后路病灶清除植骨内固定联合不同入路腰大肌脓肿清除局部化疗治疗胸腰椎结核

Treatment of thoracolumbar spinal tuberculosis by posterior focus debridement and bone grafting and fixation combined with psoas abscess debridement and local chemotherapy via different approachs

目的比较前、后路腰大肌脓肿清除及脓腔内局部化疗联合后路病灶清除植骨内固定治疗胸腰椎结核的临床疗效,探讨后路腰大肌脓肿清除的可行性。方法回顾分析2012年6月—2015年12月治疗的37例胸腰椎结核伴腰大肌脓肿患者临床资料。所有患者行后路病灶清除、植骨内固定术,根据腰大肌脓肿清除的手术入路不同分为A组(21例,行后路脓肿清除及脓腔内局部化疗)和B组(16例,行前路脓肿清除及脓腔内局部化疗)。两组患者性别、年龄、病程、病变节段、术前红细胞沉降率、术前C反应蛋白、腰大肌脓肿侧别、腰大肌脓肿最大横径及纵径、伴随脓肿、脓腔分隔情况、术前病变节段Cobb角、术前美国脊髓损伤协会(ASIA)分级等一般资料比较差异均无统计学意义(P>0.05),具有可比性。记录并比较两组患者手术时间、术中出血量、术后住院时间、脓肿吸收时间及骨融合时间;观察患者术前及末次随访时的病变节段Cobb角变化情况;采用ASIA分级评价脊髓神经功能。结果除B组手术时间显著长于A组(t=–2.985,P=0.005)外,两组间术中出血量、术后住院时间、脓肿吸收时间及骨融合时间比较,差异均无统计学意义(P>0.05)。两组患者均获随访,随访时间18～47个月,平均31.1个月。术中及术后均无脑脊液漏发生。A组4例二次行前方脓肿清除置管化疗。末次随访时所有患者脓肿均吸收,红细胞沉降率及C反应蛋白均正常。两组患者末次随访时病变节段Cobb角均较术前显著改善(P<0.05),末次随访时两组间病变节段Cobb角以及矫正度比较,差异无统计学意义(P>0.05)。术前9例伴脊髓神经功能损害者中,末次随访时神经功能均改善,与术前比较差异有统计学意义(Z=–2.716,P=0.007)。结论治疗胸腰椎结核伴腰大肌脓肿,单纯后路病灶清除、植骨内固定联合脓肿清除及脓腔内局部化疗可取得良好疗效,但特殊情况下仍需行前路脓肿清除。

Objective To compare the effectiveness of posterior and anterior psoas abscess debridement and local chemotherapy in abscess cavity combined with focus debridement, bone grafting, and fixation via posterior approach in treatment of thoracolumbar spinal tuberculosis, and explore the feasibility of psoas abscess debridement via posterior approach. Methods Between June 2012 and December 2015, the clinical data of 37 patients with thoracolumbar spine tuberculosis and psoas abscess were retrospectively analyzed. All the patients underwent posterior focus debridement,bone grafting, and internal fixation, and were divided into two groups according to different approaches to psoas abscess debridement. Twenty-one patients in group A underwent abscess debridement and local chemotherapy in abscess cavity via posterior approach; 16 patients in group B underwent abscess debridement and local chemotherapy in abscess cavity via anterior approach. No significant difference was found between two groups in gender, age, disease duration, involved segments, preoperative erythrocyte sedimentation rate（ESR）, preoperative C-reactive protein（CRP）, side of psoas abscess,maximum transverse diameter and sagittal diameter of psoas abscess, accompanying abscess, abscess cavity separation,preoperative Cobb angle of involved segments, preoperative American Spinal Injury Association（ASIA） classification（P〉0.05）. The operation time, intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion were recorded and compared between 2 groups. The change of pre-and post-operative involved segments Cobb angle was observed. Neurological function was assessed according to ASIA classification. Results Except that the operation time of group B was significantly longer than that of group A（t=–2.985, P=0.005）, there was no significant difference in intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion between 2 groups（P〉0.05）. All patients were followed up 18-47 months（mean, 31.1 months）. No cerebrospinal fluid leakage occurred intra-and postoperation. Four patients in group A underwent second-stage operation of abscess debridement and local chemotherapy in abscess cavity via anterior approach. All patients got abscess absorption, meanwhile ESR and CRP level normalized at last follow-up. The involved segments Cobb angle improved significantly when compared with preoperative values in both 2 groups（P〈0.05）; and there was no significant difference between 2 groups at last follow-up（P〉0.05）. Nine patients with spinal cord injury had significant neurological recovery at last follow-up（Z=–2.716, P=0.007）. Conclusion Posterior focus debridement, bone grafting, and internal fixation combined with abscess debridement and local chemotherapy in abscess cavity is effective in treatment of thoracolumbar spinal tuberculosis, but in some cases anterior abscess debridement is still required.