一期后路病灶清除病椎置钉短节段内固定加椎间或关节突间植骨治疗单间隙腰椎布鲁杆菌病性脊柱炎

One stage posterior lumbar radical debridement combined with disease of vertebral nailing and posterior short-segment pedicle internal fixation, and bone grafting on single gap brucellar spondylitis of the lumbar vertebrae

目的 评价一期后路病灶清除、病椎置钉短节段内固定加椎间或关节突间植骨治疗单间隙腰椎布鲁杆菌病性脊柱炎（BS）的可行性及疗效.方法 回顾性分析2015年1月—2016年1月河北北方学院附属第一医院收治的27例BS患者的临床资料,其中男15例、女12例,年龄42～65岁.患者均为单间隙病变,累及两个椎体,其中L1～21例,L2～33例,L3～48例,L4～512例,L5～S13例;患者均合并不同程度神经功能损伤,术前至少经过一个疗程的规范药物治疗.均选用一期后路病灶清除、病椎置钉短节段内固定加椎间或关节突间植骨术治疗.对比手术前后Cobb角、VAS、美国脊髓损伤协会（ASIA）脊髓功能评定、红细胞沉降率（ESR）、C反应蛋白（CRP）、虎红平板凝集试验（RBPT）指标,以及X线片、CT、MRI影像学表现,结合临床预后进行临床疗效评价.结果 术后27例均获随访,随访时间12～25个月,平均18个月,无一例发生窦道形成及复发.侧凸Cobb角术前及术后3、6个月分别为14.89° ±1.48°、4.00° ±1.44°和4.01° ±0.87°,VAS术前及术后3、6、12个月分别为（8.4±1.6）、（3.1±0.3）、（1.1±0.3）及（0.7±0.2）分,术后各时间点均较术前显著改善,差异均有统计学意义（P值均〈0.05）;ASIA脊髓功能分级较术前明显好转,差异均有统计学意义（P值均〈0.01）;随时间推移,术后ESR、CRP、Cobb角明显减小,术后各时间点与术前比较,差异均有统计学意义（P值均〈0.01）.RBPT术后转阴率（正常率）逐渐增高,术后3个月为48.14％,6个月为100％.临床疗效评价：术后3、6、12个月治愈率分别为59.25％（治愈16例、改善10例、无效1例）、81.48％（治愈22例、改善5例）、96.29％（治愈26例、改善1例）,后一个时间点治愈率与前一个时间点比较,差异均有统计学意义（P值均〈0.05）.结论 在应用有效的药物控制前提下,一期后路病灶清除、病椎置钉短节段内固定加椎间或关节突间植骨治疗单间隙BS是可行的,其在解除疼痛、稳定脊柱及恢复神经功能等方面具有较好的临床疗效.

Objective To evaluate the feasibility and efficacy of the treatment on single-lumbar brucellosis spondylitis with a short-segment fixation of the posterior pedicle screw fixation and the removal of the intervertebral bone graft.Methods From January 2015 to January 2016, the clinical data of 27 patients with lumbar spondylitis in the First Affiliated Hospital of Hebei North University were retrospectively analyzed. Fifteen males and 12 females, aged from 42 to 65 years, mean 55.2 years. All patients were single-gap lesions involving two vertebral bodies. Among them, L1-2 1 patient, L2-3 3 patients, L3-4 8 patients, L4-5 2 patients, L5-S1 3 patients, 27 patients were combined with varying degrees of neurological impairment, and were given at least a course of regular drug treatment before operation. Twenty-seven patients with surgical indications of lumbar brucellosis spondylitis patients with a posterior pediatric stapler stent fixation plus lesion removal of intervertebral bone graft surgery. Preoperative, postoperative and follow-up were examined by Cobb angle, visual analogue scale （VAS）, American Spinal Injury Association （ASIA） rating of spinal cord function recovery, laboratory test erythrocyte sedimentation rate Erythrocyte sedimentation rate （ESR）, C reactive protein （CRP）, rose bengal plate agglutination test （RBPT） and X-ray, CT and MRI,and “cure, improvement and ineffective” used as clinical evaluation criteria.Results Twenty-seven cases were followed up from 12 to 25 months, an average of 18 months, no sinus formation and recurrence. The mean Cobb angle was 14.89°±1.48° at preoperation, 4.00°±1.44° at 3 months postoperatively, 4.01°±0.87°at 6 months postoperatively, and VAS scores were （8.4±1.6） points, （3.1±0.3） points, （1.1±0.3） points and （0.7 ± 0.2） points 3, 6 and 12 months postoperatively, respectively. The postoperative time of all the patients was significantly improved （all P values〈0.05）.After the operation ,the ESR, CRP and Cobb angle were reduced evidently over time, the differences were statistically significant （all P values〈0.01）. The negative rate （normal rate） of the RBPT was 48.14% at 3 months postoperatively, and 100% at 6 months postoperatively.Clinical curative effect evaluation： with postoperative time, cure rate increased gradually, 3, 6, 12 months the cure rate was 59.25% （16 patients cured, 10 patients were improved and 1 patient had no effect）, 81.48%（22 patients cured, improved in 5 patients）, 96.29% （cure 26 patients, improvement in 1 patient） when cure rate before a time point was compared with that after a time point, the difference was statistically significant （all P values〈0.05）.Conclusions There is feasibility and efficacy on the treatment of single-lumbar brucellosis spondylitis with a short-segment fixation of the posterior pedicle screw fixation and the removal of the intervertebral bone graft under the application of effective control of the drug. It has obvious advantages in relieving pain, stabilizing spine and restoring nerve function.