前与后路病灶清除植骨融合治疗腰椎结核的比较

Anterior versus posterior approach for debridement,fusion and internal fixation in treatment of lumbar tuberculosis

[目的]通过对比前、后路手术治疗腰椎结核的治愈率、神经功能改善、畸形矫正以及腰椎平衡重建等,评价两种手术方式临床疗效及技术特点。[方法]回顾性分析2012年2月~2015年12月在本院接受手术治疗的79例腰椎结核病例,根据手术方式分为两组。前路组共36例,男13例,女23例,平均年龄33.6岁,接受前路腹膜外入路病灶清除、植骨融合内固定术治疗。后路组共43例,男21例,女22例,平均年龄36.2岁,接受后路经椎间孔、椎旁入路病灶清除、植骨融合内固定术治疗。对比两组手术时间、出血量、并发症、结核愈合、神经功能改善、局部后凸畸形矫正以及腰椎前凸重建等情况。[结果]所有病例均顺利完成手术,无严重并发症发生。两组间手术时间、出血量、并发症发生率差异无统计学意义(P>0.05)。所有患者均获得至少1年以上随访,平均随访时间(24.9±11.2)个月(12~61个月),除后路组2例患者结核复发经二次手术治愈,其余患者均获得一期治愈,无内固定相关并发症发生。末次随访时两组神经功能损害患者神经功能均恢复至ASIA分级E级。前路组后凸畸形平均(24.73±10.05)°,术后下降至(3.58±6.54)°,末次随访时(6.63±7.64)°;后路组后凸畸形平均(34.38±23.46)°,术后下降至(-0.78±10.01)°,末次随访时(1.16±11.09)°。两组畸形矫正与术前相比差异均具有统计学意义(P<0.05),其中后路组矫正角度更大,与前路组相比差异具有统计学意义(P<0.05)。后路组有后凸畸形病例平均腰椎前凸角术后与术前相比,差异具有统计学意义(P<0.05),前路组无差异(P>0.05)。[结论]前、后路手术治疗腰椎结核均可获得良好的临床疗效,后路手术在矫正畸形和重建腰椎生理曲度上更具有优势。

[Objective] To compare the outcomes, including neurological function, deformity correction, and lumbar rebal- ance, between anterior and posterior approach in treatment of lumbar tuberculosis. [Method] We retrospectively analyzed 79 pa- tients who underwent surgical treatment for lumbar tuberculosis between Feb.2012 and Dec. 2015 in our hospital. Of them, 36 patients, including 13 males and 23 females, had the debridement, fusion and internal fixation performed through the anterior retroperltoneal approach （the anterior group） , whereas the remaining 43 patients, consisted of 21 males and 22 females, re- ceived transforaminal or paraspinal debridement, fusion and internal fixation through the posterior approach （the posterior group） . The operation time, blood loss, complication, healing rate of tuberculosis lesion, neurological function, focal kyphosis re- alignment and lumbar lordosis reconstruction were compared between the two groups. [Results] All the patients underwent suc- cessful operations without serious complication. No statistical differences were noted in operation time, blood loss and complica- tion between the two groups （P〉0.05）. All of the patients were followed up for 12 to 61 months with an average of （24.9±11.2） months. Except 2 patients who in the posterior group suffered from recurrent tuberculosis, which cured followed the second sur- gery, all the remaining patients got primary healing of the lesion after surgery without complications related to internal fixation.Neurological function in all of the patients was categorized as Grade E in term of ASIA grading system at the latest follow up. The kyphosis angle varied from （24.73± 10.05）° in the anterior group versus （34.38±23.46）° in the posterior group preoperatively, to the （3.58 ±6.54）° versus （-0.78±10.01）° immediately postoperatively, further to （6.63±7.64）° versus （1.16±11.09）° at the latest follow up, which revealed statistical differences between the two groups （P〈O.05）, meant that the pos- terior technique had more powerful capacity of kyphosis correction over the anterior approach. [Conclusion] Both anterior and posterior approaches provide successful clinical outcomes for treatment of lumbar tuberculosis. By contrast, the operation through the posterior approach has considerable advantages in deformity correction and lumbar lordosis reconstruction over the anterior operation.