一期极外侧入路病灶清除植骨融合闭式冲洗引流联合后路内固定术治疗原发性腰椎间隙感染

Treatment of primary spondylodiscitisby: one-stage extreme lateral debridement, bone autograft and continuously closed irrigation combined with posterior internal fixation

目的 :探讨一期极外侧入路病灶清除植骨融合闭式冲洗引流联合后路内固定术治疗原发性腰椎间隙感染的临床疗效。方法:回顾性分析2010年8月~2016年6月收治的23例原发性腰椎间隙感染患者的临床资料,其中男13例,女10例;年龄16~78岁(55.2±17.0岁)。均为单一腰椎间隙感染,其中L1/2 3例,L2/3 5例,L3/4 8例,L4/5 7例。均经保守治疗2周无效或效果不佳,均行一期极外侧入路病灶清除植骨融合闭式冲洗引流联合后路内固定术,术中留取病灶组织标本进行细菌培养及病理学检查,术后感染椎间隙持续闭式冲洗引流2~3周,术后抗生素应用4~6周。手术前后采用VAS评分评价腰痛程度,JOA评分评价神经功能,Barthel指数(BI)评价日常生活能力,检测血沉(ESR)、C反应蛋白(CRP)。术后定期复查腰椎X线片、CT,评价内固定和植骨融合情况。结果:均成功实施手术,术中及术后均未发生严重并发症。术后病灶组织细菌培养显示金黄色葡萄球菌2例、大肠埃希菌1例、肺炎克雷白杆菌1例、缓症链球菌1例,余18例均为阴性;病理检查结果均符合急慢性炎性反应表现。随访12~24个月(18.0±3.5个月)。术后1、3、6、12个月腰痛VAS评分、JOA评分、BI、ESR、CRP均较术前明显改善(P<0.05)。随访期间无感染复发,无内固定松动,术后3~12个月(6.0±1.7个月)植骨均获骨性融合。结论:一期极外侧入路病灶清除植骨融合闭式冲洗引流联合后路内固定术治疗原发性腰椎间隙感染临床疗效满意,具有病灶清除彻底、植骨充分、操作安全的特点。

Objectives： To evaluate the clinical outcome of one-stage extreme lateral debridement, bone autograft and continuously closed irrigation combined with posterior internal fixation in treating primary spondylodiscitis. Methods： A retrospective analysis was made on the clinical data of 23 patients with primary spondylodiscitis between August 2010 and June 2016. There were 13 males and 10 females with an average age of 55.2±17.0 years （range, 16-78 years）. All patients suffered from single-level spondylodiscitis, including 3 patients at L1/2, 5 patients at L2/3, 8 patients at L3/4, and 7 patients at L4/5. Conservative treatment for 2 weeks resulted in no or poor effect, and thus all 23 cases underwent one-stage extreme lateral debridement, autogenous iliac grafting combined with posterior internal fixation. Tissue samples in focus were collected for bacterial culture and pathological test during operation. Then continuously closed irrigation was applied for 2-3 weeks postoperatively. Antibiotics was administered for 4-6 weeks postoperatively. Prior to and after surgery, the VAS score was used to evaluate the degree of low back pain, the JOA score was used to evaluate the neurological function, and the Barthel index（BI） was used to evaluate the daily living ability. CRP and ESR was also tested pre- and postoperatively. After operation, X-ray and CT were reviewed regularly to evaluate the internal fixation and bone graft fusion. Results： All patients underwent surgery without serious complications. Bacterial culture revealed staphylococcus aureus in 2 case, escherichia coli in 1 case, klebsiella pneumonia in 1 case, streptococcus mitis in 1 case, negative finding in the other 18 cases. Pathological tests indicated acute or chronic inflammation. The mean follow-up was 18.0±3.5 months （range, 12-24 months）, and the symptom of pain was relieved significantly. Compared with preoperative ones, lumbar VAS score, JOA score, BI, ESR and CRP level were significantly improved at 1, 3, 6 and 12 months after surgery （P〈0.05）. The X-ray and CT showed well internal fixation and no recurrent infection. Solid bony fusion was found in all patients at 3-12 months （average, 6.0±1.7 months） after surgery. Conclusions： For patients with primary spondylodiscitis, one-stage extreme lateral debridement, bone autograft and continuously closed irrigation combined with posterior internal fixation has the advantages of complete focus clearance, sufficiently bone autograft, operation safety, reliable imbolization, as well as satistactory clinical effects, and therefore it is an effective method in the treatment of primary spondylodiscitis.