腰骶部结核改良倒L形切口腹膜外手术入路的临床应用

Clinical application of modified inverted L-shape incision by extraperitoneal approach to lumbosacral tuberculosis

目的:探讨后路Ⅰ期内固定联合前路改良倒L形切口、腹膜后入路行病灶清除并植骨治疗腰骶部多节段结核的临床疗效。方法:回顾分析2008年2月至2014年12月收治的腰骶部多节段结核15例,其中男9例,女6例,年龄26~72岁,平均(47.0±13.9)岁。病变累及节段:L_4-S_112例,L_4-S_21例,L_3-S_12例。5例患者有神经根性症状,2例有马尾压迫症状。均采用后路椎弓根钉固定联合前路改良倒L形切口腹膜外手术入路行L_(4,5),L_5S_1结核病灶清除植骨融合术,记录手术时间、出血、切口长度及术后首次肛门排气时间,术后定期随访,行腰椎CT及MRI检查观察植骨融合及病灶吸收情况,定期复查血沉、CRP评估结核治疗情况。结果:15例患者均获得随访,时间18~24个月,平均(20.0±2.73)个月。术后腰骶部疼痛症状均得到改善,钉棒系统无松动、断裂,植骨块无松动,前后路手术时间210~250 min,平均(231.0±12.1)min;出血量320~705 ml,平均(495.0±130.3)ml;手术切口15~21 cm,平均(16.4±3.4)cm,其中倒L形切口延长部分长度为6~9 cm,平均(7.1±2.6)cm。术后首次肛门排气时间14~40 h,平均(24.1±7.4)h。末次随访植骨均获得融合,脊髓症状得到恢复,血沉、CRP均正常,停药3个月后无反复。结论:采用后路椎弓根钉固定联合前路改良倒L形切口腹膜外入路病灶清除植骨融合术治疗腰骶部多节段结核具有可操作性与实用性,该术式较传统入路具有手术创伤小、解剖显露清楚、术后并发症少、安全性高等优点。

Objective：To explore the clinical effects of one-stage posterior transpedicular screw system internal fixation combined with anterior debridement and bone grafting with modified inverted L-shape incision by extraperitoneal approach in treating multiple lumbosacral tuberculosis. Methods：The clinical data of 15 patients with multiple lumbosacral tuberculosis underwent operation from February 2008 to December 2014 were retrospectively analyzed. There were 9 males and 6 females with an average of （47.0±13.9） years old. The lesions involved L-S1 in 12 cases ,L4-S2 in 1 case ,L3-S1 in 2 cases. Five cases complicated with nerve root symptoms and 2 cases with cauda equina symptoms. All patients were treated with posterior transpedicular screw system internal fixation combined with anterior L4.5, L5S1 debridement and bone grafting with modified in- verted L-shape incision by extraperitoneal approach. Operation time, blood loss,incision length ,first passage of gas by anus were recorded. The condition of bone fusion and focus absorption were observed by lumbar CT and MRI; and ESR and CRP were regularly rechecked. Results：Fifteen patients were followed up for 18-24 months with an average of （20.0±2.73） months. All lumbosacral pain obtained improvement, and no hardware loosening, breaking, or bone graft block loosening was found. The operative time of anterior-posterior approach surgery was 210-250 min with an average of （231.0±12.1 ） min ;the blood loss was 320-705 ml with an average of （495.± 130.3 ） ml;the incision length was 15-21 cm with an average of （16.4±3.4） cm, and the extended length of inverted L-shape incision was 6 to 9 cm with an average of （7.1±2.6） cm. The time of first passage of gas by anus was 14 to 40 h with an average of （24.1±7.4） h after operation. All bone graft obtained fusion at final follow-up, and spinal cord symptoms got recovery, ESR and CRP restored normal level with no recurred at 3 months after drug withdrawal. Conclusion：The treatment of multiple lumbosaeral tuberculosis with posterior transpedicular screw system internal fixation combined with anterior debridement and bone fusion with modified inverted L-shape incision by extraperitoneal approach isfeasible and practical. This method has advantages of little trauma, good exposure,less complications and high security.