非典型胸腰椎结核的临床诊断和手术治疗

Diagnosis and surgical treatment of atypical thoracic and lumbar spinal tuberculosis

目的:总结和分析非典型胸腰椎结核的临床诊断和手术治疗特点,为非典型脊柱结核的诊治提供参考。方法:回顾性分析我院骨科2013年12月~2018年12月明确诊断并手术治疗的脊柱结核患者资料,根据影像学特点筛选出非典型胸腰椎结核13例,男8例,女5例,年龄20~71岁(44.2±18.7岁)。2例以腹股沟区包块为首发表现,2例患者以发热和咳嗽首发症状,其余患者均以腰背痛首发症状。术前疼痛视觉模拟评分(visual analogue scale,VAS)为5~8分(6.2±0.8分)。神经功能Frankel分级C级1例,D级3例,E级9例。术前均行X线片、CT和MRI检查,影像学上未见明显椎间隙狭窄、后凸畸形,CT可见不同程度的椎体骨破坏或囊性变、边缘硬化灶、“磨玻璃”样改变,MRI表现为椎体破坏、炎症水肿和椎旁脓肿改变。4例行正电子发射计算机断层显像(positron emission tomography-computer tomography,PET-CT)检查,10例行T细胞酶联免疫斑点试验(enzyme-linked immuno Spot,ELISPOT)检查均为阳性,4例术前行病灶活检。术前四联抗结核药物治疗至少1~2周,根据病灶位置及椎体破坏情况,7例行后路手术,6例行前后路联合手术。术后继续采用标准疗程抗结核药物治疗。结果:非典型胸腰椎结核患者占同期手术治疗脊柱结核的20.3%(13/64)。胸椎6例,腰椎5例,胸腰椎均累及2例。根据CT及MRI影像学分类,单脊椎型2例,椎间盘型1例,多脊椎连续型10例。手术时间130~260min(177.7±43.0min),出血量400~1000ml(638.5±198.1ml),无术中并发症。手术清除病灶组织均送病理检查,报告为肉芽肿性病变和/或凝固性坏死;结核菌涂片和培养各有1例阳性。术后伤口感染1例,经清创后好转。术后随访12~72个月(45.1±22.2个月),随访期间钛网移位1例,因无明显症状,未翻修,术后32个月随访无继续移位及内固定断裂;其余患者末次随访时均无内固定断裂。植骨在术后3~6时可见融合,随访期间无复发病例。术后疼痛及神经功能均有明显改善,末次随访时VAS评分1~4分(1.8±0.9分),神经功能Frankel分级末次随访均为E级。结论:非典型胸腰椎结核确诊需多种诊断手段相结合,手术结合抗结核药物治疗可取得较好的疗效。

Objectives:To analyze and summarize the clinical diagnosis and surgical treatment features of atypical thoracic and lumbar spinal tuberculosis.Methods:Patients with spinal tuberculosis who were surgically treated from December 2013 to December 2018 were reviewed.A total of 13 patients with atypical spinal tuberculosis were selected according to the imaging features,including 8 males and 5 females.The clinical features,diagnosis and treatment procedures,follow-up results were analyzed.The average age of patients was 44.2±18.7 years old(ranged 20 to 71 years old).As the initial symptoms,the inguinal mass occurred in 2 patients,fever and cough occurred in 2 patients,back pain occurred in the remaining patients.Visual analogue scale(VAS)for preoperative pain was 5-8,with an average of 6.2±0.8.Frankel′s grade for neurological function was C in 1 case,D in 3 cases,and E in 9 cases.All patients were investigated by X-rays,CT and MRI.There was no radiological collapse of intervertebral disc or spinal kyphosis.CT showed various vertebral bone destruction,cystic change,sclerosis at the edge of the lesion,and glass-like opacity.MRI showed vertebral bone destruction,edema signal and abscess.Positron emission tomography-computer tomography(PET-CT)was performed in 4 patients.Enzyme-linked immuno spot(ELISPOT)was performed in 10 patients,and all of whom were positive.Preoperative biopsy was performed in 4 patients.Quadruple anti-tuberculosis drugs were used in all the patients for at least 1-2 weeks preoperatively.Seven patients underwent posterior surgery and six underwent anterior combined posterior surgery.Standard course of chemotherapy was performed postoperatively.Results:There were 13 patients in 64 cases with spinal tuberculosis were atypical cases in the same period,with the rate of 20.3%,6 cases of thoracic tuberculosis,5 cases of lumbar tuberculosis,and 2 cases of thoracolumbar tuberculosis.Classification of atypical spinal tuberculosis according to imaging features:2 cases of single vertebral involvement,1 case of intervertebral disc involvement,and 10 cases of multiple vertebral involvement.The operation time lasted for 130-260min(177.7±43.0min),and the bleeding volume was 400-1000ml(638.5±198.1ml).The pathological reports of lesion tissue were granulomatous lesion and/or coagulative necrosis.There was 1 patient of positive tissue smears,and 1 patient of positive tissue culture of tuberculosis bacteria.There was no obvious intraoperative complication.One patient had postoperative wound infection,which was healed after debridement.The follow-up time was 45.1±22.2 months(ranged,12-72 months).One patient had titanium mesh displacement during follow-up,who was kept under observation because of no clinical symptom.And there was no internal fixation displacement and rupture at the last follow-up of 32 months.Bone graft fusion was observed at 3-6 months.There was no other failure of internal fixations or recurrence of tuberculosis.The VAS score at the last follow-up was 1-4,with an average of 1.8±0.9.Frankel′s grade returned to E at the last follow-up.Conclusions:Multiple diagnostic methods are required for atypical spinal tuberculosis.Surgery combined with anti-tuberculosis drugs can achieve satisfactory results.