Tuberculosis of the spine

Pott’s spine,commonly known as spinal tuberculosis(TB),is an extrapulmonary form of TB caused by Mycobacterium TB.Pott’s paraplegia occurs when the spine is involved.Spinal TB is usually caused by the hematogenous spread of infection from a central focus,which can be in the lungs or another location.Spinal TB is distinguished by intervertebral disc involvement caused by the same segmental arterial supply,which can result in severe morbidity even after years of approved therapy.Neurological impairments and spine deformities are caused by progressive damage to the anterior vertebral body.The clinical,radiographic,microbiological,and histological data are used to make the diagnosis of spinal TB.In Pott’s spine,combination multidrug antitubercular therapy is the basis of treatment.The recent appearance of multidrug-resistant/extremely drug-resistant TB and the growth of human immunodeficiency virus infection have presented significant challenges in the battle against TB infection.Patients who come with significant kyphosis or neurological impairments are the only ones who require surgical care.Debride-ment,fusion stabilization,and correction of spinal deformity are the cornerstones of surgical treatment.Clinical results for the treatment of spinal TB are generally quite good with adequate and prompt care.

One-stage Surgical Treatment for Thoracic and Lumbar Spinal Tuberculosis by Transpedicular Fixation, Debridement, and Combined Interbody and Posterior Fusion via a Posterior-only Approach

This study examined the clinical outcomes of one-stage surgical treatment for patients with spinal tuberculosis via a posterior-only approach. Twenty-four patients with thoracic or lumbar spinal tuberculosis whose lesions were confined to adjacent segments were admitted to our hospital and treated. The American Spinal Injury Association（ASIA） impairment scale was used to assess the neurological function. All patients were treated with one-stage surgical treatment via a posterior-only approach. The clinical efficacy was evaluated by the Japanese Orthopaedic Association（JOA） scores and oswestry disability index（ODI） of nerve function. Patients were evaluated preoperatively and postoperatively by measurement of spinal deformity using Cobb angle and radiological examination. All the patients were followed up for 13 to 27 months. They had significantly postoperative improvement in JOA score, ODI and ASIA classification scores. The kyphotic angles were significantly corrected and maintained at the final follow-up. Bone fusion was achieved within 4–12 months. It was concluded that one-stage surgical treatment via a posterior-only approach is effective and feasible for the treatment of spinal tuberculosis.

Susceptibility of spinal tuberculosis and its related gene polymorphisms

Spinal tuberculosis,as one of the most serious forms of extrapulmonary tuberculosis,is one of the primary causes of spinal deformity and paralysis in developing countries.It immensely affects people's quality of life with high incidences of deformity and disability.The onset of spinal tuberculosis is related to many factors such as gender,age,environment,habits and hereditary factor.As a genetic factor,gene polymorphism plays an important role in the occurrence and development of tuberculosis.This article reviews the research progress of the susceptibility of spinal tuberculosis and its related gene polymorphisms,in order to provide reference for early prevention and treatment of spinal tuberculosis.

Surgical treatment of spinal tuberculosis in older patients

Objective To discuss perioperative features,operative approach and surgical effects of spinal tuberculosis in older patients.Methods Retrospective analysis was conducted to analyze the clinical data of 45 patients with spinal

Differential study of DCE-MRI parameters in spinal metastatic tumors, brucellar spondylitis and spinal tuberculosis

Objective： In the present study, spinal metastatic tumors, brucellar spondylitis and spinal tuberculosis werequantitatively analyzed using dynamic contrast-enhanced magnetic resonance imaging （DCE-MRI） to assess thevalue of DCE-MRI in the differential diagnosis of these diseases.Methods： Patients with brucellar spondylitis, spinal tuberculosis or a spinal metastatic tumor （30 cases of each）received conventional MRI and DCE-MRI examination. The volume transfer constant （Ktrans）, rate constant （Kep）,extravascular extracellular volume fraction （Ve） and plasma volume fraction （Vp） of the diseased vertebral bodieswere measured on the perfusion parameter map, and the differences in these parameters between the patients werecompared.Results： For pathological vertebrae in cases of spinal metastatic tumor, brucellar spondylitis and spinaltuberculosis, respectively, the Ktrans values （median ＋ quartile pitch） were 0.989±0.014, 0.720±0.011 and0.317±0.005 min-1; the Kep values were 2.898±0.055, 1.327±0.017 and 0.748±0.006 min-1; the Ve values were0.339±0.008, 0.542±0.013 and 0.428±0.018; the Vp values were 0.048±0.008, 0.035±0.004 and 0.028±0.009; thecorresponding H values were 50.25 （for Ktrans）, 52.47 （for Kep）, 48.33 （for Ve） and 46.56 （for Vp）, and all differenceswere statistically significant （two-sided P〈0.05）.Conclusions： The quantitative analysis of DCE-MRI has a certain value in the differential diagnosis of spinalmetastatic tumor, brucellar spondylitis and spinal tuberculosis.

Diagnosis and treatment of spinal tuberculosis after liver transplantation

BACKGROUND: Spinal tuberculosis is a common disease in orthopedic clinical practice; however, it is seldom reported after organ transplantation. The aim of this study was to investigate the diagnosis and treatment of spinal tuberculosis after organ transplantation. METHOD: Two cases were diagnosed as spinal tuberculosis after liver transplantation and were treated with socarboxazide, rifampicin, streptomycin and ethambutol for more than one year. RESULTS: After treatment with anti-tuberculosis drugs for several months, the symptoms of both patients clearly improved. Back pain disappeared, and erythrocyte sedimentation and body temperature returned to normal. CONCLUSIONS: We should highly suspect spinal tuberculosis if notalgia and night sweats are present after organ transplantation. Anti-tuberculosis therapy is an effective treatment for spinal tuberculosis after organ transplantation.

Treatment of Thoracic Spine Tuberculosis by Paraspinal Muscle Gap Approach

Objective: To evaluate the clinical feasibility and efficacy in treatment of thoracic tuberculosis via paraspinal approach. Methods: From June 2011 to August 2016, 24 patients with mono-segmental thoracic spine tuberculosis were treated by transfacet debridement combined with bone grafting and internal fixation through paraspinal approach. There were 11 males and 13 females with age ranging from 21 to 63 years (average, 39.5). There were 3 patients in T4/5, 2 patients in T5/6, 3 patients in T7/8, 3 patients in T8/9, 4 patients in T9/10, 3 patients in T10/11, and 6 patients in T11/12. Patients had different degraded local kyphosis deformity shown on X-ray, and different degraded bone destruction and abscess in thoracic spine shown on CT and MRI before the operation. All of the patients before the regular anti tuberculosis treatment for 2 to 4 weeks, the surgical approach used by paraspinal muscle approach, postoperative regular anti tuberculosis treatment for 9 to 12 weeks. Record the clinical symptoms of patients before and after surgery, preoperative Frankel functional classification of spinal cord injury, the operative time, intraoperative blood loss, postoperative ESR, CRP, complications, VAS score, ODI score and Cobb angle changes, imaging check regularly to evaluate the fusion and follow-up of nerve functional recovery. Results: The average operation time was 198 min. The average blood loss was 436 ml. There were no severe complications during and after operation. All patients were followed up for 1 year to 2 years, average 1.5 years of follow-up, the clinical symptoms improved significantly after operation and last follow-up ESR, CRP, VAS score, ODI score and Cobb angle were significantly improved after operation (P < 0.05), grade I Eck fusion, the fusion rate was 100% and the neurological function were improved. Conclusion: on the basis of strict anti tuberculosis chemotherapy, the use of paraspinal muscle gap approach for the treatment of thoracic tuberculosis is less invasive, less destructive to spinal stability, and can achieve obvious curative effect. It is worthy of clinical application.

The Effect of Intensive Psychological Nursing on the Mood and Solutions of Spinal Tuberculosis Patients

Objective:To investigate the effect of intensive psycho1ogical nursing on the mood and coping ways of spinal tuberculosis patients.Methods:The clinical data of 102 patients undergoing spinal tuberculosis surgery in our hospital from February 2017 to January 2020 were retrospectively analyzed.A11 the cases were grouped according to different nursing plans,patients who received routine care were included in the control group(n=50),and the ones with intensive psychological care were included in the observation group(n=52).Compare negative emotions after nursing[assessment using self-assessment scale of anxiety(SAS),depression self-assessment scale(SDS)]and solutions[assessment using medical response questionnaire(MCMQ)]of the two groups.Results:After nursing,the SAs,SDs scores,avoidance and yield scores of the two groups were reduced,and the coping scores were increased,and the change of the observation group was greater than that of the control group,the difference was statistically significant(P<0.05).Conclusion:Spinal tuberculosis surgery patients were treated with intensive psychological care,which can relieve patients'negative emotions,improve solutions and are worthy of clinical use.

psk1 virulence gene-induced pulmonary and systemic tuberculosis in a young woman with normal immune function:A case report

BACKGROUND Tuberculosis is a chronic infectious disease and an important public health pro-blem.Despite progress in controlling tuberculosis,the incidence of tuberculosis in China is still very high,with 895000 new cases annually.This case report des-cribes the investigation of a case of severe disseminated tuberculosis in a young adult with normal immune function,conducted to ascertain why a Mycobacterium tuberculosis(M.tuberculosis)strain caused such severe disease.CASE SUMMARY A previously healthy 28-year-old woman presented to our hospital with a 1-mo-nth history of fever and fatigue.She was diagnosed with severe disseminated pulmonary tuberculosis,spinal tuberculosis with paravertebral abscesses,and tuberculous meningitis.M.tuberculosis was isolated from bronchoal-veolar lavage fluid.She was treated with standard antituberculous therapy and underwent debridement,bone graft,and internal fixation surgery for spinal tuberculosis.She responded to therapy and regained her ability to walk following the surgery.We analysed the whole-genome sequence of the strain and designated it BLM-A21.Additional M.tuberculosis genomes were selected from the Virulence Factor Database(http://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium)for comparison.An evolutionary tree of the BLM-A21 strain was built using PhyML maximum likelihood software.Further gene analysis revealed that,except for the pks1 gene,BLM-A21 had similar virulence genes to the CDC 1551 and H37Rv strains,which have lower dissemination.CONCLUSION We speculate that the pks1 virulence gene in BLM-A21 may be the key virulence gene responsible for the wide-spread dissemination of M.tuberculosis infection in this previously healthy adult with normal immune function.

优化T-SPOT.TB在区分脊柱结核与其他脊柱感染中的诊断效能

目的 探讨结核感染T细胞斑点试验(T-SPOT.TB)在脊柱结核(STB)鉴别诊断中的效能,并通过受试者工作特征(ROC)曲线最佳截断值优化诊断效能。方法 收集2010年1月—2019年5月某院脊柱感染患者的临床资料,包括术前T-SPOT.TB检测结果、白细胞计数、C-反应蛋白、血沉、降钙素原和结核抗体等相关数据,根据诊断标准进行临床诊断,分析T-SPOT.TB在术前诊断STB与其他脊柱感染中的灵敏度和特异度,评价优化后的T-SPOT.TB指标的诊断效能。结果 共纳入132例患者,其中78例(59.09%)为STB,54例(40.91%)为非结核脊柱感染。T-SPOT.TB在鉴别诊断STB方面的灵敏度为67.68%,特异度为66.67%。单因素logistic回归分析显示,与非结核脊柱感染比较,T-SPOT.TB检测诊断STB的OR值为4.188(95%CI:1.847~9.974,P<0.001)。优化T-SPOT.TB评价指标,通过绘制ROC曲线,确定ESAT-6、CFP-10、CFP-10+ESAT-6在STB和非结核脊柱感染鉴别诊断中的最佳截断值,分别为12.5、19.5、36,曲线下面积(AUC)分别是0.765 6、0.741 5、0.778 6,均具有较好的诊断性能,其中以CFP-10+ESAT-6的AUC最高。CFP-10+ESAT-6特异性斑点数在脊柱结核诊断中性能更佳,其诊断准确度为75.56%,较优化前T-SPOT.TB的67.42%高。结论 T-SPOT.TB检测在区分STB与非结核脊柱感染方面显示出较高的诊断效能,T-SPOT.TB检测呈阳性,尤其是当CFP-10+ESAT-6的斑点数超过36时,提示脊柱结核的可能性较大。

脊柱结核术后TLR-4、TNF-α、IL-6、IL-17的变化及与预后的相关性研究

目的分析脊柱结核术后Toll样受体(TLR)-4、肿瘤坏死因子(TNF)-α、白细胞介素(IL)-6、IL-17的变化及与预后的相关性。方法选择2021年1月—2022年12月收治的60例接受手术治疗的脊柱结核患者作为观察组,另选60例非脊柱结核且行脊柱手术的患者作为对照组(部分病例由基金项目中合作医院提供)。检测两组患者血清及病灶组织TLR-4、TNF-α、IL-6、IL-17表达水平。根据观察组患者术后6个月的预后情况,分为预后良好组和预后不良组,比较两组术前及术后6个月的血清TLR-4、TNF-α、IL-6、IL-17表达水平,使用Pearson相关性分析评价脊柱结核患者术前血清TLR-4、TNF-α、IL-6、IL-17表达水平与术后6个月改良巴氏指数(MBI)量表评分的关系,受试者工作特征(ROC)曲线分析术后血清TLR-4、TNF-α、IL-6联合IL-17对脊柱结核术后预后不良的预测效能。结果观察组术前血清及病灶组织的TLR-4、TNF-α、IL-6、IL-17表达水平均高于对照组,差异均有统计学意义(P<0.05);预后不良组术前血清TLR-4、TNF-α、IL-6、IL-17表达水平均高于预后良好组,差异均有统计学意义(P<0.05);术后6个月,预后良好组血清TLR-4、TNF-α、IL-6、IL-17表达水平较术前明显降低,与预后不良组比较,差异均有统计学意义(P<0.05);经Pearson相关性分析,脊柱结核患者术前血清TLR-4、TNF-α、IL-6、IL-17表达水平与术后6个月MBI量表评分呈负相关(P<0.05);经ROC曲线分析,术前血清TLR-4、TNF-α、IL-6联合IL-17预测脊柱结核术后预后不良的ROC曲线下面积为0.921。结论脊柱结核术后血清TLR-4、TNF-α、IL-6、IL-17较术前明显降低,与预后密切相关,术前血清TLR-4、TNF-α、IL-6联合IL-17预测预后不良的效能较好,值得临床予以重视。

Analytic Study of Spinal Infections: Clinical Picture, Treatment, and Outcomes in King Fahad Military Medical Complex in Dhahran, Saudi Arabia

Objective: To evaluate the prevalence of spinal infection in a hospital located in the eastern region of Saudi Arabia through a retrospective review and to identify the associated etiological agents in terms of clinical picture, treatment, and outcomes. Design: Retrospective cross-sectional study. Setting: Single hospital in Dhahran, Saudi Arabia. Patients: Patients with any type of spinal infection and/or who had undergone neurosurgical intervention for spinal infection between January 2006 and December 2018. Methods: We collected data on all patients with an established diagnosis of spinal infection from January 2006 to December 2018 in the King Fahad Military Medical Complex in Dhahran, Saudi Arabia. A validated and structured checklist was used for data collection. Spinal infection diagnosis was based on the clinical manifestation, microbiological evidence, radiological findings, and antimicrobial therapy response. Results: Seventeen patients were included in this study, and their mean age was 54.93 years. Twelve of the patients were male and four were female. The approximate time from symptom onset to diagnosis was 2 - 6 months. Most of the patients experienced back pain, with lumbosacral spondylitis being the most commonly cited type (61.11%), followed by thoracolumbar spondylodiscitis (25%) and cervical spondylodiscitis (6.25%). The most frequently isolated organism was Mycobacterium tuberculosis (8 patients, 50%), followed by extended-spectrum beta lactamase (ESBL)-producing Escherichia coli (4 patients, 25%), Brucella spp (3 patients, 18.75%), Staphylococcus aureus (1 patient, 6.25%), and Quambalaria cyanescens (1 patient, 6.25%). Totally, in 50% of the patients with thoracolumbar and lumbosacra site involvement, tuberculosis spondylodiscitis was observed, while another 50% of the cases showed complications associated with paravertebral abscess that required surgical drainage. Conclusion: M. tuberculosis was found to be the major cause of infectious spondylodiscitis. Additionally, Quambalaria cyanescens was isolated;this is the second reported case of the organism being isolated and the first associated with spinal infection.

宏基因组二代测序技术对结核性与非结核性脊柱感染疾病的诊断价值研究

背景结核性脊柱感染是脊柱外科比较棘手的疾病之一,其早期临床症状大多不典型,实验室检查、影像检查及组织病理学检查的特异性不高。病原学诊断是结核性脊柱感染诊断的“金标准”,但病原微生物培养存在周期长、阳性率低的缺点。宏基因组二代测序技术(metagenomic next-generation sequencing,mNGS)目前已应用到临床的诊断中,但关于mNGS与其他常见临床检测方法之间比较的研究较少。目的探讨mNGS对结核性脊柱感染疾病的诊断价值。方法收集2021年2月—2023年9月收入解放军总医院第八医学中心脊柱外科的脊柱感染患者的病历信息,提取采集血液、脓液及病灶组织标本进行血清学检测、细菌培养、结核菌培养、病理学检查、X-pert和mNGS检测的结果,以临床诊断(病理学结果)为“金标准”,比较不同检测方式的诊断价值。结果共收集112例脊柱感染患者,男性68例,女性44例,年龄14~87(58.98±13.70)岁。临床诊断结果为非结核性脊柱感染63例,脊柱结核感染49例。mNGS法检出脊柱感染阳性90例(80.4%),微生物培养法检出阳性51例(45.5%)。判断脊柱感染中的结核性感染方面,mNGS阳性检出34例(69.39%);微生物培养阳性检出仅17例(34.69%)。mNGS法检出病原微生物102例,其中细菌70例。在mNGS、微生物培养、T-spot、X-pert对脊柱结核的临床诊断效能分析结果中,mNGS效能最高(AUC=0.839),其诊断的准确度最高,甚至高于目前临床常用的方法。mNGS以及4种方法联合的诊断效能最高,ROC-AUC(95%CI)分别为0.846(0.701~0.971)和0.876(0.773~0.962),显著高于其他3种单独方法,Delong检验P<0.05。结论宏基因二代测序技术能够快速、高效地对脊柱感染性疾病的病原微生物进行检测,并且对于结核性脊柱感染疾病有着较高的检出率、敏感度和特异度。该技术是诊断与鉴别脊柱感染性疾病较好、较快的方法,可为结核性脊柱感染性疾病的诊断提供指导。

脊柱结核病灶清除植骨融合内固定术后住院时间延长的危险因素及预测模型

目的:分析脊柱结核患者行病灶清除植骨融合内固定术后住院时间(length of stay,LOS)延长的危险因素,建立预测模型并进行验证。方法:回顾性分析2016年2月~2020年12月在西安交通大学附属红会医院行病灶清除植骨融合内固定术的152例脊柱结核患者的临床资料,根据患者术后LOS是否超过整体研究队列第75%分位的术后LOS分为LOS延长组(PLOS组)和LOS正常组(NLOS组)。对两组患者的性别、年龄、高血压、糖尿病、截瘫、抗凝史、结核耐药、术前抗结核时间、输血、手术部位、手术入路、融合椎体数目、手术时间、术中出血量(intraoperative blood loss,IBL)、术后并发症、输血费用、住院费用、C反应蛋白(C-reactive protein,CRP)、血沉(erythrocyte sedimentation rate,ESR)、白蛋白(albumin,ALB)、血常规、凝血功能等进行单因素分析。根据套索(Lasso)回归,选择与脊柱结核术后LOS延长显著相关的危险因素;随后将筛选出来的危险因素纳入多因素Logistic回归分析,最终依据多因素Logistic回归分析结果建立预测模型,并通过绘制列线图对模型进行可视化,以此来预测脊柱结核术后LOS延长的风险概率。使用自举法(Bootstrap)进行模型内部验证,绘制受试者工作特征(receiver operating characteristic,ROC)曲线、校准曲线和决策曲线分析(decision curve analysis,DCA)验证该模型的区分度、准确度以及临床适用性。结果:纳入研究的152例患者中位LOS为10d,75%LOS为14d,PLOS组96例,NLOS组56例。单因素分析显示,两组患者的年龄、高血压、糖尿病、抗凝史、结核耐药、术前抗结核时间、手术部位、手术入路、手术时间、IBL、术后并发症、CRP、ESR、术前ALB、血常规、凝血功能等均无统计学差异(P>0.05),两组患者的性别、截瘫、输血、融合椎体数目、输血费用、住院费用差异有统计学差异(P<0.05)。将患者手术时间、IBL、术前Hb、术前ALB,按ROC的约登指数为分割点,手术时间临界值为198(min)、IBL临界值为1000(mL)、术前Hb临界值为118(g/L)、术前ALB临界值为38.8(g/L)。筛选出与脊柱结核术后LOS延长密切相关的危险因素为女性、输血、融合椎体数目≥3、手术时间≥198min和IBL≥1000mL、术前Hb<118g/L和术前ALB<38.8g/L。多因素Logistic回归分析显示,女性、融合椎体数目≥3、手术时间≥198min和IBL≥1000ml是脊柱结核患者术后LOS延长的危险因素(P<0.05)。构建Logistic回归的可视化列线图模型,列线图中的预测因子包括女性、融合椎体数目、手术时间和IBL。进行1000次Bootstrap自助抽样以完成模型内部验证,C指数值为0.882,ROC曲线下面积(area under curve,AUC)为0.884(95%CI:0.782~0.985)。校准曲线显示模型的表观曲线与偏差校正后的曲线拟合良好。DCA曲线显示在0.2~0.9的阈值区间具有最大临床效益。结论:女性、融合椎体数目≥3、手术时间≥198min和IBL≥1000ml是脊柱结核患者行后路病灶清除植骨融合内固定术后LOS延长的主要危险因素,基于以上危险因素所绘制的连线图可以帮助医生做出临床决策并优化围术期管理。

脊柱结核分枝杆菌感染早期椎体骨小梁微结构及骨密度变化的研究

目的观察比较脊柱结核分枝杆菌感染早期椎体骨密度的变化。方法连续收集2023年1月1日—12月31日就诊于中南大学湘雅医院脊柱外科的脊柱结核手术患者(脊柱结核组),依据性别匹配椎管狭窄就诊的非脊柱结核手术患者为对照组。对入组患者进行双能X线扫描,比较两组患者椎体骨密度的差异。构建脊柱结核分枝杆菌感染动物模型(简称动物模型),比较动物模型脊柱结核组与对照组的骨小梁微结构差异,选择骨组织/体积骨量(BV/TV)、骨小梁厚度(Tb.Th)、骨小梁数量(Tb.N)和骨小梁分离度(Tb.Sp)作为评价指标,进一步分析病椎与邻椎的骨质差异。结果脊柱结核组和对照组分别纳入69例患者,脊柱结核组患者骨密度[0.793(0.712,0.869)g/cm 2]低于对照组[0.907(0.800,1.020)g/cm 2],差异有统计学意义(P<0.05)。动物模型脊柱结核组小鼠的骨小梁微结构BV/TV[(18.4±5.4)%]、Tb.Th[(0.124±0.010)mm]较对照组BV/TV[(22.6±3.2)%]、Tb.Th[(0.160±0.017)mm]发生明显改变(均P<0.05)。动物模型脊柱结核组中,小鼠病椎骨小梁微结构BV/TV[(25.5±6.7)%]、Tb.N[(1.871±0.443)/mm]低于邻椎的BV/TV[(26.6±6.8)%]、Tb.N[(1.969±0.454)/mm],差异均有统计学意义(均P<0.05)。结论结核分枝杆菌感染椎体早期可引起骨小梁微结构发生改变,进而导致骨密度降低。

3D打印人工骨在脊柱结核骨缺损植骨中应用的研究进展

脊柱结核骨缺损是临床上常见的结核性感染性病灶,具有手术难度大、治疗周期长、并发症多等特点,快速高效促进病灶骨缺损修复的植骨材料是临床医师寻求的新材料。近年来,3D打印技术在医疗领域应用越来越广泛,在骨组织工程支架制备领域展现出了良好的发展前景。作者对3D打印载药人工骨支架修复脊柱结核骨缺损相关研究进行综述,并阐述了3D打印载药人工骨优化策略及未来发展方向。

加速康复外科理念下血液管理在腰椎结核围手术期的应用

目的:探索加速康复外科(ERAS)理念下腰椎结核围手术期的血液管理情况。方法:采用回顾性研究方法,收集2020年5月至2023年5月河北省胸科医院经规范抗结核治疗后行单纯腰椎后路手术的61例腰椎结核患者资料,根据围手术期内不同的血液管理方式将患者分为ERAS血液管理组(观察组;32例)和常规血液管理组(对照组;29例)。比较两组患者手术时间、术中输血量、术后3d引流量、术后卧床时间和围手术期总失血量,记录术后并发症、血栓及刀口愈合情况,并使用疼痛视觉模拟评分(VAS)和Oswestry功能障碍指数(ODI)评估腰部疼痛及功能恢复情况。结果:所有患者均顺利完成手术并获得随访。观察组手术时间[(127.65±25.37)min]、术中输血量[200(100,400)ml]、术后卧床时间[(5.09±1.15)d]、围手术期总出血量[833.30(678.76,897.22)ml]均明显低于对照组[(159.10±21.02)min、450(400,800)ml、(5.86±1.03)d、1086.37(793.60,1264.00)ml],差异均有统计学意义(t=5.240,P=0.000;Z=3.469,P=0.001;t=2.748,P=0.008;Z=3.134,P=0.002)。观察组和对照组患者术后共有5例发生皮疹、3例下肢血栓形成、8例因结核感染致刀口丙级愈合,发生率分别为9.38%(3/32)和6.89%(2/29)、6.25%(2/32)和3.45%(1/29)、15.63%(5/32)和10.34%(3/29),术后6个月的ODI评分分别为(7.38±1.07)%和(7.41±1.02)%,VAS评分分别为(2.81±0.74)分和(2.97±0.68)分,差异均无统计学意义(χ^(2)=0.124,P=1.000;χ^(2)=0.255,P=1.000;χ^(2)=-0.593,P=0.553;t=0.145,P=0.885;t=0.843,P=0.403)。结论:ERAS指导下围手术期血液管理可明显降低手术时间、术后卧床时间和围手术期总失血量,有利于手术的顺利实施,降低手术失血风险,使患者尽快康复,有一定临床积极意义;但术后并发症、血栓形成、刀口愈合,以及腰部疼痛和功能恢复与常规血液管理方式并无差异,说明两种方式的术后并发症和远期疗效一致,安全性相同。

腰骶椎结核单纯后路手术联合局部置管早期持续化疗的临床疗效

目的 探讨单纯后路病灶清除植骨融合内固定联合局部置管早期持续病灶内化疗治疗腰骶椎结核的临床疗效。方法 回顾性分析2014年1月至2018年1月西安交通大学附属红会医院收治的32例腰骶椎结核患者的临床资料,患者均采用单纯后路病灶清除植骨融合内固定联合局部置管早期持续化疗(即术中局部置管、术后1个月内经导管向病灶内持续注入异烟肼)。所有患者腰、骶椎结核均以单节段椎体及椎间隙破坏为主;22例存在椎旁或椎管内少量脓肿,但脓肿范围局限在病变节段范围内,未发生远处流注及两侧腰大肌侵袭。记录手术时间、术中出血量、卧床时间、围手术期并发症、导管注入抗结核药物情况及药物不良反应,评估手术前后疼痛视觉模拟量表(VAS)评分和美国脊柱损伤协会(ASIA)分级,通过腰椎正侧位X线片或三维CT评估植骨融合情况,监测红细胞沉降率(ESR)、C-反应蛋白(CRP)变化。结果 手术时间(116.2±15.4)min,术中出血量(320.2±103.4)m L,卧床时间(4.7±1.2)d;无大血管或神经损伤、硬脊膜破裂病例,伤口均一期愈合,无深部感染发生。随访时间12~24个月(平均15个月)。患者术后4~10个月均获骨性融合;术后3个月ESR、CRP均恢复正常,末次随访VAS评分和后凸Cobb角较术前明显改善(P <0.05)。22例术前存在神经损伤的患者末次随访时均有不同程度恢复;末次随访未见结核复发,随访期间无结核药物严重不良反应发生。结论 对以椎体及椎间隙破坏为主、椎旁或椎管内脓肿范围局限、伴节段不稳及神经损伤的单节段腰骶椎结核,予以单纯后路手术联合局部置管早期持续病灶内化疗可获得满意疗效。

后路病灶清除植骨融合内固定手术治疗跳跃性脊柱结核的疗效分析

目的:总结跳跃性脊柱结核的临床特点,探讨一期后路病灶清除植骨融合内固定手术治疗跳跃性脊柱结核的疗效。方法:回顾性分析2016年7月~2022年5月我院手术治疗的31例跳跃性脊柱结核患者的临床资料,其中患者男18例,女13例,年龄49.5±27.5岁。其中2处病灶24例,3处病灶7例。对每例患者明确责任椎,确定手术病灶、融合节段、内固定方式,以制定个体化手术方案,随访29.7±14.7个月(15~85个月)。记录患者手术时间、术中出血量,并记录术中及术后并发症情况;术前和术后1个月、3个月、1年及末次随访的红细胞沉降(ESR)和C-反应蛋白(CRP);术前及术后1周、1个月、3个月、1年及末次随访的疼痛视觉模拟评分(VAS);术前及术后1周、末次随访时病灶后凸Cobb角;记录术前及末次随访时美国脊髓损伤协会(ASIA)分级;末次随访时采用Bridwell骨愈合标准分级以评估术后结核活动性、症状改善、畸形矫正及骨愈合。结果:31例患者中20例(65.4%)只有1处病灶出现临床症状,23例(74.2%)以疼痛为主诉入院,15例(48.4%)在病程中只有疼痛症状,而11例(35.5%)只有1处病灶出现疼痛症状,18例(58.1%)患者初诊时至少有1处病灶漏诊。所有患者手术顺利,手术时间280.0±52.2min(165~330min),失血量567.7±332.0mL(150~1000mL)。术后出现脑脊液漏4例,切口感染3例,经对症处理后痊愈;所有结核病灶均治愈,未出现复发。术前及术后1个月、3个月、1年、末次随访时ESR为41.5±26.3mm/h、16.3±13.4mm/h、12.5±6.3mm/h、11.4±5.2mm/h、9.2±3.1mm/h;CRP为32.8±23.2mg/L、7.3±5.6mg/L、6.2±4.1mg/L、5.1±3.7mg/L、2.8±2.3mg/L;术前及术后1周、1个月、3个月、1年、末次随访时VAS评分为6.4±2.4分、2.4±1.7分、2.3±1.3分、1.6±0.9分、0.9±0.7分、0.4±0.3分。术后各个时间点CRP、ESR、VAS评分较术前均有显著改善(P<0.05)。术前Cobb角25.7°±4.9°,术后1周15.4°±2.1°,末次随访时17.1°±2.3°,术后均较术前有统计学差异(P<0.05);10例存在术前神经功能损伤患者,末次随访时1例术前A级患者恢复至C级;4例术前B级患者1例恢复至C级,3例恢复至D级;5例术前C级患者2例恢复至D级,3例恢复至E级;术后6~12个月42处植骨病灶均获得骨融合,末次随访时34处病灶BridwellⅠ级愈合,8处病灶BridwellⅡ级融合。结论:对跳跃性脊柱结核患者,明确责任椎及各处病灶病变特点,一期后路病灶清除植骨融合内固定手术治疗安全且高效,能得到满意的疗效。

miR⁃146a通过TGF⁃β1/SMAD通路调控脊柱结核进展的分子机制

目的探讨miR⁃146a/转化生长因子-β(transforming growth factor⁃β1,TGF⁃β1)/母亲抗肢瘫(small mother against decapentaplegic,SMAD)通路在脊柱结核进展中的调控机制。方法收集脊柱结核病人和正常病人髓核组织,验证miR⁃146a/TGF⁃β1/SMAD通路在结核髓核组织中的表达量;分离培养髓核细胞,敲低/过表达miR⁃146a,分别应用qPCR、Western blot、CCK⁃8、划痕实验验证miR⁃146a对TGF⁃β1/SMAD通路表达及髓核细胞增殖、迁移能力的影响。结果与正常病人比较,脊柱结核病人髓核细胞增殖及迁移能力显著减低,miR⁃146a在脊柱结核病人髓核组织中表达量显著减低,而脊柱结核病人髓核组织中SMAD同系物2(SMAD2)、SMAD同系物3(SMAD3)、SMAD同系物4(SMAD4)、TGF⁃β1基因表达增高,SMAD同系物7(SMAD7)表达减低,提示miR⁃146a与TGF⁃β1/SMAD通路活性显著负相关。过表达miR⁃146a可抑制SMAD2、SMAD3、SMAD4、TGF⁃β1和促进SMAD7表达,而敲低miR⁃146a可促进SMAD2、SMAD3、SMAD4、TGF⁃β1 mRNA和抑制SMAD7表达水平。细胞实验进一步证实过表达miR⁃146a可促进脊柱结核病人髓核细胞增殖和迁移能力,而敲低miR⁃146a可显著抑制其增殖和迁移能力。结论miR⁃146a是脊柱结核进展的关键调控因子,其可通过抑制TGF⁃β1/SMAD通路活性进而调控髓核细胞增殖及迁移活性。