前路小切口病灶清除结合后路微创内固定治疗单节段腰椎结核

Combination of anterior debridement via small incision and posterior mini-invasive internal fixation for the treatment of single segment lumbar tuberculosis

目的回顾分析前路小切口病灶清除结合后路微创固定治疗单节段腰椎椎体结核的临床疗效。方法本组为2010年7月—2015年7月收治的无附件受累的单节段腰椎结核(均为边缘性结核),并接受一期前路小切口病灶清除、植骨融合、后路微创内固定患者共31例。其中男19例、女12例,年龄21~61岁,平均(36.1±17.8)岁。病程2~16个月,平均11(9,12)个月。均为单节段受累,其中L2~3受累者7例,L3~4受累者10例,L4~5受累者6例,L5~S1受累者8例。31例患者均有腰背部疼痛,疼痛视觉模拟评分(VAS)平均7(6,8)分。脊髓损伤程度ASIA分级:E级25例,D级6例。合并椎旁脓肿22例,髂窝流注性脓肿9例,伴后凸畸形12例,术前脊柱局部平均后凸Cobb角度21°±6°。术前采用四联抗结核方案化疗至少2周。手术均先俯卧位行后路微创固定,其中经皮微创螺钉18例(经皮组),经Wiltse入路置钉13例(经Wiltse入路组),再取侧卧位行前路病灶清除、植骨和/或钛网融合。结果 31例患者手术时间160~240 min,平均(204±54)min,出血量100~300 m L,平均(168±73)m L。1例前路手术切口延迟愈合,经换药2周后伤口愈合,余30例刀口一期愈合。无手术相关神经功能、血管损伤等并发症。经皮组和经Wiltse入路组术后3 d伤口VAS疼痛评分分别为(1.3±0.3)分和(2.1±1.4)分,差异有统计学意义(P<0.05)。患者总体术后3个月腰痛VAS评分降至2(1,3)分,较术前差异具有统计学意义(P<0.05)。6例合并神经症状者术后均恢复至E级。12例合并后凸畸形者平均Cobb角矫正15°±5°,较术前减小(P<0.05)。所有患者均获有效随访,时间12~72个月,平均(36.8±9.3)个月。末次随访时均达到结核愈合标准,无腰椎后凸畸形、内固定松动、断裂、脱出、钛网塌陷及其他并发症。结论后路微创内固定结合前路小切口病灶清除治疗单节段腰椎椎体结核可有效清除病灶,通过短节段固定重建脊柱稳定性,减少融合节段,降低前路手术创伤及并发症。

Objective To review and analyze the clinical effect of combined posterior mini-invasive fixation with anterior debridement via small incision for the treatment of single segment lumbar vertebral tuberculosis.Methods Totally31cases with single segment lumbar tuberculosis(both borderline tuberculosis)without attachment involvement underwentone-stage anterior debridement,interbody fusion and posterior mini-invasive fixation from July2010to July2015.Amongthese patients,19were male and12were female.The average age was(36.1±17.8)years old(ranged21-61years old).Theaverage course of disease was11(9,12)months(ranged from2to16months).All were single segment involvement,and theinvolved segment was L2-3in7cases,L3-4in10cases,L4-5in6cases,and L5-S1in8cases.The clinical manifestationsincluded lumbar back pain in31cases with an average pain visual analog score(VAS)of7(6,8)points.ASIA grade of spinalcord injury was E in25cases and D in6cases.Paravertebral abscess occurred in22cases and iliac fossa gravity abscessappeared in9cases.Kyphosis was observed in12cases and the average Cobb angle was21°±6°.Quadruple antituberculosischemotherapy was used for at least2weeks preoperatively.Posterior mini-invasive fixation was fulfilled onprone position,including mini-invasive percutaneous screws in18cases and pedicle screw fixation via Wiltse approach in13cases.Posterior distraction and deformity correction were performed simultaneously for patients with kyphosis.Then thepatients were changed to lateral position for anterior debridement,bone grafting and/or titanium mesh fusion.Results Theaverage operation time was(204±54)min(ranged160-240min)in31patients,and the mean blood loss was(168±73)mL(ranged100-300mL).Delayed healing of anterior incision occurred in1case and the incision healed after two-weekdressing of wound.The incision healed well in the rest30cases.No complications such as nerve function,blood vessel injurywere found in patients.The VAS scores of the3days after operation were1.3±0.3and2.1±1.4in percutaneous group andWiltse approach group,respectively,and the difference between them was statistically significant(P<0.05).The VAS scoreof low back pain was2(1,3)points in all the31patients three months after operation,which was significantly lower than thatbefore surgery(P<0.05).The six patients with neurological symptoms recovered to E grade after operation.The averageCobb angle correction was15°±5°in12patients with kyphosis(P<0.05),which was significantly decreased compared withthat before surgery(P<0.05).All patients were followed up for an average of(36.8±9.3)months(ranged from12to72months).The clinical healing of tuberculosis was achieved at the final follow-up in all the31patients.No complicationswere observed,such as lumbar kyphosis,internal fixation loosening and breakage,dislocation and titanium mesh subsidence.Conclusion Mini-invasive posterior internal fixation and anterior debridement via small incision is effective for thetreatment of single segment lumbar vertebral tuberculosis in lesion debridement and spine stability reconstruction by shortsegment fixation.This technique can reduce fused segments,surgical trauma of anterior approach and related complications.