经皮椎弓根钉内固定联合扩张通道微创侧方小切口病灶清除椎间植骨治疗腰椎结核

Treatment of lumbar tuberculosis with percutaneous pedicle screw internal fixation and minimally invasive lateral small incisions lesion debridement and bone graft fusion via dilated channels

目的探讨经皮椎弓根钉内固定联合扩张通道微创侧方小切口病灶清除椎间植骨融合术治疗腰椎结核的临床疗效。方法回顾分析2016年1月—2018年6月22例采用经皮椎弓根钉内固定联合扩张通道微创侧方小切口病灶清除椎间植骨融合术治疗的22例腰椎结核患者临床资料。其中男12例,女10例;年龄22~75岁,平均47.5岁。病变节段:L_(2、3)5例,L_(3、4)8例,L_(4、5)9例。病程4~14个月,平均8.6个月。术前神经功能按美国脊髓损伤协会(ASIA)分级,C级3例,D级9例,E级10例。记录手术时间、术中出血量及术后并发症发生情况。术前、术后3个月、末次随访时,检测C反应蛋白(C reactive protein,CRP)、红细胞沉降率(erythrocyte sedimentation rate,ESR)以评价结核控制情况;采用疼痛视觉模拟评分(VAS)评价疼痛恢复情况,Oswestry功能障碍指数(ODI)评价患者腰背部功能恢复情况;测量病变椎体后凸Cobb角,并计算Cobb角丢失值(末次随访与术后3个月Cobb角的差值)。末次随访时采用ASIA分级评价神经功能恢复情况,按照改良MacNab标准评定疗效。结果手术时间110~148 min,平均132.8 min;术中出血量70~110 mL,平均89.9 mL。术后2例患者出现切口脂肪液化,延迟愈合;其余患者切口均Ⅰ期愈合。所有患者均获随访,随访时间18~24个月,平均21.3个月。所有植骨均达骨性融合,椎弓根钉固定位置可靠,无松动、移位及钉棒断裂发生,无结核复发。术后3个月及末次随访时患者ESR、CRP、VAS评分、ODI评分及病变节段后凸Cobb角均较术前显著改善(P<0.05),末次随访与术后3个月比较差异均无统计学意义(P>0.05),其中Cobb角丢失值为(0.6±0.5)°。患者神经功能恢复明显,末次随访时ASIA分级为C级1例、D级1例、E级20例,较术前明显改善(Z=-3.066,P=0.002)。按照改良MacNab标准评定,获优16例、良3例、可2例,差1例,优良率86.4%。结论经皮椎弓根钉内固定联合扩张通道微创侧方小切口病灶清除椎间植骨融合术具有出血少、创伤小、恢复快等优点,治疗腰椎结核安全、有效。

Objective To explore the efficacy of percutaneous pedicle screw internal fixation and minimally invasive lateral small incisions lesion debridement and bone graft fusion via dilated channels in the treatment of lumbar tuberculosis.Methods The clinical data of 22 cases of lumbar tuberculosis treated with percutaneous pedicle screw internal fixation combined with dilated channels with minimally invasive lateral small incision lesion debridement and bone graft fusion between January 2016 and June 2018 were retrospectively analyzed.There were 12 males and 10 females,with an average age of 47.5 years(range,22-75 years).The affected segments were L2,3 in 5 cases,L3,4 in 8 cases,and L4,5 in 9 cases,with an average disease duration of 8.6 months(range,4-14 months).Preoperative neurological function was classified according to the American Spinal Injury Association(ASIA),with 3 cases of grade C,9 cases of grade D,and 10 cases of grade E.The operation time,intraoperative blood loss,and postoperative complications were recorded.At preoperation,3 months after operation,and last follow-up,the C reactive protein(CRP)and erythrocyte sedimentation rate(ESR)were tested to evaluate tuberculosis control;the pain visual analogue scale(VAS)score was used to evaluate the recovery of pain,and the Oswestry disability index(ODI)was used to evaluate the function recovery of the patient’s lower back;the kyphosis Cobb angle was measured,and the loss of Cobb angle(the difference between the Cobb angle at last follow-up and 3 months after operation)was calculated.At last follow-up,the ASIA classification was used to evaluate the recovery of neurological function,and the effectiveness was evaluated according to the modified MacNab standard.Results The operation time was 110-148 minutes(mean,132.8 minutes)and the intraoperative blood loss was 70-110 mL(mean,89.9 mL).Two patients experienced fat liquefaction of the incision and delayed healing;the incisions of the remaining patients healed by first intention.All patients were followed up 18-24 months,with an average of 21.3 months.All bone grafts achieved osseous fusion,the pedicle screws were fixed in reliable positions,without loosening,displacement,or broken rods.There was no recurrence of tuberculosis.The ESR,CRP,VAS scores,ODI scores,and kyphosis Cobb angle of the affected segment at 3 months after operation and last follow-up were significantly improved(P<0.05);there were no significant differences between at last follow-up and 3 months after operation(P>0.05),and the loss of Cobb angle was(0.6±0.5)°.The patient’s neurological function recovered significantly.At last follow-up,the ASIA grades were classified into 1 case with grade C,1 case with grade D,and 20 cases with grade E,which were significantly improved when compared with preoperative grading(Z=−3.066,P=0.002).According to the modified MacNab standard,16 cases were excellent,3 cases were good,2 cases were fair,and 1 case was poor.The excellent and good rate was 86.4%.Conclusion Percutaneous pedicle screw internal fixation combined with dilated channels with minimally invasive lateral small incisions lesion debridement and bone graft fusion has the advantages of less bleeding,less trauma,and faster recovery,which is safe and effective in the treatment of lumbar tuberculosis.