保守方法治疗轻型脊柱结核的临床疗效

Clinical efficacy of conservative treatment for mild spinal tuberculosis

目的:探讨保守方法治疗轻型脊柱结核的疗效及临床应用价值。方法:采用回顾性研究方法,搜集2015年6月至2018年5月在河北省胸科医院骨科采用保守方法治疗的51例脊柱结核患者的临床资料。无结核分枝杆菌培养和药物敏感性试验(简称“药敏试验”)结果者,常规给予H-R-Z-E(H:异烟肼;R:利福平;Z:吡嗪酰胺;E:乙胺丁醇)抗结核治疗方案,视复查实验室检查结果[血红细胞沉降率(ESR)和C反应蛋白(CRP)]、影像学检查结果,以及临床症状改善情况,调整用药方案;有结核分枝杆菌培养和药敏试验结果者,依据药敏试验结果应用敏感性抗结核药物4~5种治疗;对于并发腰大肌及椎旁脓肿者,予以局部穿刺或置管引流术辅助治疗;对并发皮下脓肿者,辅以皮下脓肿切开引流术;对局部窦道形成者,行窦道搔刮术。所有患者辅以支具保持脊柱制动。动态观察研究对象ESR、CRP变化情况,疼痛缓解情况,以及脊柱结核治愈率。结果:43例研究对象的病灶或痰液标本进行结核分枝杆菌培养及药敏试验,其中,培养阳性21例(48.8%),4例耐药;8例研究对象无法取得标本未行培养,但常规应用抗结核药物后,临床症状及炎性指标逐渐下降至正常,骨病灶完全恢复。治疗4周后研究对象ESR、CRP、VAS评分分别为28(20,37)mm/1 h、25(17,34)mg/L、3(2,4)分,均明显低于治疗前[分别为36(29,55)mm/1 h、32(26,40)mg/L、5(3,6)分],差异均有统计学意义(Z值分别为-5.377、-5.260、-6.017,P值均<0.001)。所有研究对象均获得良好随访,随访18~30个月,48例通过保守方法达到脊柱结核完全治愈,无复发,治愈率为94.1%(48/51)。结论:对有适应证的轻型脊柱结核,采取保守治疗联合必要的辅助治疗方法可获得良好效果。

Objective:To explore the efficacy and clinical application value of conservative treatment for mild spinal tuberculosis.Methods:A retrospective study was conducted 51 patients with spinal tuberculosis who were treated conservatively in the Orthopaedics Department of Hebei Chest Hospital from June 2015 to May 2018.The clinical data of them were collected.Those who without the results of Mycobacterium tuberculosis culture and drug sensitivity test were routinely given H-R-Z-E(H:isoniazid;R:rifampicin;Z:pyrazinamide;E:ethambutol)anti-tuberculosis treatment,and the medication plan was adjusted according to the laboratory examination results(erythrocyte sedimentation rate(ESR)and C-reactive protein(CRP)),imaging findings,and the improvement of clinical symptoms.Those who with Mycobacterium tuberculosis culture and drug sensitivity test results should be treated with 4-5 sensitive anti-tuberculosis drugs according to the drug sensitivity test results.For those who complicated with psoas major muscle and paravertebral abscess,local puncture or catheter drainage should be used as auxiliary treatment.For those who complicated with subcutaneous abscess,incision and drainage of subcutaneous abscess should be supplemented.For those who with local sinus formation,sinus curettage was performed.All patients were assisted by braces to maintain spinal braking.The changes of ESR and CRP,pain relief and cure rate of spinal tuberculosis were dynamically observed.Results:Mycobacterium tuberculosis culture and drug sensitivity test were carried out on 43 lesions or sputum samples of the subjects,of which 21 cases were positive(48.8%),4 cases were drug-resistant.Eight subjects could not obtain specimens and were not cultured,but after application of routine anti-tuberculosis drugs,the clinical symptoms and inflammatory indicators gradually decreased to normal,and the bone lesions completely recovered.Four weeks after treatment,the ESR,CRP and VAS scores of the subjects were 28(20,37)mm/1 h,25(17,34)mg/L and 3(2,4)respectively,which were significantly lower than those before treatment(36(29,55)mm/1 h,32(26,40)mg/L and 5(3,6),respectively)(Z values were-5.377,-5.260 and-6.017,respectively;all P values<0.001).All the subjects were well followed up for 18 to 30 months.And 48 cases of spinal tuberculosis were completely cured by conservative methods without recurrence,the cure rate was 94.1%(48/51).Conclusion:For mild spinal tuberculosis with indications,conservative treatment combined with necessary adjuvant treatment can achieve good results.