后路病灶清除仿生骨支撑植骨融合内固定术治疗胸腰椎结核的疗效分析

Clinical effects of posterior debridement combined with biomimetic bone graft and internal fixation for thoracic and lumbar spinal tuberculosis

目的 :评估后路一期病灶清除辅以纳米仿生骨支撑植骨融合内固定术治疗胸腰椎结核的临床疗效。方法:回顾性分析2011年1月~2015年5月收治的17例胸腰椎结核患者,其中男性11例,女性6例,年龄25~71岁,平均41.2±5.6岁;胸椎(T4~T10)结核9例,胸腰段(T11~L2)结核7例,下腰椎(L3~L5)结核1例;单节段病变12例,两节段病变5例;脊髓神经损伤情况按照ASIA损伤分级:B级1例、C级4例、D级6例、E级6例。本组患者均行后路一期病灶清除纳米仿生骨笼支撑植骨融合内固定术治疗,从术前2周~术后18个月规范应用抗结核药物。术后1个月、3个月、6个月、12个月、24个月定时随访,观察植骨区融合情况并比较术前及术后患者疼痛视觉模拟评分(VAS)、脊柱后凸Cobb角、神经功能ASIA分级变化情况。结果:本组17例患者均成功完成手术,手术时间264~366min,平均294±88min;术中出血量457~1350ml,平均731±78ml。所有患者均获得随访,随访时间18~27个月,平均23±6个月,随访期间无结核症状加重及相关并发症,术后切口均Ⅰ期愈合,均未出现切口感染及内固定物松动。1例患者术中出现胸膜破裂,予以修补并采用胸腔闭式引流后正常出院。术后6个月植骨融合率为88.2%,术后12个月时植骨区均可见骨性融合,融合率为100%。术前VAS评分为8.1±0.6分,术后2周时为2.1±0.3分,末次随访时为1.1±0.2分;术前Cobb角为28.3°±9.8°,术后2周时为8.1°±1.5°,末次随访时为9.8°±2.1°,终末矫正率为65.3%。末次随访时ASIA分级D级4例,E级13例。手术前后VAS评分、Cobb角、ASIA分级差异比较均有统计学意义(P<0.05)。结论:在抗结核药物治疗的基础上,一期后路病灶清除结合纳米仿生骨植骨融合内固定手术治疗较局限的胸腰椎结核可取得较为满意的效果。

Objectives： To explore the clinical effects of one stage single posterior approach for thoracic and lumbar spinal tuberculosis. Methods： A total of 17 patients with thoracic and lumbar spinal tuberculosis in our hospital from January 2011 to May 2015 were selected. There were 11 males and 6 females, aged from 25 to 71 years（average, 41.2±5.6 years）; 9 cases with thoracic spinal tuberculosis（T4-T10）, 7 cases with tho- racic lumbar spinal tuberculosis（T11-L2）, 1 case with lower lumbar spinal tuberculosis（L3-LS）. There were 12 cases in single segment and 5 cases in two segments. According to American Spinal Injury Association（ASIA） grading system, 1 case was in grade B, 4 cases in grade C, 6 cases in grade D and 6 cases in grade E. All patients underwent one stage simple posterior debridement, interbody fusion and internal fixation. Antitubercu- losis drugs were used from 2 weeks before operation to 18 months after operation. The clinical effects were evaluated according to pain visual analogue seale（VAS）, Cobb angle correction, recovery of neurological func- tion which was classified based on the ASIA grading system, and bone graft fusion rate. Results： All surg- eries were successfully performed, and the average operation time and blood loss during operation were 294± 88min（264-366min） and 731±78ml（457-1350ml） respectively. All those patients were followed up, and theaverage follow-up time was 23＋6 months（18-27 months）. No patients were noted complications such as inci- sion infection and recurrence of tuberculosis. One patient who suffered from pleura rupture during surgery re- covered after repairement of pleura and closed drainage. The 6-month and 12-month bone graft fusion rate was 88.2% and 100% respectively. VAS score of preoperation, 2 weeks postoperation and final follow-up was 8.1±0.6, 2.1±0.3 and 1.1±0.2 respectively; Cobb angle was 28.3°±9.8°, 8.1°±1.5° and 9.1°±3.5° respectively. At final follow-up, the final correct rate was 65.3%; ASIA grade was grade D in 4, grade E in 13. The VAS score, Cobb angle and ASIA grade were statistically significant before and after surgery（P〈0.05）. Conclusions： One stage posterior debridement, interbody fusion and internal fixation is a good choice for short segment and circumscribed thoracic and lumbar tuberculosis.