一期后路病灶清除植骨内固定治疗化脓性脊柱炎的疗效观察

Single-stage Debridement,Spinal Fusion and Internal Fixation through a Posterior Approach for Eradication of Pyogenic Spondylodiscitis:a Clinical Observational Study

目的评价一期后路病灶清除植骨内固定治疗化脓性脊柱炎的临床疗效.方法回顾性分析首都医科大学附属北京胸科医院2012年1月至2016年12月采用一期后路病灶清除植骨内固定治疗的31例化脓性脊柱炎患者的临床资料.其中,男19例,女12例;年龄33~79岁,平均(60.7±11.2)岁。病变位于腰椎者23例.位于胸椎者8例.术前17例患者出现神经功能障碍,按照美国脊柱损伤协会(ASIA)神经功能分级.D级15例、C级1例、B级1例。术后1、3、6、12个月进行随访,进行X线摄影、CT扫描三维重建、MRI复査,同时观察疼痛视觉模拟评分(visual analogues cale,VAS),ASIA分级的变化.以及脊柱后凸角度(Cobb角)的矫正情况,以评价临床疗效。结果本组患者手术时间112-300min,平均(184.9±46.9)min;术中出血量200-1400ml,平均(537.1±286.6)ml.所有患者均获随访,随访时间12~71个月.平均(42.3±15.4)个月.截至末次随访,有1例患者复发.复发率为3.2%1/31)。患者术后3个月VAS评分为(3.06±1.59份,术后6个月为(1.77±1.28)分,术后12个月为(1.03±1.22)分.末次随访为(0.42±0.85)分,均明显低于术前的(6.74±1.13)分,差异均有统计学意义(r值分别为13.15.19.73,18.12、24.73,P值均<0.05);术后患者神经功能较术前改善.16例恢复至E级、1例恢复至D级.患者术前Cobb角测量,胸椎病变者为(26.4±16.8)°.腰椎病变者为(31.0±3.2)°.术后1个月Cobb角.胸椎病变者为(21.4±14.6)°,腰椎病变者为(21.3±5.2)°,较术前分别矫正5.0°和9.7°,差异均有统计学意义(r值分别为4.41,13.09,P值均<0.05).末次随访时,胸椎病变者为(22.5±15.0)°,腰椎病变者为(23.8±4.8)°,与术后1个月相比分别丢失1.1°和2.5°(r值分别为3.81、15.30,P值均<0.05).结论一期后路病灶清除植骨内固定术是治疗化脓性脊柱炎的有效方法。

Objective To evaluate the feasibility,clinical and radiological outcome of single-stage debridement,spinal fusion and internal fixation through a posterior approach in the surgical management of patients with pyogenic spondyiodiscitis.Methods From January 2012 to December 2016,31 inpatients(19 males and 12 females;aged 33-79 years;mean age,60.7±11.2 years)suffering from pyogenic spondyiodiscitis were included.AH the patients received a single-step radical debridement of the infected intervertebral disc space,posterior screw-and-rod instrumentation and spinal fusion.Intravenous or oral antibiotics were continued for 12 weeks postoperatively and patients were followed up routinely after the operation.The lesion was located in lumbar spine in 23 patients and thoracic spine in 8 patients.There were 17 patients with neurological dysfunction before the operation,among which 15 cases of ASIA D,1 case of ASIA C and 1 case of ASIA B.At 1,3,6 and 12 months after surgery,X-ray,three-dimensional CT scan and MRI were performed.The changes in pain scores(visual analogue score,VAS)and nerve function based on ASIA classification and the correction of Cobb's angles were assessed for efficacy evaluation.Results The operation time ranged 112-300 min(mean(184.9±46.9)min).The intraoperative blood loss was 200-1400 ml(mean(537.1±286.6)ml).All patients were followed up for(42.3±15.4)months on average(ranged 12-71 months).One of the 31 patients demonstrated of recurrent infection(3.2%(1/31)).The postoperative VAS scores of pain at 3 months(3.06±1.59),6 months(1.77±1.28),12 months(1.03±1.22),and last follow-up(0.42±0.85)were significantly decreased when compared with preoperative score(6.74±1.13)(t values were 13.15,19.73,18.12,24.73,all P values<0.05).Postoperative neurological function was improved after surgery,16 cases were restored to ASIA E and 1 was restored to ASIA D.The preoperative Cobb's angle was(26.4±16.8)°in thoracic spine and(31.0±3.2)°in the lumbar spine.One month after operation,these Cobb's angles improved to(21.4±14.6)°and(21.3±5.2)°,representing mean corrections of 5.0°and 9.7°in the thoracic and lumbar spines,respectively.The differences were statistically significant(t values were 4.41,13.09,all P values<0.05).At last follow-up,these Cobb*s angles were(22.5±15.0)°and(23.8±4.8)°,representing mean losses of 1.1°(t=3.81,P<0.05)and 2.5°(t=15.30,P<0.05)in the thoracic and lumbar spine,respectively.Conclusion Single-stage debridement,spinal fusion and internal fixation through a posterior approach is an effective and feasible surgical method for pyogenic spondylodiscitis.