原发性化脓性胸腰椎感染术中重建脊柱稳定性方式的选择
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摘要
目的探讨原发性化脓性胸腰椎感染手术治疗中内固定重建脊柱稳定性方式的选择及疗效评价。方法回顾性分析2011年1月至2017年1月陆军特色医学中心脊柱外科收治的46例化脓性胸腰椎感染且经后路脊柱病灶清除、内固定重建脊柱稳定性手术患者的临床资料。所有患者先给予卧床、营养支持和抗生素治疗,效果不佳或症状加重采用手术方式清除病灶,其中单纯椎管内脓肿者11例,椎体及椎间盘感染者35例。对单纯椎管内脓肿,术中保留棘上韧带及两侧关节突关节,超声骨刀切除内侧椎板及棘突根部,清除脓肿后采用棘突椎板回植、微型钛板固定术,其余累及椎体及椎间盘者采用彻底的病灶清除、椎管减压、椎弓根螺钉内固定术。结果手术时间105～190 min,平均155 min。失血量55～620 m L,平均280 m L。术后随访12～18个月,1例患者术后切口延迟愈合,1例患者术后3年再次出现手术部位脓肿形成,其余病例术后未出现内固定物松动、切口感染,无医源性脊髓及神经根损伤,未见回植组织移位、塌陷及继发椎管狭窄。术后X射线片显示棘突椎板回植术后脊柱完整性基本得以保留,椎弓根螺钉内固定术后脊柱可获得牢固的稳定。术后Oswestry功能障碍指数评分明显下降,与术前相比差异有统计学意义(P <0. 05)。结论及时有效的抗生素应用是治疗化脓性脊柱炎的基础,对于严重的化脓性感染且全身情况不佳时,是否在病灶清除术后一期植入内固定仍需谨慎选择,当出现脊柱结构破坏、畸形、病变范围扩大及神经功能障碍等情况时应积极手术治疗,内固定的方式要考虑化脓位置及椎间关节稳定性,以保留其灵活性完整性或重建其稳定性。
Objective To explore the surgical treatment strategies and the evaluation of spine reconstruction during the treatment of primary suppurative thoracolumbar infection. Methods Retrospectively analyzed the clinical data of 46 patients who were treated surgically from January 2011 to January 2017 in spinal surgery of army specialty medical center. All patients were treated with bed rest,nutritional support and antibiotics,and the lesions were removed surgically if the effect was not good or the symptoms were aggravated. There were 11 cases of simple intraspinal abscess and 35 cases of vertebral body and intervertebral disc infection. For patients of simple intraspinal abscess,the superior spinous ligament and bilateral facet joints were retained,and the medial vertebral plate and spinous process root were removed by ultrasonic osteotomyduring the surgery. After the abscess was removed,spinous process lamina replantation and mini-plate fixation were performed. For patients of vertebral body and intervertebral disc infection,thorough focus removal,spinal decompression and pedicle screw fixation were performed. Results The operation time was 105 to 190 minutes,with an average of 155 minutes. The amount of blood loss was 55 to 620 m L,with an average of 280 m L.All of the patients were followed up for 12 to 18 months,during which no loosening of internal fixation,incision infection,iatrogenic spinal cord and nerve root injury,replantation tissue displacement,collapse and secondary spinal canal stenosis were found,except for one case of delayed wound healing and one case of postoperative abscess formation 3 years after surgery. The postoperative X-ray showed that the spinal integrity was largely preserved after spinous process lamina replantation,and the spinal stability was stable after pedicle screw fixation. Oswestry disability index score decreased significantly after surgery and the difference was statistically significant compared with that before surgery( P < 0. 05). Conclusion Timely and effective antibiotic application is the basis for the treatment of suppurative spondylitis. For severe suppurative infections and poor general condition,whether the first stage of internal fixation after the removal of the lesion should be carefully selected,when the spine structure is destroyed,abnormalities,extensive lesions,and neurological dysfunction should be treated aggressively. The internal fixation should consider the location of the suppuration and the stability of the intervertebral joints to preserve their flexibility or to rebuild their stability.
Objective To explore the surgical treatment strategies and the evaluation of spine reconstruction during the treatment of primary suppurative thoracolumbar infection. Methods Retrospectively analyzed the clinical data of 46 patients who were treated surgically from January 2011 to January 2017 in spinal surgery of army specialty medical center. All patients were treated with bed rest,nutritional support and antibiotics,and the lesions were removed surgically if the effect was not good or the symptoms were aggravated. There were 11 cases of simple intraspinal abscess and 35 cases of vertebral body and intervertebral disc infection. For patients of simple intraspinal abscess,the superior spinous ligament and bilateral facet joints were retained,and the medial vertebral plate and spinous process root were removed by ultrasonic osteotomyduring the surgery. After the abscess was removed,spinous process lamina replantation and mini-plate fixation were performed. For patients of vertebral body and intervertebral disc infection,thorough focus removal,spinal decompression and pedicle screw fixation were performed. Results The operation time was 105 to 190 minutes,with an average of 155 minutes. The amount of blood loss was 55 to 620 m L,with an average of 280 m L.All of the patients were followed up for 12 to 18 months,during which no loosening of internal fixation,incision infection,iatrogenic spinal cord and nerve root injury,replantation tissue displacement,collapse and secondary spinal canal stenosis were found,except for one case of delayed wound healing and one case of postoperative abscess formation 3 years after surgery. The postoperative X-ray showed that the spinal integrity was largely preserved after spinous process lamina replantation,and the spinal stability was stable after pedicle screw fixation. Oswestry disability index score decreased significantly after surgery and the difference was statistically significant compared with that before surgery( P < 0. 05). Conclusion Timely and effective antibiotic application is the basis for the treatment of suppurative spondylitis. For severe suppurative infections and poor general condition,whether the first stage of internal fixation after the removal of the lesion should be carefully selected,when the spine structure is destroyed,abnormalities,extensive lesions,and neurological dysfunction should be treated aggressively. The internal fixation should consider the location of the suppuration and the stability of the intervertebral joints to preserve their flexibility or to rebuild their stability.
引文
[1]胡波,王颖博,宋前明,等.原发性化脓性脊柱炎的临床表现及治疗方式选择[J].实用骨科杂志,2018,24(3):253-255.doi:10.13795/j.cnki.sgkz.2018.03.015.
[2]Rutges JP,Kempen DH,van Dijk M,et al.Outcome of conservative and surgical treatment of pyogenic spondylodiscitis:a systematic literature review[J].Eur Spine J,2016,25(4):983-999.doi:10.1007/s00586-015-4318-y.
[3]Shiban E,Janssen I,da Cunha PR,et al.Safety and efficacyof polyetheretherketone(PEEK)cages in combination withposterior pedicel screw fixation in pyogenic spinal infection[J].Acta Neurochir(Wien),2016,158(10):1851-1857.doi:10.1007/s00701-016-2924-z.
[4]朱小龙,徐卫星,刘杰.椎间隙感染的诊断与治疗进展[J].中国骨伤,2016,29(9):870-874.doi:10.3969/j.issn.1003-0034.2016.09.020.
[5]Crock HV.Goldwasser M.Anatomic studies of the circulationin the region of the vertebral end-plate in adult Greyhounddogs[J].Spine(Phila Pa 1976),1984,9(7):702-706.
[6]葛云林,卢一生,符楚迪,等.病灶清除联合骨钛板内固定治疗脊柱化脓性感染的疗效分析[J].中华医院感染学杂志,2015,25(24):5669-5671.doi:10.11816/cn.ni.2015-151670.
[7]Zarghooni K,Rollinghoff M,Sobottke R,et al.Treatment of spondylodiscitis[J].Int Orthop,2012,36(2):405-411.doi:10.1007/s00264-011-1425-1.
[8]Walters R,Verong-Roberts B,Ffaser R,et al.Therapeutic use of cephazolin to prebent complications of spine surgery[J].Inflammophamacology,2006,14(3/4):138-143.doi:10.1007/s10787-006-1503-y.
[9]董彦,刘英杰,刘尚礼,等.原发性化脓性椎间隙感染发病机理及治疗方法的探讨[J].中国矫形外科杂志,2004,12(13):983-984.
[10]Lehovsky J.Pyogenic vertebral osteom yelitis/disc infection[J].Baillieres Best Pract Res Clin Rheumatol,1999,13(1):59-75.doi:10.1053/berh.1999.0006.
[11]Denis F.Spinal instability as defined by the three-colume spine concept in acute spinal trauma[J].Clin Orthop,1984(189):65-76.
[12]Mc Girt MJ,Ambrossi GL,Parker SL,et al.Short-term progressive spinal deformity following laminoplasty versus laminectomy for resection of intradural spinal tumors:analysis of 238 patients[J].Neurosurgery,2010,66(5):1005-1012.doi:10.1227/01.NEU.0000367721.73220.C9.
[13]Wiedemayer H,Sandalcioglu IE,Aalders M,et al.Reconstruction of the laminar roof with miniplates for a posterior approach in intraspinal surgery:technical considerations and critical evaluation of follow-up results[J].Spine,2004,29(16):E333-E442.
[14]Katsikogianni M,Missirlis YF.Concise review of mechanisms of bacterial adhesion to biomaterials and of techniques used in estimating bacteria-material interactions[J].Eur Cell Mater,2004,8:37-57.doi:10.22203/e CM.v008a05.
[15]李晶,吕国华,康意军,等.术后重症腰椎间盘炎治疗方法的比较[J].中华骨科杂志,2002,22(2):69-71.doi:10.3760/j.issn:0253-2352.2002.02.002.
[16]Lim JK,Kim SM,Jo DJ,et al.Anterior interbody grafting and instrumentation for advanced spondylodiscitis[J].J Korean Neurosurg Soc,2008,43(1):5-10.doi:10.3340/jkns.2008.43.1.5.
[17]Lee JS,Suh KT.Posterior lumbar interbody fusion with an autogenous iliac crest bone graft in the treatmentof pyogenic spondy lodiscitis[J].J Bone Joint Surg(Br),2006,88(6):765-770.doi:10.1302/0301-620X.88B6.17270.
[18]杨小春,常龙,尚雁冰,等.后路病灶清除、植骨融合治疗非特异性腰椎椎间隙感染[J].中华骨科杂志,2017,37(18):1136-1142.
[19]魏景超,李文毅,高尚聚,等.椎间孔镜下病灶清除联合臭氧消融治疗原发性腰椎间隙感染[J].颈腰痛杂志,2017,38(3):227-230.doi:10.3969/j.issn.1005-7234.2017.03.004.
[2]Rutges JP,Kempen DH,van Dijk M,et al.Outcome of conservative and surgical treatment of pyogenic spondylodiscitis:a systematic literature review[J].Eur Spine J,2016,25(4):983-999.doi:10.1007/s00586-015-4318-y.
[3]Shiban E,Janssen I,da Cunha PR,et al.Safety and efficacyof polyetheretherketone(PEEK)cages in combination withposterior pedicel screw fixation in pyogenic spinal infection[J].Acta Neurochir(Wien),2016,158(10):1851-1857.doi:10.1007/s00701-016-2924-z.
[4]朱小龙,徐卫星,刘杰.椎间隙感染的诊断与治疗进展[J].中国骨伤,2016,29(9):870-874.doi:10.3969/j.issn.1003-0034.2016.09.020.
[5]Crock HV.Goldwasser M.Anatomic studies of the circulationin the region of the vertebral end-plate in adult Greyhounddogs[J].Spine(Phila Pa 1976),1984,9(7):702-706.
[6]葛云林,卢一生,符楚迪,等.病灶清除联合骨钛板内固定治疗脊柱化脓性感染的疗效分析[J].中华医院感染学杂志,2015,25(24):5669-5671.doi:10.11816/cn.ni.2015-151670.
[7]Zarghooni K,Rollinghoff M,Sobottke R,et al.Treatment of spondylodiscitis[J].Int Orthop,2012,36(2):405-411.doi:10.1007/s00264-011-1425-1.
[8]Walters R,Verong-Roberts B,Ffaser R,et al.Therapeutic use of cephazolin to prebent complications of spine surgery[J].Inflammophamacology,2006,14(3/4):138-143.doi:10.1007/s10787-006-1503-y.
[9]董彦,刘英杰,刘尚礼,等.原发性化脓性椎间隙感染发病机理及治疗方法的探讨[J].中国矫形外科杂志,2004,12(13):983-984.
[10]Lehovsky J.Pyogenic vertebral osteom yelitis/disc infection[J].Baillieres Best Pract Res Clin Rheumatol,1999,13(1):59-75.doi:10.1053/berh.1999.0006.
[11]Denis F.Spinal instability as defined by the three-colume spine concept in acute spinal trauma[J].Clin Orthop,1984(189):65-76.
[12]Mc Girt MJ,Ambrossi GL,Parker SL,et al.Short-term progressive spinal deformity following laminoplasty versus laminectomy for resection of intradural spinal tumors:analysis of 238 patients[J].Neurosurgery,2010,66(5):1005-1012.doi:10.1227/01.NEU.0000367721.73220.C9.
[13]Wiedemayer H,Sandalcioglu IE,Aalders M,et al.Reconstruction of the laminar roof with miniplates for a posterior approach in intraspinal surgery:technical considerations and critical evaluation of follow-up results[J].Spine,2004,29(16):E333-E442.
[14]Katsikogianni M,Missirlis YF.Concise review of mechanisms of bacterial adhesion to biomaterials and of techniques used in estimating bacteria-material interactions[J].Eur Cell Mater,2004,8:37-57.doi:10.22203/e CM.v008a05.
[15]李晶,吕国华,康意军,等.术后重症腰椎间盘炎治疗方法的比较[J].中华骨科杂志,2002,22(2):69-71.doi:10.3760/j.issn:0253-2352.2002.02.002.
[16]Lim JK,Kim SM,Jo DJ,et al.Anterior interbody grafting and instrumentation for advanced spondylodiscitis[J].J Korean Neurosurg Soc,2008,43(1):5-10.doi:10.3340/jkns.2008.43.1.5.
[17]Lee JS,Suh KT.Posterior lumbar interbody fusion with an autogenous iliac crest bone graft in the treatmentof pyogenic spondy lodiscitis[J].J Bone Joint Surg(Br),2006,88(6):765-770.doi:10.1302/0301-620X.88B6.17270.
[18]杨小春,常龙,尚雁冰,等.后路病灶清除、植骨融合治疗非特异性腰椎椎间隙感染[J].中华骨科杂志,2017,37(18):1136-1142.
[19]魏景超,李文毅,高尚聚,等.椎间孔镜下病灶清除联合臭氧消融治疗原发性腰椎间隙感染[J].颈腰痛杂志,2017,38(3):227-230.doi:10.3969/j.issn.1005-7234.2017.03.004.