脊柱内镜下椎体内病灶清除及灌洗引流治疗腰椎结核的临床研究

Endoscopic vertebral debridement and lavage drainage in the treatment of lumbar tuberculosis

目的探讨经皮脊柱内镜下椎体内病灶清除并持续灌洗引流在腰椎结核手术中的有效性与安全性。方法回顾性分析2012年1月至2018年1月在我院行椎弓根穿刺取病理组织活检或培养确诊为腰椎结核,口服抗结核药物保守治疗3个月无效后,入院经脊柱内镜下椎体内病灶清除及灌洗引流治疗的31例腰椎结核患者的临床资料。分析患者的手术时间、术中出血量、术中有无大血管、脊髓及神经损伤来评估患者术中情况;通过手术前后患者血沉(erythrocyte sedimentation rate,ESR)、C反应蛋白(C-reactive protein,CRP)及疼痛视觉模拟评分(visual analogue scale,VAS)评估患者局部结核恢复情况;术后随访18~84个月,平均46个月,末次随访患者腰椎前凸角(lumbar lordosis,LL)、骶骨倾斜角(sacral inclination,SI)、日本骨科协会(Japanese orthopaedic association,JOA)评分及影像学资料,综合评估患者术后脊柱结构及功能恢复情况。结果本组31例均顺利完成手术,未出现大血管、脊髓和神经损伤等并发症。ESR术后3个月(11.58±2.79) mm/h,6个月(11.77±4.22) mm/h,12个月(9.97±3.38) mm/h,均恢复至正常水平,和术前1天(45.94±8.02) mm/h比较,差异有统计学意义(P<0.05);CRP术后3个月(4.69±0.85) mg/L,6个月(4.50±0.42) mg/L,12个月(4.37±0.18) mg/L,均恢复至正常水平,与术前1天(44.72±5.80) mg/L比较,差异有统计学意义(P<0.05);VAS评分由术前(6.42±1.31)分,降至术后3个月(2.26±1.32)分,术后6个月(1.87±0.92)分,术后12个月(1.74±0.97)分,均显著低于术前,差异有统计学意义(P<0.05);末次随访患者LL (42.61±2.81)°,SI (38.16±2.62)°,JOA评分(26.10±1.54)分,与术前LL (33.58±1.79)°,SI(30.81±1.87)°,JOA评分(15.26±1.93)分比较,改善明显,差异有统计学意义(P<0.05)。末次影像学腰椎X线片提示病变椎体未见明显塌陷及椎间隙变窄,CT及MRI提示椎体病灶愈合。结论脊柱内镜下椎体病灶清除并灌洗引流治疗腰椎结核具有手术时间短、术中出血量少、安全并有效,可为脊柱结核提供一种新的手术治疗方法。

Objective To investigate the effectiveness and safety of endoscopic vertebral debridement and lavage drainage in the treatment of lumbar tuberculosis.Methods Clinical data of 31 patients with lumbar tuberculosis,diagnosed by biopsies or mycobacterium culture,were retrospectively analyzed from January 2012 to January 2018.All patients underwent anti-tuberculosis conservative treatment for 3 months,but failed.Operations were evaluated by operation time,blood loss,macrovascular,spinal cord or nerve root injury.Erythrocyte sedimentation rate (ESR),C-reactive protein (CRP) and visual analogue scale (VAS) before and after operation were recorded to evaluate the recovery.All patients were followed up for 18 to 84 months (mean:46 months).Lumbar lordosis (LL),sacral inclination (SI) Japanese Orthopaedic Association (JOA) scores and imaging data were used at the last follow-up to evaluate the recovery of spinal structure and functions after operation.Results All patients completed the operation successfully.No macrovascular,spinal cord or nerve injury occurred.The ESR decreased from (45.94±8.02) mm / h1 day before surgery to (11.58±2.79) mm / h,(11.77±4.22) mm / h,(9.97±3.38) mm / h 3 months,6 months,12 months after operation with statistical significance (P < 0.05).The CRP decreased from (44.72±5.80) mg / L1 day before surgery to (4.69±0.85) mg / L,(4.50±0.42) mg / L,(4.37±0.18) mg / L 3 months,6 months,12 months after operation with statistical significance (P < 0.05).The VAS decreased from (6.42±1.31) 1 day before surgery to (2.26±1.32),(1.87±0.92),(1.74±0.97) 3 months,6 months,12 months after operation with statistical significance (P < 0.05).The LL,SI,and JOA decreased from (33.58±1.79) °,(30.81±1.87) °,(15.26±1.93) before operation to (42.61±2.81) °,(38.16±2.62) °,(26.10±1.54) at the last follow-up with statistical significance (P < 0.05).No collapse of the vertebral body or narrowing of the intervertebral space was observed on X-ray images at the last follow-up.CT and MRI images suggested that the vertebral lesions healed.Conclusions Endoscopic vertebral debridement and lavage drainage is a safe and effective surgical treatment of spinal tuberculosis with short operation time and less intraoperative bleeding.