经皮内镜下清创联合经皮椎弓根螺钉内固定治疗腰椎化脓性椎间盘炎

Percutaneous endoscopic debridement with percutaneous pedicle screw fixation for lumbar pyogenic spondylodiscitis

目的评估经皮内镜下清创联合经皮椎弓根螺钉内固定术治疗腰椎化脓性椎间盘炎的可行性和疗效。方法回顾性收集2014年1月至2017年3月于中山大学孙逸仙纪念医院和珠海市人民医院脊柱骨科接受经皮内镜下清创联合经皮椎弓根螺钉内固定术的49例腰椎化脓性椎间盘炎患者资料,男29例、女20例,年龄(51.2±13.9)岁(范围19~81岁)。病变节段行经皮椎弓根螺钉内固定术后,在内镜引导下对病灶进行彻底清创。对比围手术期及随访期间患者症状改善情况、实验室相关指标变化、视觉模拟评分(visua lanalogs cale,VAS)、美国脊髓损伤协会脊髓损伤分级(American Spinal Injury Association impairment scale,AIS)、Oswestry功能障碍指数(Oswestry disability index,ODI)和影像结果。结果所有患者均获得随访,随访时间为(12.7±6.4)个月(范围6~36个月)。手术时间为(110.1±19.8)min(范围80~165min),术中出血量为(47.8±20.6)ml(范围20~120ml)。术后3个月49例C反应蛋白由术前(62.1±37.2)mg/L降至(7.5±5.8)mg/L,白细胞计数由术前(14.2±3.9)×10^(9)/L降至(6.2±1.1)×10^(9)/L,红细胞沉降率由术前(90.3±37.4)mm/1h降至(16.9±7.2)mm/1h,各指标术前与术后3个月比较的差异均有统计学意义(t=10.15,P<0.001;t=13.49,P<0.001;t=13.82,P<0.001)。36例检出病原菌,其中葡萄球菌属占50%(18/36)。术后1~2年行腰椎CT的37例患者中57%(21/37)稳定融合、22%(8/37)部分融合、22%(8/37)未融合。至末次随访,49例VAS由术前(7.4±0.6)分降至(0.5±0.3)分,ODI由术前78.2%±9.1%改善至14.0%±8.6,差异均有统计学意义(t=72.00,P<0.001;t=35.89,P<0.001);术前AISE级38例、D级11例,末次随访时E级43例、D级6例。术后11例出现手术相关并发症,包括感染复发2例、神经功能受损2例。结论经皮内镜下清创联合经皮椎弓根螺钉内固定术创伤小,可有效清除椎间感染病灶及稳定椎体,显著改善患者的临床结局。

Objective To access the feasibility and efficacy of percutaneous endoscopic debridement(PED)combined with percutaneous pedicle screw fixation(PPSF)in the treatment of lumbar pyogenic spondylodiscitis.Methods 49 patients(male 29,female 20),aged 51.2±13.9 years(range 19-81 years),who were diagnosed with lumbar pyogenic spondylodiscitis and received PED with PPSF in Orthopedic Department,Sun Yat-Sen Memorial Hospital and Zhuhai People's Hospital from January 2014 to March 2017,were retrospectively reviewed.The patients were operated in the prone position with the infected locus thoroughly debrided,vertebrae fixed and clinical outcomes were assessed by observing the changes of complaining symptoms,laboratory parameters,clinical functional scores(American Spinal Injury Association impairment scale,AIS;visual analog scale,VAS;Oswestry disability index,ODI)and imaging studies during perioperative and follow-up stages.Results The mean operative time was 110.1±19.8 min(80-165 min),with intra-operative blood loss 47.8±20.6 ml(range 20-120 ml).All patients reported relief of back pain.Causative pathogens were identified in 36 of 49 biopsy specimens,with staphylococcal bacteria being the most prevalent strain(accounting for 50.0%).During 3-12 months'follow-up,95.9%(47/49)patients'infection was well-controlled.At 3 month post-operative,C-reactive protein declined from 62.1±37.2 mg/L to 7.5±5.8 mg/L,white blood cell declined from(14.2±3.9)×10^(9)/L to(6.2±1.1)×10^(9)/L,ESR declined from 90.3±37.4 mm/1 h to 16.9±7.2 mm/1 h,and the values at 3 months post-operative had significant difference compared with values at pre-operative(t=10.15,P<0.001;t=13.49,P<0.001;t=13.82,P<0.001).Spontaneous fusion was observed among 56.8%(21/37)of the patients during long-term radiological follow-ups(more than 1.5 years).At the last follow-up,the VAS declined from 7.4±0.6 points pre-operative to 0.5±0.3 post-operative,ODI declined from 78.2%±9.1%pre-operative to 14.0%±8.6%post-operative,and the values at the last follow-up had significant difference compared with values at pre-operative(t=72.00,P<0.001;t=35.89,P<0.001).There were 38 cases of AIS E,and 11 cases of AIS D at pre-operative,while 43 cases of AIS E and 6 cases of AIS D.However,there were 11 patients developed post-operative complications,among whom 2 with recurrent infection,2 with secondary neurological impairment.Conclusion PED combined with PPSF effectively eliminated infected locus,stabilized the affected vertebrae,improved patients'clinical outcomes with small trauma,thereby offering an alternative for the treatment of lumbar pyogenic spondylodiscitis.