腹旁正中小切口经腹膜后入路在下腰椎结核治疗中的应用

The Mini-open Anterior Paramedian Retroperitoneal Approach for the Treatment of Lower Lumbar Spinal Tuberculosis

目的:探讨腹部旁正中小切口经腹膜后入路治疗下腰椎结核的可行性及临床疗效。方法:回顾分析2011年8月至2015年3月于本科行腹旁正中小切口腹膜外入路结核病灶清除植骨融合手术的下腰椎结核患者21例,其中9例辅以前路钛板固定,12例在前路病灶清除术前先行后路椎弓根钉内固定。记录手术时间、术中出血量、手术入路相关并发症、植骨融合情况,以及比较术前、术后疼痛视觉模拟评分(VAS)、美国脊髓损伤协会(ASIA)分级、红细胞沉降率(ESR)、腰椎局部前凸角(LLA)。结果:21例均顺利完成手术,切口一期愈合,平均随访(32.5±11.8)个月,无结核复发,均获骨性融合,VAS,ESR,ASIA及LLA均较术前显著改善。4例手术相关并发症均发生于前路手术时:2例为髂腰静脉撕裂,经压迫后止血;2例腹膜撕裂,及时修补后无并发症。结论:腹旁正中小切口经腹膜后入路可安全、有效清除下腰椎结核病灶,辅以内固定有助于重建脊柱力线,并达到固定和融合的目的。

Objective：To investigate the feasibility and the clinical effects of mini-open anterior paramedian retroperitoneal approach for the treatment of lower lumbar spinal tuberculosis.Methods：Twenty-one patients diagnosed with lumbar or lumbosacral tuberculosis from August 2011 to March 2015 were analyzed retrospectively.Among these patients,9 cases were treated with anterior debridement and strut grafting with instrumentation,the other 12 cases were treated with posterior instrumentation before anterior debridement,and anterior debridement and bone graft in a single procedure.The operation time,the amount of bleeding during operation,major complications associated with the approach and bone fusion were recorded.Visual analogue scale（VAS）pain,ESR,local lordotic angle（LLA）,and neurological performance were assessed before and after surgery.Results：A satisfactory lesion exposure was obtained in all the patients.Operation-correlated complications occurred in 4 patients,included 2 iliolumbar vein tear and 2 peritoneal tear,without severe sequelae after successful management in the 4 patients.Patients were followed 12~55 months（mean 32.5 months）,interbody fusion was obtained in all of them,and there were no instances of spinal tuberculosis recurrence.The VAS,ESR,ASIA and LL were all significantly improved compared with preoperative levels.Conclusion：The anterior debridement and interbody fusion by the mini-open anterior paramedian retroperitoneal approach can be an effective and safe treatment option for lower lumbar tuberculosis.Combined with internal fixation,it can restore the alignment of sagittal profile and reach high fusion rate.