后路手术治疗胸腰椎骨折部位脊柱化脓性骨髓炎

Posterior surgery for thoracolumbar fractures accompanied with secondary spinal suppurative osteomyelitis

[目的]探讨后路手术治疗胸腰椎骨折继发脊柱化脓性骨髓炎的临床疗效。[方法]回顾分析本科2010年1月~2017年12月收治的胸腰椎压缩骨折继发非特异性化脓性脊柱骨髓炎患者共5例,所有患者伤后均行非手术治疗,其中男3例,女2例,年龄52~76岁,平均(64.83±3.67)岁。5例患者均采用后路清创融合固定,并应用敏感抗菌药物。采用痛觉视觉模拟评分(VAS)、ASIA神经功能分级、白细胞计数(WBC)、红细胞沉降率(ESR),C反应蛋白(CRP)、影像学检查评价其疗效。[结果]5例患者均顺利完成手术,无血管神经损伤、硬膜破裂等严重并发症,手术时间125~165 min,平均(145.37±14.83)min,出血量150~350 ml,平均(179.11±52.24)ml。2例患者术后第2 d出现伤口区剧痛,反复高热,最高达39.5℃,伴低蛋白血症,其中1例细菌培养为耐甲氧西林金黄色葡萄球菌(MRSA)。按照药敏结果继续行抗菌、补充蛋白等支持对症治疗,所有患者1周后体温正常,白细胞计数、红细胞沉降率和C反应蛋白下降,伤口一期愈合。VAS评分由术前(9.13±0.88)分减小至术后1周(2.52±1.21)分,进一步减少至末次随访时(1.60±1.19)分(P<0.05)。术前3例ASIA评分D级的患者术后均完全恢复。Cobb角由术前(29.26±6.59)°显著减少至术后1周(10.26±2.03)°,末次随访时(11.43±4.67)°(P<0.05)。依Eck融合分级标准,术后12个月融合率达到100%,感染无复发。[结论]胸腰椎骨折后继发骨折部位化脓性脊柱骨髓炎早期诊断困难,椎体破坏较重并伴不同程度后凸畸形。一期经后路手术+规范抗菌药物治疗可以达到良好的治疗效果。

[Objective]To explore the clinical outcomes of posterior surgery for thoracolumbar fracture accompanied with secondary spinal suppurative osteomyelitis.[Methods]A retrospective study was conducted on 5 patients who suffered from suppurative spinal osteomyelitis secondary to thoracolumbar compression fracture which primarily treated with conservative methods from January 2010 to December 2017 in our department,including 3 males and 2 females,aged 52~76 years with an average of(64.83±3.67)years.The onset of infection ranged from 1.2 to 3.5 months with a mean of(2.71±1.72)month after fracture.All the 5 patients underwent posterior debridement and instrument fusion,with usage of antibiotics for 6-8 weeks.The clinical consequences were evaluated by using visual analogue scale(VAS)for pain,ASIA neurological function score,white blood cell count(WBC),erythrocyte sedimentation rate(ESR),reactive responsive protein(CRP)and imaging examination.[Results]All the 5 patients had surgical procedure performed successfully,without serious intraoperative complications,such as neurovascular injuries and dural tears.The operation lasted for 125~165 min with an average of(145.37±14.83)min,associated with intraoperative blood loss in a mean of(179.11±52.24)ml ranged from 150 to 350 ml.Of them,2 patients had sharp pain of incision,accompanied with recurrent fever to 39.5℃and hypoproteinemia at 2 days after operation,1 of the 2 patients got positive culture results of methicillin-resistant staphylococcus aureus(MRSA).After sensitive antibiotic therapy,protein support and symptomatic treatment,all the patients had temperature returned to normal level in 1 week,associated with decline of ESR and CRP and primary incision healing.The VAS scores significantly decreased form(9.13±0.88)preoperatively to(2.52±1.21)at 1 week postoperatively and(1.60±1.19)at the latest follow up(P<0.05).The three patients who were marked as ASIA grade D preoperatively achieved totally neurological function recovery at the latest follow up.In addition,the kyphotic Cobb’s angle significantly decreased from(29.26±6.59)°preoperatively to(10.26±2.03)°at 1 week postoperatively,and(11.43±4.67)°at the latest follow up(P<0.05).Based on the Eck’s criteria,bony fusion was obtained in all the patients with no recurrence of infection.[Conclusion]The suppurative spinal osteomyelitis secondary to thoracolumbar fracture is obscure in clinical presentation,usually accompanied with severe kyphosis.This one-stage posterior debridement and instrumented fusion combined with sensitive antibiotic therapy might achieve satisfactory therapeutic outcomes.