阶梯手术治疗胸椎脊柱结核

De-escalation of surgical procedure for thoracic spinal tuberculosis

[目的]评价阶梯手术治疗胸椎结核的临床疗效与意义。[方法]回顾性分析2005年1月~2016年1月收治并获有效随访的239例胸椎结核患者。依据病变程度及全身情况将患者分为3组,分别采用3个阶梯的手术治疗方式。穿刺组153例,采用单纯后路经皮穿刺置管药物治疗;小切口组30例,采用后路小切口神经减压联合经皮穿刺置管药物治疗;切开组48例为对照手术组,采用后路切开减压病灶清除内固定手术治疗。[结果]三组患者均顺利手术,均未发生大血管、脊髓神经和重要内脏损伤。手术时间、切口长度和术中失血量依次为穿刺组<小切口组<切开组,三组间的差异均有统计学意义(P<0.05)。随访20~144个月,平均(48.35±20.13)个月。随访过程中,无结核症状复发,置管部位无窦道形成。下地行走时间差异无统计学意义(P>0.05)。末次随访时,小切口组和切开组神经损害ASIA分级均较术前显著改善,差异有统计学意义(P<0.05);三组患者VAS和ODI评分均较术前显著减少(P<0.05);影像检查显示脓肿消失,病变椎体与周围正常椎体信号相似,病变部位全部愈合,内固定患者影像学检查均未见内固定物松动、移位和断裂。[结论]依据患者病变程度和全身情况,个性化选择3个阶梯手术治疗,可获得合理的满意临床疗效。

[Objective]To evaluate the clinical outcomes and significance of surgical de-escalation for thoracic spinal tu berculosis.[Methods]A retrospective study was conducted on 239 patients who underwent surgical treatment for thoracic tuber culosis in our hospital between January 2005 and January 2016.Based on the extent of tuberculosis lesion involved and general condition of the patient,one of 3 surgical steps were selected for each patient individually.Of them,160 patients received percu taneous catheter(PC)for irrigation,drainage and local antituberculosis drug administration through a posterior interlaminar ap proach;while 31 patients had debridement,decompression through posterior small incision(SI)combined with percutaneous catheter,if necessary instrumented fixation added,and the remaining 48 patients underwent open debridement and instrument ed fusion(ODIF).[Results]All the patients had operation performed smoothly without serious complication,such as iatrogenic injuries to spinal cord,nerve root,major vessel and internal organ.The operation time,incision length and intraoperative blood loss were ranked in the sequence of PC<SI<ODIF,where were statistically significant(P<0.05).During the follow up period ranged from 20 to 144 months with a mean of(48.35±20.13)months,no recurrence of tuberculosis and sinus formation were not ed in anyone of them.The times to return ambulation and full weight bearing were also arranged down-up PC<SI<ODIF,with statistically significant differences(P<0.05).At the latest follow up,the ASIA grade for nerve function significantly improved in the SI and ODIF groups(P<0.05),in addition,the VAS and ODI score significantly decreased in all 3 groups compared with those before operation(P<0.05).Regarding to radiographic assessment,the tuberculosis lesion subsided with the ab scess absorbed,and homogenic signals between the affected and adjacent normal vertebral bodies on MRI,whereas with out loosening,displacement or breaking of the implants.[Conclusion]This individualized selection of the 3 steps of surgical procedures based on the extent of lesion and general condi tion is a reasonable strategy to achieve satisfactory clinical results.