原发性与脊柱术后化脓性脊柱炎的对比研究及预后因素分析

Comparative study of native vertebral osteomyelitis and pyogenic postoperative and analysis of prognostic factors

目的:比较原发性化脓性脊柱炎(native vertebral osteomyelitis,NVO)与脊柱术后化脓性脊柱炎(postoperative vertebral osteomyelitis,PVO)的微生物学、临床特点及治疗效果,并分析影响预后的因素。方法:回顾性分析2010年12月至2019年12月诊治化脓性脊柱炎46例患者的病历资料,按发生原因分为NVO组和PVO组。NVO组30例,男18例,女12例;年龄(50.47±20.45)岁(范围15~73岁);病变位于腰椎23例(76.7%)、胸椎5例(16.7%)、颈椎2例(6.7%)。PVO组16例,男10例,女6例;年龄(52.13±18.80)岁(范围14~73岁);病变位于腰椎11例(68.8%)、胸椎5例(31.2%)。术前28例患者存在神经功能障碍,按照美国脊柱损伤协会(American Spinal Injury Association,ASIA)神经功能分级,D级25例(NVO组16例,PVO组9例),C级3例(NVO组1例,PVO组2例)。所有患者先予卧床、营养支持和抗生素治疗,效果不佳或症状加重者采用手术治疗。观察指标包括白细胞计数、红细胞沉降率和C-反应蛋白评价感染控制情况,通过影像学检查评估内固定装置有无松动、断裂。同时记录疼痛视觉模拟评分(visual analogue scale,VAS)、ASIA神经功能分级的变化以评价临床疗效。结果:NVO组2例患者行抗感染保守治疗,余28例患者均顺利完成手术,术中病变组织送病检,结果均诊断为化脓性脊柱炎。所有患者均获12~24个月随访,均采用静脉注射与口服抗生素治疗,PVO组抗生素治疗总时间较NVO组延长,但差异无统计学意义(t=1.74,P=0.088)。两组患者术后各随访时间点白细胞计数、C-反应蛋白、红细胞沉降率、VAS评分均较术前明显改善(P<0.05)。两组间术后相同时间点白细胞计数、C-反应蛋白、红细胞沉降率、VAS评分的差异均无统计学意义(P>0.05)。术后患者神经功能较术前明显改善,NVO组16例患者ASIA分级由D级恢复至E级、1例自C级恢复至D级;PVO组9例由D级恢复至E级,2例自C级恢复至D级。至末次随访NVO组3例复发,复发率为10%;PVO组7例复发,复发率为43.8%,差异有统计学意义(χ^(2)=5.14,P=0.023)。存在脊柱内植物的39例患者中5例(12.8%)患者(NVO组1例,PVO组4例)在内固定术后反复出现感染,故再次手术取出内固定物以控制感染,术后经制动、全身抗感染等保守治疗后痊愈。单因素分析结果显示多个椎体受累(OR=11.00,P=0.006)、脓肿形成(OR=9.00,P=0.047)与化脓性脊柱炎复发明显相关;微生物感染(OR=1.867,P=0.416)、脊柱假体(OR=7.20,P=0.074)、异体骨(OR=1.78,P=0.478)有相关趋势,但无相关性。多因素分析结果显示多椎体受累(OR=10.49,95%CI:1.133,97.05,P=0.038)是影响化脓性脊柱炎复发的危险因素。结论:对PVO的治疗比NVO更具挑战性,特别是在脊柱内植物感染的情况下,虽然PVO的抗生素治疗时间比NVO延长,但PVO复发率较高。更长的抗生素治疗及必要时手术清创或去除内植物是成功治疗PVO的重要方法。

Objective To compare the microbiology,clinical characteristics and therapeutic efficacy of native suppurative spondylitis(NVO)and postoperative suppurative spondylitis(PVO),and analyze the factors affecting the prognosis.Methods All patients with suppurative spondylitis were retrospectively analyzed from December 2010 to December 2019.A total of 46 patients were enrolled in this study.They were divided into two groups.There were 30 cases in NVO group,18 males and 12 females;The age was 50.47±20.45 years,aged 15-73 years.There were 16 cases in PVO group,10 males and 6 females;The age was 52.13±18.80 years,aged 14-73 years.In group NVO,23 cases(76.7%)were in lumbar vertebrae,5 cases(16.7%)in thoracic vertebrae and 2 cases(6.7%)in cervical vertebrae;in group PVO,11 cases(68.8%)in lumbar vertebrae and 5 cases(31.2%)in thoracic vertebrae.Twenty-eight patients had neurological dysfunction before surgery.There were 25 cases of grade D(16 cases in group NVO and 9 cases in group PVO)and 3 cases of grade C(1 case in group NVO and 2 cases in group PVO),following the instructions of American Spinal Injury Association(ASIA)neurological function classification.All patients were given bed rest,nutritional support and antibiotic therapy;surgical treatment for patients with poor outcomes or aggravated symptoms.The patients were followed up after operation,the observation indexes included leukocyte count,erythrocyte sedimentation rate and C-reactive protein to evaluate the postoperative curative effect.The internal fixation device was evaluated for looseness and fracture by imaging examination.At the same time,the changes of visual analogue scale,ASIA neurological function grade were recorded to evaluate the clinical efficacy.Results Two patients in NVO group were treated with antibiotics,and all the other patients successfully completed the operation.The diseased tissues were sent for pathological examination during the operation.The results showed that they were diagnosed as suppurative spondylitis.All patients were followed up for 12-24 months.Both groups were treated with intravenous and oral antibiotics,and the time of antibiotic treatment in group PVO was longer than that in group NVO without significant difference(t=1.74,P=0.088).The leukocyte,C-reactive protein,erythrocyte sedimentation rate,visual analogue scale(VAS),were significantly improved in both groups at different time points after operation(P<0.05).There was no significant difference in leukocyte,C-reactive protein,erythrocyte sedimentation rate or VAS score between the two groups at the same time point after operation(P>0.05).The neurological function of patients after operation was significantly improved compared with that before operation.In group NVO,16 cases recovered from ASIA grade D to grade E,1 case from grade C to grade D;9 cases in group PVO recovered from grade D to grade E and 2 cases recovered from grade C to grade D.Till the last follow-up,3 patients in group NVO recurred,the recurrence rate was 10%(3/30);7 patients in group PVO recurred,the recurrence rate was 43.8%;the recurrence rate of group PVO was higher than that of group NVO,the difference was statistically significant(χ^(2)=5.14,P=0.023).Among 39 patients with spinal internal fixation,12.8%(1 NVO,4 PVO)had recurrent infection after internal fixation.Therefore,re-operation was performed to remove the internal fixator for infection control,patients recovered after conservative treatment such as immobilization and systemic anti-infection By univariate analysis,multiple vertebral involvement and abscess formation(OR=11.00,P=0.006;OR=9.00,P=0.047)were significantly associated with pyogenic spondylitis recurrence;there was a tendency for pyogenic spondylitis recurrence among microbial infection(OR=1.87,P=0.416),spinal prosthesis(OR=7.20,P=0.074)and allogenic bone(OR=1.78,P=0.478),yet not obvious.Multivariate analysis indicated that multiple vertebral involvement(OR=10.49,P=0.038)was a risk factor for pyogenic spondylitis recurrence.Conclusion The treatment of PVO is more challenging than NVO,especially in the cases of spinal implant infection.Although the antibiotic treatment time of PVO is longer than that of NVO,the recurrence rate of PVO is higher.Longer antibiotic therapy and,if necessary,surgical debridement or removal of implants are important approaches to successful treatment of PVO.