一期后路病灶清除植骨融合内固定术治疗腰骶段脊柱结核的临床效果研究

One-stage posterior debridement, interbody bone grafts and instrumentation for lumbosacral tuberculosis

目的探讨一期后路病灶清除植骨融合内固定术治疗腰骶段脊柱结核的临床疗效。方法回顾性分析2012年9月至2015年11月,我院采用一期后路手术方式治疗并获得较满意疗效的117例腰骶段脊柱结核患者的临床资料。术前所有患者均行X线片,CT及磁共振检查,确定所有患者均为L4~S2范围内的腰骶段脊柱结核,所选取的117例均有不同程度的神经功能障碍(Frankel分级分别为:B级3例,C级60例,D级54例)。手术方式为一期后路病灶清除植骨融合内固定术,并联合局部化疗方法,术前术后联合正规抗结核治疗。定期随访每间隔3个月一次,复查术后红细胞沉降率(erythrocyte sedimentation rate,ESR),X线片评估结核活动情况及植骨融合情况,对比记录术前后手术患者的腰骶角变化。并在每次随访时对患者疼痛视觉模拟评分(visual analogue scale,VAS)以及Frankel分级进行重新评估。结果所有患者术后均获随访,随访时间10~21个月,平均(12.6±3.4)个月。术中术后无严重并发症发生,随访期间未发生术后结核复发病例。腰骶部前凸角度从术前平均(13.3±5.4)°恢复至术后3个月平均(25.4±5.2)°,末次复查平均为(24.1±4.9)°;ESR由术前的(46.33±19.98)mm/h下降至术后3个月的(12.12±3.56)mm/h和术后6个月的(10.06±2.50)mm/h;VAS评分由术前的(6.23±1.54)分减小至术后3个月的(1.92±0.86)分,术后6个月则为(0.53±0.51)分;术前及术后的腰骶部前凸角度、ESR、VAS评分变化差异均有统计学意义(P<0.05);术后椎间隙骨性融合时间8~12个月,平均8.9个月,无内固定松动及断裂。末次随访时117例均有不同程度的神经功能恢复,Frankel评分结果为:13例C级,36例D级,68例E级。结论对于腰骶部脊柱结核,在术前术后的积极抗结核药物治疗的辅助下,通过行一期后路病灶清除植骨融合内固定术是行之有效的治疗方案。

Objective To investigate the clinical outcomes of one-stage posterior debridement, interbody bone grafts and instrumentation for lumbosacral tuberculosis. Methods A total of 117 cases with lumbosacral tuberculosis from September 2012 to November 2015 were reviewed retrospectively. All patients underwent X-ray, CT and MRI examinations to determine the lesion segment （ L4 - S2 ）. All patients had neurological dysfunction. Based on Frankel grade, 3 cases were of grade B, 60 cases grade C and 54 cases grade D. All patients received one-stage posterior debridement, interbody bone grafts and instrumentation, combining with local chemotherapy, preoperative and postoperative regular anti-tuberculosis treatment. Regular follow-up was conducted every 3 months. Erythrocyte sedimentation rate （ ESR ） and X-ray were applied to evaluate the tuberculosis, bone graft fusion, and changes of lumbosacral angle. Visual analogue scale （ VAS ） and Frankel ratings were used for re-evaluation at each follow-up. Results All patients were followed up for 10 - 21 months with the average of （ 12.6 ± 3.4 ） months. There were no severe complications intraoperatively and postoperatively. No recurrent cases of tuberculosis were found during the follow-up. The average lumbosacral angle recovered from （ 13.3 ± 5.4 ）°; preoperatively to （ 25.4 ± 5.2 ）° 3 months postoperatively, （ 24.1 ± 4.9 ） ° in the latest follow-up. ESR decreased from （ 46.33 ± 19.98 ） mm / h preoperatively to （ 12.12 ± 3.56 ） mm / h 3 months postoperatively and （ 10.06 ± 2.50 ） mm / h 6 months postoperatively. VAS decreased from （ 6.23 ± 1.54 ） preoperatively to （ 1.92 ± 0.86 ） 3 months postoperatively, and （ 0.53 ± 0.51 ） 6 months postoperatively. There were statistical differences on lumbosacral angle, ESR and VAS preoperatively and postoperatively （ P 〈 0.05 ）. Lumbar interbody fusion was achieved 8 - 12 months postoperatively （ the mean, 8.9 months ）. No internal fixation loosening or fracture occurred. At the latest follow-up, 117 patients had different degrees of nerve function recovery. Frankel： 13 cases were of grade C, 36 cases grade D, 68 cases grade E. Conclusions For lumbosacral tuberculosis, the treatment of one-stage posterior debridement, interbody bone grafts and instrumentation, combining with positive anti-tuberculosis treatment before and after the surgery, is effective.