自体肋骨捆绑移植重建胸椎结核病灶清除术后骨缺损

The autologous bundled multi-segment rib graft reconstruction for bone defects after thoracic spinal tuberculosis debridement

目的探讨自体肋骨捆绑移植重建治疗胸椎结核病灶清除术后骨缺损的疗效。方法 2006年1月—2013年12月,采用前路病灶清除、捆绑肋骨椎间植骨融合,前路或后路内固定术治疗36例胸椎结核术后骨缺损。男20例,女16例;年龄21~60岁,平均50.5岁。病程5~11个月,平均6.8个月。胸椎结核位于T_(4、5) 1例,T_(5、6) 4例,T_(6、7) 4例,T_(7、8) 4例,T_(8、9) 9例,T_(9、10) 8例,T_(10、11) 5例,T_(11、12) 1例。伴神经损害34例,根据Frankel分级为B级2例、C级8例、D级24例。记录患者手术前后红细胞沉降率(erythrocyte sedimentation rate,ESR)、C反应蛋白(C reactive protein,CRP)、疼痛视觉模拟评分(VAS)及胸椎后凸Cobb角;根据CT三维重建分析植骨融合情况。结果术后测量捆绑肋骨的横截面积为136.8~231.2 mm^2,平均197.1 mm^2;相邻上、下位椎体终板表面积为425.0~677.6 mm^2,平均550.6 mm^2;肋骨占终板表面积百分比为29%~50%,平均33.6%。手术时间125~160 min,平均125 min;术中出血量280~850 mL,平均450 mL。患者均获随访,随访时间2~8年,平均4.4年。术后出现肋间神经痛2例、胸腔积液1例、结核药物导致肝功能损害2例,均经对症治疗后治愈。其余患者未发生任何呼吸道并发症及伤口感染,无肋骨支撑体骨折、移位和吸收,无结核病灶复发,无内固定物松动断裂、脊柱后凸畸形。术后6个月三维CT示融合率为86.1%(31/36),术后12个月为97.2%(35/36)。术后3个月及末次随访时ESR、CRP、VAS评分及胸椎后凸Cobb角均较术前显著改善(P<0.05),术后3个月及末次随访间比较差异无统计学意义(P>0.05)。术前Frankel分级B级2例均恢复至D级,术前C级8例恢复至D级1例、E级7例,术前D级24例均恢复至E级。结论对中下胸椎结核病灶清除术后小于2个椎体和椎间盘的骨缺损,采用自体肋骨捆绑支撑移植是可行的。

Objective To investigate the effectiveness of bundled multi-segment autologous rib graft reconstruction for bone defects after thoracic spinal tuberculosis debridement. Methods The anterior debridement, multi-segment autologous rib interbody fusion, anterior or posterior internal fixation were used for treating the bone defect after thoracic spinal tuberculosis debridement in 36 cases between January 2006 and December 2013. There were 20 males and 16 females with an average age of 50.5 years （range, 21-60 years）, and an average disease duration of 6.8 months （range, 5-11 months）. The thoracic vertebral tuberculosis located at T4, 5 in 1 case, T5, 6 in 4 cases, T6, 7 in 4 cases, T7, 8 in 4 cases, T8, 9 in 9 cases, T9, 10 in 8 cases, T10, 11 in 5 cases, and T11, 12 in 1 case. Neurological impairment of 34 patients was assessed as grade B in 2 cases, grade C in 8 cases, and grade D in 24 cases according to Frankel classification. The pre- and post-operative erythrocyte sedimentation rate （ESR）, C reactive protein （CRP）, visual analogue scale （VAS） score, and kyphosis Cobb angle were evaluated. The fusion rate was analysed based on CT three-dimensional reconstruction. Results The cross-sectional area of the bundled multi-segment rib graft was 136.8-231.2 mm2 （mean, 197.1 mm2）; the endplate surface area of adjacent upper and lower vertebral bodies was 425.0-677.6 mm2 （mean, 550.6 mm2）; and the cross-sectional area of rib graft accounted for 29%-50% （mean, 33.6%） of the endplate surface area. The operation time was 95-160 minutes （mean, 125 minutes） and the intraopeartive blood loss was 280-850 mL （mean, 450 mL）. All the patients were followed up 2-8 years （mean, 4.4 years）. The postoperative complications included intercostals neuralgia in 2 cases, pleural effusion in 1 case, and liver function damage caused by antituberculosis drugs in 2 cases, who were all cured after symptomatic treatment. The rest patients had no respiratory complications and wound infection; and there was no fracture, displacement, absorption of rib support, tuberculosis recurrence, internal fixation loosening, and kyphosis occurred in all patients. CT three-dimensional reconstruction showed that the fusion rate was 86.1 （31/36） at 6 months after operation and was 97.2% （35/36） at 12 months after operation. The ESR, CRP, VAS scores, and kyphosis Cobb angle at 3 months after operation and last follow-up were significantly improved when compared with preoperative values （P〈0.05）, but there was no significant difference between at 3 months after operation and last follow-up （P〉0.05）. Neurological deficits were all improved at last follow-up according to Frankel classificaiton, including 2 cases with grade B recovered to grade D, 8 cases with grade C to grade D in 1 case and to grade E in 7 cases, 24 cases with grade D all to grade E. Conclusion Bundled multi-segment autologous rib graft reconstruction is an alternative method for less than 2 discs and vertebral bone defect created by radical debridement for thoracic spinal tuberculosis.