脊柱结核非手术治疗临床管理路径研究（附102例临床分析）

The management policy about non-operative treatment of spinal tuberculosis： 102 cases clinical analysis

目的探讨脊柱结核的非手术治疗临床管理路径的可行性及有效性。方法将山东省胸科医院2010年1月至2015年6月符合入组条件的102例脊柱结核患者，全部纳入非手术治疗临床管理路径的研究。分时段观察记录患者的疼痛视觉模拟评分（VAS）、红细胞沉降率（ESR）、C反应蛋白（CRP）的变化情况，影像学评估骨融合及骨桥形成情况，记录并发症的发生情况。分时段评估患者的心理状态并给予一对一的心理疏导，评估患者的营养状态并给予营养支持疗法。依据评估结果制定个体化治疗措施并进行严格随访。结果4例非手术治疗失败转为手术治疗，98例（96．1％）至疗程结束评估结果符合临床停药标准，其中3例遗留小的脓肿。37例（36．3％）出现胃肠道不良反应，经保护胃黏膜等处理后症状逐渐消失；23例（22．5％）化疗过程中出现肝功能损伤，其中6例需停药，5例视物模糊，停用乙胺丁醇后逐渐恢复。完成治疗的98例患者入院时VAS、ESR、CRP分别为（6±2）分、（43±20）mm／1h、（21±10）mg／L，抗结核药物治疗1个月时降为（4±2）分、（32±11）mm／1h、（12±8）mg／L，3个月时降为（2±1）分、（15±7）mm／1h、（6±2）mg／L，其中CRP下降的速率高于ESR。治疗后6、9、12个月对患者进行影像学复查，显示骨融合及骨桥形成者分别为37例（37．8％）、72例（73．5％）、89例（90．8％）。入院时心理状态评估焦虑、抑郁、愤怒、孤独总分高达（104．1±10．8）分，1个月时降为（69．0±10．5）分，3个月时降为（52．6±8．1）分，至6个月时降为（32．8±6．9）分，接近正常人。入院时营养状态评估总分≥3分者53例，治疗后1、3、6、12、18个月分别为38例、19例、10例、3例、1例。这些数据提示患者心理状态与营养状态的改善需要较长的时间。结论在全方面评估、个体化抗结核药物治疗联合辅助措施的临床管理路径指导下，对脊柱结核患者有选择地进行非手术治疗是有效可行的。

Objective To evaluate the feasibility and effectiveness of clinical management pathway about nonoperative treatment for patients with spinal tuberculosis. Methods From Jan 2010 to June 2015,102 patients with spinal tuberculosis at Shandong Provincial Chest Hospital were subordinated to the clinical management pathway study about non-operative treatment. They were all coincided with the diagnostic criterion of spinal tuberculosis. The visual analogue scale （VAS）, erythrocyte sedimentation rate （ESR）, C-reaction protein （CRP） were recorded at admission. They were took direct digital radiography （DR）, computed tomography （CT） or magnetic resonance im- aging （MRI） to find the hone fusion and osteogenesis. The complications were recorded. The situation of mentality were measured according to the mental status scale in non-psychiatric settings （MSSNS） and the situation of nourishment were assessed according to the nutritional risk screening （NRS 2002） at dmission. The personalizing management policy was established and the effectiveness and feasibility was measured during the follow-up. Results Four patients were failure with non-operative treatment and 98 （96.1%） patients were come up to the standard of drug discontinuance, but 3 patients were found to have a small abscess. There were 37 patients occur- ring gastrointestinal reaction, 23 patients occurring hepatic impairment and six of which had to stop anti-tuberculosis drugs, five patients occurring blurred vision. The decrease of VAS, ESR and CRP is the important identifications that indicating turn for the better of spinal tuberculosis. The VAS, ESR and CRP were （6±2） points, （43± 20） mm/1 h and （21±10） mg/L at admission, （4±2） points, （32±11） mm/1 h and （12±8） mg/L after 1 months, （2±1） points, （15±7） mm/1 h and （6±2） mg/L after 3 months, respectively. The bone fusion and osteogenesis was discovered at 37 （37. 8%） patients in six months and 72 （73.5%） patients in nine months and 89 （90. 8%） patients in 12 months, respectively. The MSSNS were （104. 1±10.8） points at admission, （69.0± 10.5） points after 1 months, （52.6±8.1） points after 3 months, and （32.8±6.9） points after 6 months, respectively. There were 53 patients whose scales of NRS 2002 is equal or greater than 3 points at admission, 38 after I months, 19 after 3 months, 10 after 6 months,3 after 11 months,and 1 after 18 months, respectively. These scales reminded that the improvement of mentality and nourishment need a long time. Conclusion Under the clinicl management pathway that including comprehensive assessment, individualization anti-tuberculosis therapy and subsidiary measures, it is feasibility and effective on non-operative treatment for some patients with spinal tuberculosis.