手术治疗腰骶椎结核的术式选择
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摘要
目的:回顾性分析一期后路病灶清除内固定椎体间植骨融合术与一期后路内固定联合前路病灶清除、椎体间植骨融合术治疗成人腰骶椎(L5-S1)结核的临床疗效。方法:2010年1月~2014年11月,我院采用手术治疗腰骶椎结核患者21例,男11例,女10例;年龄17~62岁(38.9±14.3岁);病程10~21个月(16.1±2.7个月)。术前抗结核药物治疗2~4周。8例以椎体破坏为主,无脓肿形成/较小椎旁脓肿或椎管内脓肿;前方存在较高血管损伤风险的患者采用一期后路固定病灶清除椎体间植骨融合术(单纯后路手术组)。13例血管分叉高,具有足够的手术操作空间;有流注脓肿形成;前中柱广泛破坏,后方病灶清除困难者采用一期后路固定联合前路病灶清除、椎体间植骨融合术(后前路联合手术组)。术后均继续抗结核药物治疗12~18个月。记录两组患者手术时间、术中失血量、卧床时间、手术前后疼痛视觉模拟评分(visual analogue scale,VAS)及神经功能改善情况,腰椎正侧位X线片或三维CT评估植骨融合情况,监测血沉、C-反应蛋白评价结核控制情况。结果:单纯后路组手术时间161.2±15.6min,失血量695.2±153.2ml,卧床时间8.5±2.5d;后前路联合入路组手术时间233.6±22.7min,失血量862.0±208.5ml,卧床时间16.9±2.0d。两组患者末次随访时VAS评分、血沉、C-反应蛋白较术前明显改善,差异具有统计学意义(P<0.05)。单纯后路组术后窦道形成2例;后前路联合手术组患者前路手术术中髂血管损伤1例,男性患者术后出现逆行性射精1例。末次随访时两组患者均获得骨性融合,未出现内固定失败。结论:单纯后路手术治疗以椎体破坏为主,无脓肿形成或较小椎旁脓肿或椎管内脓肿的腰骶椎结核可以获得满意的疗效;伴有较大骶骨前脓肿、病灶位于前柱的患者应采用后前联合入路手术,且需要髂血管分叉高,具有足够的手术操作空间。
Objectives:To analyze the clinical efficacy and indication of the two surgical approach choices in adult lumbosacral tuberculosis:simple posterior approach(P-approach) for debridement,fusion and instru-mentation,one-stage combined posterior instrumentation and anterior debridement and fusion(PA-approach).Methods:Twenty-one patients with lumbosacral tuberculosis underwent operation in our hospital from January2010 to November 2014,11 males and 10 females,with a mean age of 38.9 ±14.3 years old(17-62 years old). The course of disease was 10-21 months,with an average of 16.1 ±2.7 months. Eight cases underwent P-approach operation including the patients with bone destruction but without abscess formation,spinal canal abscess formation or lower iliaca vessels bifurcation. Thirteen cases underwent PA-approach surgery including the patients with gravitation abscess formation,extensive bone destruction or high iliaca vessels bifurcation.All the patients were treated by antituberculous chemotherapy and nutrition support for 2-4 weeks preopera-tively and 12-18 months postoperatively. The operation duration,bleeding volume,rest time on bed,visual analogue scale(VAS) score,nerve function recovery,clinical status and complications were recorded in all the patients. Bone graft fusion was assessed by X-ray or three-dimensional CT. The control of tuberculosis was assessed by erythrocyte sedimentation rate(ESR) and C-reactive protein(CRP). Results:The average duration was 161.2±15.6min,intraoperative bleeding volume was 695.2±153.2ml,and rest time on bed was 8.5±2.5d in P-approach group,and those were 233.6±22.7min,862.0±208.5ml and 16.9±2.0d respectively in PA-approach group. Compared with preoperative values,the VAS score,ESR and CRP of patients in two groups were statistically significantly improved at the final follow-up. Sinus tract formed in 2 cases who underwent P-approach surgery and cured after dressing change and anti-tuberculosis treatment with no revision surgery.Among patients undergoing PA-approach surgery,rupture of iliac vessels occured in 1 case and cured after vascular surgical repair. Retrograde ejaculation was observed in 1 male patient. On the final follow-up visit,all the patients in two groups achieved bone graft fusion with no failure of internal fixation. Conclusions:Simple posterior debridement,fusion and instrumentation work effectively in patients with bone destruction but without abscess formation,spinal canal abscess formation or lower iliaca vessels bifurcation. One-stage combined posterior instrumentation and anterior debridement and fusion is recommended for patients with gravitation abscess formation,extensive bone destruction or high iliaca vessels bifurcation.
Objectives:To analyze the clinical efficacy and indication of the two surgical approach choices in adult lumbosacral tuberculosis:simple posterior approach(P-approach) for debridement,fusion and instru-mentation,one-stage combined posterior instrumentation and anterior debridement and fusion(PA-approach).Methods:Twenty-one patients with lumbosacral tuberculosis underwent operation in our hospital from January2010 to November 2014,11 males and 10 females,with a mean age of 38.9 ±14.3 years old(17-62 years old). The course of disease was 10-21 months,with an average of 16.1 ±2.7 months. Eight cases underwent P-approach operation including the patients with bone destruction but without abscess formation,spinal canal abscess formation or lower iliaca vessels bifurcation. Thirteen cases underwent PA-approach surgery including the patients with gravitation abscess formation,extensive bone destruction or high iliaca vessels bifurcation.All the patients were treated by antituberculous chemotherapy and nutrition support for 2-4 weeks preopera-tively and 12-18 months postoperatively. The operation duration,bleeding volume,rest time on bed,visual analogue scale(VAS) score,nerve function recovery,clinical status and complications were recorded in all the patients. Bone graft fusion was assessed by X-ray or three-dimensional CT. The control of tuberculosis was assessed by erythrocyte sedimentation rate(ESR) and C-reactive protein(CRP). Results:The average duration was 161.2±15.6min,intraoperative bleeding volume was 695.2±153.2ml,and rest time on bed was 8.5±2.5d in P-approach group,and those were 233.6±22.7min,862.0±208.5ml and 16.9±2.0d respectively in PA-approach group. Compared with preoperative values,the VAS score,ESR and CRP of patients in two groups were statistically significantly improved at the final follow-up. Sinus tract formed in 2 cases who underwent P-approach surgery and cured after dressing change and anti-tuberculosis treatment with no revision surgery.Among patients undergoing PA-approach surgery,rupture of iliac vessels occured in 1 case and cured after vascular surgical repair. Retrograde ejaculation was observed in 1 male patient. On the final follow-up visit,all the patients in two groups achieved bone graft fusion with no failure of internal fixation. Conclusions:Simple posterior debridement,fusion and instrumentation work effectively in patients with bone destruction but without abscess formation,spinal canal abscess formation or lower iliaca vessels bifurcation. One-stage combined posterior instrumentation and anterior debridement and fusion is recommended for patients with gravitation abscess formation,extensive bone destruction or high iliaca vessels bifurcation.
引文
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13.高延征,余正红,高坤,等.腰骶结核不同手术方式的选择及疗效分析[J].中华骨科杂志,2014,34(2):143-148.
14.张泽华,陈非凡,李建华.不同类型腰骶椎结核手术治疗方式的有效性和安全性研究[J].中华骨科杂志,2016,36(11):662-671.
15.王自立,施建党.胸、腰椎脊柱结核手术方式选择的基本问题[J].中华骨科杂志,2014,34(2):232-239.
16.崔旭,马远征,陈兴.脊柱结核前后路不同术式的选择及其疗效[J].中国脊柱脊髓杂志,2011,21(10):807-812.
17.Inamasu.J,Kim.DH,Logan.L.Three-dimensional.computed.tomographic.anatomy.of.the.abdominal.great.vessels.pertinent.to.L4-L5.anterior.lumbar.interbody.fusion[J].Minim.Invasive.Neurosurg,2005,48(3):127-31.
18.周忠杰,李涛,宋跃明.旁正中腹膜后入路病灶清除植骨融合内固定治疗腰5骶1结核[J].中华骨科杂志,2016,36(11):691-698.
19.张宏其,郭强,郭超峰.单纯后路、单纯前路或前后联合入路治疗成人腰椎结核的中期疗效比较[J].中华骨科杂志,2016,36(11):651-661.
20.郝定均,郭华,许正伟.腰骶段脊柱结核的手术治疗[J].中国脊柱脊髓杂志,2010,20(10):806-810.
2.Moon.MS,Moon.JL,Moon.YW,et.al.Pott′s.paraplegia.in.patients.with.severely.deformed.dorsal.or.dorsolumbar.spines:treatment.and.prognosis[J].Spinal.Cord,2003,4l(3):164-171.
3.郭海龙,刘毅,盛伟斌,等.后路病灶清除内固定治疗腰骶段结核[J].中华骨科杂志,2011,31(8):840-845.
4.王自立.进一步规范脊柱结核的治疗[J].中国脊柱脊髓杂志,2010,20(10):793-794.
5.Wood.KB,Devine.J,Fischer.D,et.al.Vascular.injury.in.elective.anterior.lumbosacral.surgery[J].Spine(Phila.Pa.1976),2010,35(9.Suppl):S66-S75.
6.Kleeman.TJ,Michael.Ahn.U,Clutterbuck.WB,et.al.Laparoscopic.anterior.lumbar.interbody.fusion.at.L4-L5:an.anatomic.evaluation.and.approach.classification[J].Spine(Phila.Pa1976),2002,27(13):1390-1395.
7.王自立.对彻底治愈脊柱结核病灶及其相关问题的管见[J].中国脊柱脊髓杂志,2008,18(8):568-870.
8.王自立.脊柱结核的病灶清除与融合固定问题[J].中国脊柱脊髓杂志,2006,16(12):888-889.
9.Moon.MS.Tuberculosis.of.spine:current.views.in.diagnosis.and.management[J].Asian.Spine.J,2014,8(1):97-111.
10.Soares.do.Brito.J,Batista.N,Tirado.A,et.al.Surgical.treatment.of.spinal.tuberculosis:an.orthopedic.service.experience[J].Acta.Med.Port,2013,26(4):349-356.
11.Issack.PS,Boachie-Adjei.O.Surgical.correction.of.kyphotic.deformity.in.spinal.tuberculosis[J].Int.Orthop,2012,36(2):353-357.
12.Jin.W,Wang.Z.Clinical.evaluation.of.the.stability.of.single-segment.short.pedicle.screw.fixation.for.the.reconstruction.of.lumbar.and.sacral.tuberculosis.lesions[J].Arch.Orthop.Trauma.Surg,2012,132(10):1429-1435.
13.高延征,余正红,高坤,等.腰骶结核不同手术方式的选择及疗效分析[J].中华骨科杂志,2014,34(2):143-148.
14.张泽华,陈非凡,李建华.不同类型腰骶椎结核手术治疗方式的有效性和安全性研究[J].中华骨科杂志,2016,36(11):662-671.
15.王自立,施建党.胸、腰椎脊柱结核手术方式选择的基本问题[J].中华骨科杂志,2014,34(2):232-239.
16.崔旭,马远征,陈兴.脊柱结核前后路不同术式的选择及其疗效[J].中国脊柱脊髓杂志,2011,21(10):807-812.
17.Inamasu.J,Kim.DH,Logan.L.Three-dimensional.computed.tomographic.anatomy.of.the.abdominal.great.vessels.pertinent.to.L4-L5.anterior.lumbar.interbody.fusion[J].Minim.Invasive.Neurosurg,2005,48(3):127-31.
18.周忠杰,李涛,宋跃明.旁正中腹膜后入路病灶清除植骨融合内固定治疗腰5骶1结核[J].中华骨科杂志,2016,36(11):691-698.
19.张宏其,郭强,郭超峰.单纯后路、单纯前路或前后联合入路治疗成人腰椎结核的中期疗效比较[J].中华骨科杂志,2016,36(11):651-661.
20.郝定均,郭华,许正伟.腰骶段脊柱结核的手术治疗[J].中国脊柱脊髓杂志,2010,20(10):806-810.