脊柱结核并发骨质疏松症患者应用抗骨质疏松药物的疗效分析

Analysis of the efficacy of anti-osteoporosis drugs on spinal tuberculosis patients complicated with osteoporosis

目的探讨脊柱结核并发骨质疏松症的治疗策略及疗效。方法选取2012年1月至2015年2月解放军第三○九医院收治的脊柱结核并发骨质疏松症患者,共102例,用分层随机抽样法分为两组:观察组(51例),对照组(51例),两组均根据病灶部位及病变程度个体化选择术式,行病灶清除、植骨、内固定术,术后抗结核药物治疗12～18个月,同时观察组接受钙剂、维生素D、双膦酸盐药物行抗骨质疏松治疗,对照组未使用抗骨质疏松药物治疗。对比观察组和对照组骨密度(BMD)、骨代谢指标、疼痛视觉评分(VSA)、病灶愈合情况、内植入物情况等。结果随访3年,末次随访观察组股骨颈(Neck)、Ward三角区(Ward)、股骨大转子(Troch)骨密度分别为(0.88±0.15)g/cm^2、(0.73±0.11)g/cm^2、(0.78±0.10)g/cm^2,高于对照组(0.71±0.14)g/cm^2、(0.59±0.13)g/cm^2、(0.61±0.13)g/cm^2,差异有统计学意义(t值分别为3.91、3.58、3.80,P值均<0.01)。观察组末次随访血清碱性磷酸酶(ALP)、I型胶原交联C-末端肽(CTX)、骨钙素(OC)水平分别为(16.06±8.05)ng/mL、(0.22±0.08)ng/mL、(6.42±1.03)ng/mL,对照组末次随访血清ALP、CTX、OC水平分别为(18.10±8.55)ng/mL、(0.52±0.13)ng/mL、(7.43±1.52)ng/mL,两组间差异有统计学意义(t值分别为-6.54、-5.47、-3.47,P值均<0.01)。至末次随访,观察组无内固定失效情况发生,对照组内固定螺钉断裂1例、松动3例、拔出2例;观察组术后局部后凸Cobb角为(10.93±6.38)°,对照组术后局部后凸Cobb角为(10.77±7.12)°,差异无统计学意义(t=0.37,P>0.05);观察组末次随访局部后凸Cobb角为(11.05±6.17)°,对照组后凸Cobb角为(14.08±8.24)°,差异有统计学意义(t=3.13,P<0.05);两组X线或CT检查提示全部植骨融合。结论钙剂、骨化三醇、双膦酸盐药物等抗骨质疏松药物治疗改善脊柱结核并发骨质疏松患者的骨密度,降低骨转化率,提高手术内固定安全性与疗效。

Objective To investigate the efficacy and strategy of surgical treatment of spinal tuberculosis combined with osteoporosis. Methods A total of 102 patients with spinal tuberculosis complicated with osteoporosis admitted to the 309 th hospital of PLA from January 2012 to February 2015 were selected and divided into two groups by stratified random grouping: observation group(n=51) and control group(n=51). Age and gender were comparable in the two groups. Surgical procedures depended on the individual lesion and pathological changes including debridement and bony grafting with instrumentation fixation. The postoperative anti-tuberculosis drug therapy lasted for 18 months. At the same time patients in group A received calcium supplements, calcitriol, and bisphosphonate anti-osteoporosis treatment. Bone mineral density(BMD), bone metabolism index, pain visual score, and surgical effect were observed in group A and B. Results After 3 years of follow-up, BMD of the neck of femur, Ward triangular region, and Troch of femur in the observation group were(0.88 ± 0.15) g/cm^2,(0.73 ± 0.11) g/cm^2,(0.78 ± 0.10) g/cm^2, higher than those in the control group(0.71 ± 0.14) g/cm^2,(0.59 ± 0.13) g/cm^2,(0.61 ± 0.13) g/cm^2, respectively. The difference was statistically significant(t=3.91, 3.58, 3.80, respectively, P <0.01). Serum ALP, c-terminal peptide(CTX) cross-linked with type I collagen, and osteocalcin(OC) in the observation group at the last follow-up were(16.06 ± 8.05) ng/mL,(0.22 ± 0.08) ng/mL,(6.42 ± 1.03) ng/mL, respectively. They were(18.10 ±8.55) ng/mL,(0.52± 0.13) ng/mL, and(7.43 ± 1.52) ng/mL at the last follow-up in the control group, respectively. The differences between the two groups were statistically significant(t=-6.54,-5.47,-3.47, respectively, P<0.01). No internal fixation failure happened in group A. Screw broken in 1 case, loosened in 3 cases, and pulled out in 2 cases in group B. The postoperative local convex Cobb angles were(10.93±6.38)° in group A, and were(10.77 ± 7.12)° in group B. No significant statistical difference was found(t=0.37, P>0.05). At the last follow-up, the local convex Cobb angles in group A were(11.05 ± 6.17)°, and were(14.08 ± 8.24)° in group B. The difference was statistically significant(t=3.13, P﹤0.05). X-ray or CT showed that all bone grafts were fused. Conclusion Calcium supplements, calcitriol, and bisphosphonate anti-osteoporosis drug therapy can improve bone mass in patients with spinal tuberculosis combined with osteoporosis, decrease serum ALP content, and increase serum BGP content, which can improve the operative efficacy.