颅脊交界区结核的治疗研究

Treatment of tuberculosis in craniovertebral junction

目的探讨颅脊交界区结核的治疗方法及疗效。方法回顾分析2010年7月—2019年1月收治的18例颅脊交界区结核患者临床资料。其中男14例,女4例;年龄1岁9个月~75岁,中位年龄35岁。病程2周~60个月,中位病程4个月。结核累及节段C0~C3。疼痛视觉模拟评分(VAS)为(6.7±1.5)分,日本骨科协会(JOA)评分为(16.1±1.8)分。神经功能根据美国脊髓损伤学会(ASIA)分级:D级6例、E级12例。其中保守治疗4例;经口咽入路病灶清除1例,经颈后入路病灶清除1例,经颈后入路(寰枢或枕颈)融合内固定后一期行经口咽入路病灶清除12例。治疗后采用VAS评分、ASIA分级及JOA评分进行评价,定期复查X线片和CT、MRI,评估结核病灶复发、颈椎稳定性和骨愈合情况。结果18例患者均获随访,随访时间3~42个月,中位时间12个月。治疗后3个月VAS评分为(1.7±1.0)分,与治疗前比较差异有统计学意义(t=15.000,P=0.000);JOA评分为(16.7±1.0)分,与治疗前比较差异无统计学意义(t=1.317,P=0.205)。6例治疗前ASIA分级为D级者改善为E级,其余E级患者无变化。影像学复查示颈椎稳定性良好,结核病灶切除彻底、未见复发,行颈后入路内固定者寰枢或枕颈间达到骨性融合。结论在正规抗结核治疗基础上,如患者无巨大脓肿引起的吞咽或呼吸困难以及寰枢椎不稳及神经症状等,可行保守治疗;反之,则需经口咽入路手术,彻底切除颅脊交界区结核病灶,一期联合颈后入路融合内固定术,能达到较好疗效。

Objective To investigate the method of treating tuberculosis in the craniovertebral junction and its effectiveness.Methods The clinical data of 18 patients with tuberculosis in the craniovertebral junction between July2010 and January 2019 was analyzed retrospectively.There were 14 males and 4 females,aged 21 months to 75 years(median,35 years).The disease duration ranged from 2 weeks to 60 months(median,4 months),and the affected segment was C0-C3.Preoperative visual analogue scale(VAS)score was 6.7±1.5 and the Japanese Orthopaedic Association(JOA)score was 16.1±1.8.The American Spinal Cord Injury Association(ASIA)grading system was applied to classify their neurological functions,according to which there were 6 cases of grade D and 12 cases of grade E.Among 18 patients,4 patients underwent conservative treatment,1 patient removed tuberculosis via transoral approach,1 patient removed tuberculosis via posterior cervical approach,and 12 patients removed tuberculosis via transoral approach immediately after posterior cervical(atlantoaxial or occipitalcervical)fusion and internal fixation.The VAS score,ASIA grading,and JOA score were applied to evaluate effectiveness.X-ray film,CT,and MRI were taken after treatment to evaluate the tubercular recurrence,cervical stability,and bone healing.Results All the patients were followed up 3 to 42 months(median,12 months).At 3 months after treatment,the VAS score was 1.7±1.0,showing significant difference when compared with preoperative score(t=15.000,P=0.000);and the JOA score was 16.7±1.0,showing no significant difference when compared with preoperative score(t=1.317,P=0.205).According to ASIA grading,6 patients with grade D before treatment had upgraded to grade E after treatment,while the remaining patients with grade E had no change in grading.The imaging examinations showed the good stability of the cervical spine.All patients had complete tuberculosis resection and no recurrence,and the patients who underwent internal fixation via posterior cervical approach achieved atlantoaxial or occipitalcervical bone fusion.Conclusion On the premise of regular chemotherapy,if there is no huge abscess causing dysphagia or dyspnea,atlantoaxial instability,and neurological symptoms,patients can undergo conservative treatment.If not,however,the transoral approach can be used to completely remove the tuberculosis lesion in the craniovertebral junction.One-stage debridement via transoral approach combined with posterior cervical fusion and internal fixation can achieve satisfactory effectiveness.