胸腔镜病灶清除融合联合椎弓钉治疗胸椎结核

Thoracoscopic debridement and fusion combined with posterior pedicle screw fixation for treatment of thoracic spine tuberculosis

[目的]介绍前路胸腔镜辅助下病灶清除植骨融合联合后路内固定治疗胸椎结核的手术技术与疗效。[方法]2009年3月~2018年7月应用胸腔镜辅助下前路病灶清除植骨融合联合后路内固定治疗11例胸椎结核患者,经后路正中切口,行病变相应节段两侧椎弓根钉棒固定。改用双腔管通气,取右侧第5肋间腋中线,作2 cm切口,置入胸腔镜镜头,同时取右侧第3肋间腋前线、右侧第5肋间锁骨中线各作1 cm、2 cm切口,置入胸腔镜操作器械。清除病变椎间盘及破坏的死骨,椎间隙植骨,缝合椎前筋膜。[结果]本组11例胸椎结核患者均顺利手术,无严重并发症。随时间推移,患者神经功能显著改善,VAS、ODI评分显著减少(P<0.05),ESR显著降低(P<0.05)。术后后凸Cobb角较术前明显改善(P<0.05),所有患者病灶骨性融合。[结论]胸腔镜病灶清除联合后路内固定治疗胸椎结核创伤小,满意疗效。

[Objective]To introduce the surgical technique and primary clinical outcomes of thoracoscopic debridement and fusion combined with posterior pedicle screw fixation for thoracic spine tuberculosis.[Methods]From March 2009 to July2018,11 patients underwent thoracoscopic debridement and fusion combined with posterior pedicle screw fixation for thoracic spine tuberculosis.The involved segments were fixed with bilateral pedicle screws and rods through a posterior midline incision.After that,using double lumen endotracheal tube ventilation,the thoracoscope was inserted through the portal at the right 5th intercostal on midaxillary line with a 2 cm incision,while the instrumentations were placed through the portals at the right 3rd intercostal on anterior axillary line with a 1 cm incision,and right 5th intercostal on midclavicular line with an incision 2 cm in length.As soon as the lesions completely removed,including the involving intervertebral tissues,caseous necrosis and abscess,the bone autografts were inserted into the intervertebral space,and the prevertebral fascia was closed by suture.[Results]All the 11 patients had operation finished smoothly with no serious complications.As time went the neurological function in term of ASIA grading significantly improved,whereas the VAS and ODI scores significantly decreased(P<0.05).The erythrocyte sedimentation rate(ESR)significantly declined over time(P<0.05).Regarding to imaging examinations,the kyphotic Cobb’s angles significantly decreased after operation compared with those before operation(P<0.05),and bony fusion of the involved segment were seen in all the patients.[Conclusion]This thoracoscopic debridement and fusion combined with posterior pedicle screw fixation does achieve satisfactory clinical outcomes with a benefit of minimizing iatrogenic trauma for thoracic spine tuberculosis.