一期后路腰骶或腰骨盆重建治疗腰骶椎结核

One-stage posterior lumbosacral or lumbopelvic reconstruction for of lumbosacral tuberculosis with sacral destruction

[目的]评估一期后路腰骶重建及腰椎骨盆重建治疗合并不同程度骶骨破坏腰骶椎结核的有效性及安全性。[方法]回顾分析2010年1月~2016年1月本院一期后路治疗L5/S1为中心的腰骶椎结核患者19例,男性11例,女性8例,年龄18~83岁,平均(50.24±11.22)岁,所有患者均合并不同程度骶骨破坏,其中S1椎体破坏小于椎体高度1/2者13例,采用腰骶椎弓根螺钉行腰骶稳定性重建;S1椎体破坏超过1/2者6例,采用腰椎椎弓根螺钉配合髂骨钉行腰椎骨盆稳定性重建。术前、术后规范四联抗结核治疗。通过对比手术前后血沉、C反应蛋白、腰痛VAS评分、腰椎前凸角度、结核愈合情况等评估手术疗效。[结果]术后随访18~48个月,平均(23.11±9.30)个月,所有患者结核得到控制并获得骨性愈合,平均骨性愈合时间为6个月。术后6个月患者血沉、C反应蛋白下降至正常水平。1例患者出现一侧髂骨钉松动,但不影响骨性愈合。腰椎前凸角度由术前(28.13±10.95)°显著增加至末次随访时(37.62±12.53)°,差异有统计学意义(P<0.01)。而腰痛VAS评分由术前(6.32±1.25)分显著减少至末次随访时(2.47±1.17)分,差异有统计学意义(P<0.01)。所有患者均恢复至术前正常生活水平。[结论]对合并骶骨破坏的腰骶椎结核病例,一期后路病灶清除植骨后,根据患者骶骨破坏的严重程度,采用腰骶椎弓根内固定或髂骨钉骨盆固定可重建病灶局部稳定性,手术创伤较小,安全性高,可为结核病灶愈合创造有利条件。

[Objective] To evaluate the efficacy and safety of one-stage posterior lumbosacral reconstruction for L5/S1 tuberculosis with different severity of sacral destruction. [Methods] From January 2010 to January 2016, 19 patients with L5/S1 tuberculosis were treated with one-stage posterior surgery. There were 11 males and 8 females with an average age of（50.24±11.22）years（18 to 83 years）. Of them, 13 patients with less than 50% of S1 vertebral body destruction were treated using pedicle screw fixation to reconstruct lumbosacral stability, while the other 6 patients with more than 50% of S1 destruction were treated with the combination of iliac screw and lumbar pedicle screw to regain lumbar pelvic stabilization. All patients were perioperatively treated with standard anti-tuberculosis chemotherapy consisting of 4 drugs, such as rifampicin, isoniazid, ethambutol, and pyrazinamide. The curative outcomes was evaluated by comparing the inflammation parameters, low back pain VAS score, lumbar lordosis angle and tuberculosis lesion before and after operation. [Results] The patients were followed up for（23.11 ± 9.30）months on average. All patients had tuberculosis subsided and bony healing with a mean duration of 6 months. At 6 months after surgery, the erythrocyte sedimentation rate（ESR） and C-reactive protein（CRP） decreased to normal levels in all patients. One patient had lateral loosening of the sacral screw, which did not affect bone healing. The lumbar lordosis statistically improved from（28.13 ±10.95）° preoperatively to（37.62 ±12.53）° at the latest follow-up（P〈0.01）. Conversely, the VAS scores of low back pain significantly decreased from（6.32±1.25） before operation to（2.47±1.17） at the final follow up（P〈0.01）. All patients returned to normal preoperative daily activity. [Conclusion] In case of L5 S1 tuberculosis with sacral destruction, one stage posterior debridement combined with pedicle screw fixation or iliac screw fixation according to the severity of sacral destruction is a relatively moderate traumatic and highly secure procedure, which can reconstruct lumbosacral or lumbar pelvic stability and facilitate the healing of tuberculosis.