腰椎椎间融合器及椎弓根螺钉系统感染的手术治疗

Surgical treatment of infections in lumbar vertebral fusion with cage and pedicle screw system

目的探讨前路或后路清创及植骨融合椎弓根螺钉内固定治疗腰椎椎间融合器及椎弓根螺钉系统感染的疗效。方法回顾性分析2013年1月至2019年12月收治的10例腰椎融合器及椎弓根钉棒感染患者,男3例、女7例;年龄(49.80±13.29)岁(范围23~66岁)。原术式为腰椎后路椎弓根螺钉固定植骨融合术,共植入14枚融合器;诊断为腰椎间盘突出症6例、腰椎管狭窄症2例、腰椎滑脱症1例、腰椎骨折1例。于术后(10.80±13.24)个月(范围2~39个月)诊断为术后融合器感染10例(12枚),其中合并椎弓根钉棒感染8例。采用前路清创融合器取出及植骨融合椎弓根螺钉内固定术7例:5例(7个椎间隙)一期前路清创及椎间植骨,1例后侧关节突已融合而未植骨,1例因后路清创取出钉棒时出血较多而在2周后行前路清创及植骨融合椎弓根螺钉内固定;合并椎弓根钉棒感染6例、断棒1例,行一期椎弓根钉棒翻修3例(2例感染、1例断棒)、单纯椎弓根钉棒取出4例。采用后路清创融合器取出及植骨融合椎弓根螺钉内固定术3例:2例一期椎间颗粒状松质骨植骨,1例因感染严重、后侧软组织缺损而未植骨;合并椎弓根钉棒感染2例,单纯取出1例、取出后更换新的椎弓根螺钉固定1例。比较患者术前、术后2个月及术后6个月的白细胞计数、红细胞沉降率、C反应蛋白、视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)。结果全部患者获得随访,随访时间(16.30±5.10)个月(范围9~24个月)。术后2个月、术后6个月白细胞计数与术前比较差异无统计学意义(F=0.855,P=0.436);红细胞沉降率由(61.10±40.81)mm/1 h下降至(19.81±7.63)mm/1 h、(11.50±6.10)mm/1 h,差异有统计学意义(F=12.024,P=0.001);C反应蛋白由(32.39±37.94)mg/L下降至(8.61±5.93)mg/dl、(5.80±4.09)mg/dl,差异有统计学意义(F=4.292,P=0.024);VAS评分由(6.60±0.84)分下降至(2.80±0.92)分、(1.60±0.97)分,差异有统计学意义(F=82.090,P<0.001);ODI指数由80.10%±8.14%下降至51.00%±8.10%、30.7%±7.36%,差异有统计学意义(F=99.378,P<0.001)。术后MRI椎体异常信号逐渐消退,完全消退时间为(5.00±1.33)个月(范围3~7个月)。前路手术中6例(8个间隙)一期植骨,其中5例(7个间隙)获得融合,融合时间为(6.80±2.28)个月(范围4~10个月);1例1个间隙未融合。后路手术中2例一期植骨,其中1例于4个月获得融合;1例因植骨区感染再次清创取出植骨,未融合。1例发生术中L5神经根牵拉损伤,1例发生术后植骨块移位。结论融合器感染早期可经后路清创取出,但受到后侧神经及骨结构的阻挡,难以做到彻底清创,存在感染复发及神经根损伤的风险。融合器感染行前路手术取出操作简便、清创彻底,但需注意邻近重要血管损伤的风险。

Objective To investigate the effect of anterior or posterior debridement on infections of the lumbar vertebral fusion with cage and pedical screw system.Methods A total of 10 cases(3 males and 7 females,age 49.80±13.29 years)with infections in the lumbar fusion device were admitted from January 2013 to December 2019.The cases were diagnosed with deep infections after the preview surgery at 10.80±13.24 months,including 10 cases with 12 cages infections and 8 cases with screw system infections.7 cases were done with debridement and removal of the cages via the anterior approach.And another 3 cases underwent posterior debridement and removal of lumbar fusion cages.The changes in laboratory examination such as WBC count,ESR,CRP,visual analogue scale(VAS)and Oswestry Disability Index(ODI)score were compared preoperatively,2 months and 6 months postoperatively.Results No patients were lost in the follow-up.The average follow-up time periods is 16.30±5.10 months(range 9-24 months).There was no significant difference in WBC count between 2 and 6 months after surgery compared with preoperation(F=0.855,P=0.436).The ESR,CRP,VAS and ODI scores decreased in 2 months and 6 months after sugery,which has significant differences compared preoperation(P<0.05).The abnormal signals in the lambar vertebral showed a gradual fading trend in the postoperative MRI.The completely fading time was 5.00±1.33 months(range 3-7 months).One-stage bone grafting was performed in 6 cases with 8 spaces via anterior approach,5 cases with 7 spaces showed the intervertebral fusion after postoperative with 6.80±2.28 months(range 4-10 months),1 case wirh 1 space was not fused.One-stage bone grafting was performed in 2 cases via posterior approach:1 case was fused after postoperative and the other patient was not,which due to bone graft area infection.Postoperative bone graft displacement occurred with 1 case and 1 case with L5 nerve root pulling injury during the operation.Conclusion The fusion cage can be removed by debridement via posterior approach,but it is difficult to done the completely debridement,which the main reason is the obstruction of the posterior nerve and bone structure.Posterior approach also have risks of infection recurrence and nerve root injury.Cage removal via anterior approach was relatively easy and debridement was thoroughly,which has the risk of injury of important adjacent vessels.