoperative and postoperative pain visual analogue scores, bone graft fusion, recovery of spinal cord function （Frankel grade）, pathologic vertebrae kyphotic Cobb angle, erythrocyte sedimentation rate （ESR） and Creactive protein （CRP） were recorded and analyze. All data were analyze using statistical software of SPSS （version 19.0）. Measurement data expressed as x^-±s. t test was used for comparison between groups. Comparison of enumeration data was used with Chi-square. P 〈 0. 05 was considered difference significantly. Results All patients were followed up for 24 months. The operation time （（242. 21± 20. 87） min）, incision length （（9. 41 ± 1.12） cm）, postoperative hospital stay （（15. 42±2. 50） d）, postoperative VAS in the 1st day （（5. 63±0. 58）） and in the 15th day （（4. 03±0. 20）） in the improved group were better than those （（291. 67±25.63） min, （23. 32±3.21） cm, （18. 78±4. 51） d, （6. 24± 0. 38）, （4.42± 0. 51）） in the traditional group with significant difference statistically （t= 6.89, P= 0. 001± 19. 78,P=0. 001; t = 3. 08, P= 0. 004; t === 3.68, P = 0. 001; t = 4. 24, P = 0. 001）. Intra-group comparison for preoperative and postoperative indexes including Frankel grade E （42. 9M （12/28） vs. 96.4% （27/28） and 48. 1± （13/27） vs. 100. 0± （27/27）; x^2 =22. 29, 20. 77, P〈0. 01）, pathologic vertebrae kyphotic Cobb angle （（17. 67± 3.31）° vs. （6. 29±2.03）° and （16. 61±3.03） vs. （7. 22±2. 24））, ESR （（54. 93±13.91） mm/1 h vs. （33. 12± 7.52） mm/lh and （54.11±15.20） mm/1 h vs. （33.21±7.64） mm/1 h）, CRP （（42.23±13.78） mg/L vs. （21. 46±6.05） mg/L and （41. 33±13.69） mg/L vs. （21. 69±6.04） mg/L） were significant difference statistically in the improved group and the traditional group （t= 13.93, 10.93, 6.47, 6.38, 7. 30 and 6.82,all of P values were less than 0.01）. Conclusion These two kinds of surgical procedures can get good treatment outcome for some indexes recovery. But the modified small incision from the 11th rib extraperitoneal for focus debridement and bone graft fusion have some advantages including shorten the operation time and incision length, improving postoperative pain, accelerating postoperative rehabilitation and can be recommended to clinical application.