后路病灶清除植骨内固定联合不同入路腰大肌脓肿清除局部化疗治疗胸腰椎结核
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摘要
目的比较前、后路腰大肌脓肿清除及脓腔内局部化疗联合后路病灶清除植骨内固定治疗胸腰椎结核的临床疗效,探讨后路腰大肌脓肿清除的可行性。方法回顾分析2012年6月—2015年12月治疗的37例胸腰椎结核伴腰大肌脓肿患者临床资料。所有患者行后路病灶清除、植骨内固定术,根据腰大肌脓肿清除的手术入路不同分为A组(21例,行后路脓肿清除及脓腔内局部化疗)和B组(16例,行前路脓肿清除及脓腔内局部化疗)。两组患者性别、年龄、病程、病变节段、术前红细胞沉降率、术前C反应蛋白、腰大肌脓肿侧别、腰大肌脓肿最大横径及纵径、伴随脓肿、脓腔分隔情况、术前病变节段Cobb角、术前美国脊髓损伤协会(ASIA)分级等一般资料比较差异均无统计学意义(P>0.05),具有可比性。记录并比较两组患者手术时间、术中出血量、术后住院时间、脓肿吸收时间及骨融合时间;观察患者术前及末次随访时的病变节段Cobb角变化情况;采用ASIA分级评价脊髓神经功能。结果除B组手术时间显著长于A组(t=–2.985,P=0.005)外,两组间术中出血量、术后住院时间、脓肿吸收时间及骨融合时间比较,差异均无统计学意义(P>0.05)。两组患者均获随访,随访时间18～47个月,平均31.1个月。术中及术后均无脑脊液漏发生。A组4例二次行前方脓肿清除置管化疗。末次随访时所有患者脓肿均吸收,红细胞沉降率及C反应蛋白均正常。两组患者末次随访时病变节段Cobb角均较术前显著改善(P<0.05),末次随访时两组间病变节段Cobb角以及矫正度比较,差异无统计学意义(P>0.05)。术前9例伴脊髓神经功能损害者中,末次随访时神经功能均改善,与术前比较差异有统计学意义(Z=–2.716,P=0.007)。结论治疗胸腰椎结核伴腰大肌脓肿,单纯后路病灶清除、植骨内固定联合脓肿清除及脓腔内局部化疗可取得良好疗效,但特殊情况下仍需行前路脓肿清除。
Objective To compare the effectiveness of posterior and anterior psoas abscess debridement and local chemotherapy in abscess cavity combined with focus debridement, bone grafting, and fixation via posterior approach in treatment of thoracolumbar spinal tuberculosis, and explore the feasibility of psoas abscess debridement via posterior approach. Methods Between June 2012 and December 2015, the clinical data of 37 patients with thoracolumbar spine tuberculosis and psoas abscess were retrospectively analyzed. All the patients underwent posterior focus debridement,bone grafting, and internal fixation, and were divided into two groups according to different approaches to psoas abscess debridement. Twenty-one patients in group A underwent abscess debridement and local chemotherapy in abscess cavity via posterior approach; 16 patients in group B underwent abscess debridement and local chemotherapy in abscess cavity via anterior approach. No significant difference was found between two groups in gender, age, disease duration, involved segments, preoperative erythrocyte sedimentation rate(ESR), preoperative C-reactive protein(CRP), side of psoas abscess,maximum transverse diameter and sagittal diameter of psoas abscess, accompanying abscess, abscess cavity separation,preoperative Cobb angle of involved segments, preoperative American Spinal Injury Association(ASIA) classification(P>0.05). The operation time, intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion were recorded and compared between 2 groups. The change of pre-and post-operative involved segments Cobb angle was observed. Neurological function was assessed according to ASIA classification. Results Except that the operation time of group B was significantly longer than that of group A(t=–2.985, P=0.005), there was no significant difference in intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion between 2 groups(P>0.05). All patients were followed up 18-47 months(mean, 31.1 months). No cerebrospinal fluid leakage occurred intra-and postoperation. Four patients in group A underwent second-stage operation of abscess debridement and local chemotherapy in abscess cavity via anterior approach. All patients got abscess absorption, meanwhile ESR and CRP level normalized at last follow-up. The involved segments Cobb angle improved significantly when compared with preoperative values in both 2 groups(P<0.05); and there was no significant difference between 2 groups at last follow-up(P>0.05). Nine patients with spinal cord injury had significant neurological recovery at last follow-up(Z=–2.716, P=0.007). Conclusion Posterior focus debridement, bone grafting, and internal fixation combined with abscess debridement and local chemotherapy in abscess cavity is effective in treatment of thoracolumbar spinal tuberculosis, but in some cases anterior abscess debridement is still required.
Objective To compare the effectiveness of posterior and anterior psoas abscess debridement and local chemotherapy in abscess cavity combined with focus debridement, bone grafting, and fixation via posterior approach in treatment of thoracolumbar spinal tuberculosis, and explore the feasibility of psoas abscess debridement via posterior approach. Methods Between June 2012 and December 2015, the clinical data of 37 patients with thoracolumbar spine tuberculosis and psoas abscess were retrospectively analyzed. All the patients underwent posterior focus debridement,bone grafting, and internal fixation, and were divided into two groups according to different approaches to psoas abscess debridement. Twenty-one patients in group A underwent abscess debridement and local chemotherapy in abscess cavity via posterior approach; 16 patients in group B underwent abscess debridement and local chemotherapy in abscess cavity via anterior approach. No significant difference was found between two groups in gender, age, disease duration, involved segments, preoperative erythrocyte sedimentation rate(ESR), preoperative C-reactive protein(CRP), side of psoas abscess,maximum transverse diameter and sagittal diameter of psoas abscess, accompanying abscess, abscess cavity separation,preoperative Cobb angle of involved segments, preoperative American Spinal Injury Association(ASIA) classification(P>0.05). The operation time, intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion were recorded and compared between 2 groups. The change of pre-and post-operative involved segments Cobb angle was observed. Neurological function was assessed according to ASIA classification. Results Except that the operation time of group B was significantly longer than that of group A(t=–2.985, P=0.005), there was no significant difference in intraoperative blood loss, hospitalization time, time of abscess absorption and bone fusion between 2 groups(P>0.05). All patients were followed up 18-47 months(mean, 31.1 months). No cerebrospinal fluid leakage occurred intra-and postoperation. Four patients in group A underwent second-stage operation of abscess debridement and local chemotherapy in abscess cavity via anterior approach. All patients got abscess absorption, meanwhile ESR and CRP level normalized at last follow-up. The involved segments Cobb angle improved significantly when compared with preoperative values in both 2 groups(P<0.05); and there was no significant difference between 2 groups at last follow-up(P>0.05). Nine patients with spinal cord injury had significant neurological recovery at last follow-up(Z=–2.716, P=0.007). Conclusion Posterior focus debridement, bone grafting, and internal fixation combined with abscess debridement and local chemotherapy in abscess cavity is effective in treatment of thoracolumbar spinal tuberculosis, but in some cases anterior abscess debridement is still required.
引文
1Hao Z,Zhang Y,Shen X,et al.Staged treatment of thoracic and lumbar spinal tuberculosis with flow injection abscess.Int J of Clin Exp Med,2015,8(10):18383-18390.
2 Yacoub Wn,Sohn HJ,Chan S,et al.Psoas abscess rarely requires surgical intervention.Am J Surg,2008,196(2):223-227.
3Büyükbebeci O,Se?kiner I,Karsl?B,et al.Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis.Eur Spine J,2012,21(3):470-473.
4 Zhang X,Zhang Z,Zhang Y,et al.Minimally invasive retroperitoneoscopic surgery for psoas abscess with thoracolumbar tuberculosis.Surg Endosc,2015,29(8):2451-2455.
5Tuli SM.Historical aspects of Pott’s disease(spinal tuberculosis)management.Eur Spine J,2013,22(Suppl 4):529-538.
6 Kim KT,Lee SH,Lee YH,et al.Clinical outcomes of 3 fusion methods through the posterior approach in the lumbar spine.Spine(Phila Pa 1976),2006,31(12):1351-1358.
7Yin XH,Zhou ZH,Yu HG,et al.Comparison between the anteroposterior and posterior only approaches for treating thoracolumbar tuberculosis(T10-L2)with kyphosis in children:a minimum 3-year follow-up.Childs Nerv Sits,2016,32(1):127-133.
8 王自立.脊柱结核的病灶清除与融合固定问题.中国脊柱脊髓杂志,2006,16(12):888-889.
9张宏其.脊柱结核病灶应清除到何种程度?中国脊柱脊髓杂志,2010,20(10):798-799.
10 Kumar MN,Joseph B,Manur R.Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting.Eur Spine J,2013,22(3):624-632.
11Qian J,Rijiepu A,Zhu B,et al.Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis.Int Orthop,2016,40(10):2081-2088.
12 Garg N,Vohra R.Minimally invasive surgical approaches in the management of tuberculosis of the thoracic and lumbar spine.Clin Orthop Relat Res,2014,472(6):1855-1867.
13Zaveri GR,Mehta SS.Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar underbody fusion(TLIF)and posterior instrumentation.J Spinal Disord Tech,2009,22(4):257-262.
14 Zhang P,Pang W,Wang X,et al.Minimum 5-year follow-up outcomes for single-stage transpedicular debridement,posterior instrumentation and fusion in the management of thoracic and thoracolumbar spinal tuberculosis in adults.Br J Neurosurg,2016,30(6):666-671.
15Jain AK,Jain S.Instrumented stabilization in spinal tuberculosis.Int Orthop,2012,36(2):285-292.
16张宏其,唐明星,王昱翔,等.多枚分网异形钛网技术在单纯一期后路脊柱结核手术中的应用.中国矫形外科杂志,2014,22(15):1353-1358.
17 Jain A,Jain RK,Kiyawat V.Evaluation of outcome of transpedicular decompression and instrumented fusion in thoracic and thoracolumbar tuberculosis.Asian Spine J,2017,11(1):31-36.
18Gao Y,Ou Y,Deng Q,et al.Comparison between titanium mesh and autogenous iliac bone graft to restore vertebral height through posterior approach for the treatment of thoracic and lumbar spinal tuberculosis.PLo S One,2017,12(4):e0175567.
19 赵增辉,朱勇,罗伟,等.一期后路经单侧入路病灶清除植骨内固定治疗多节段胸腰椎结核.中国修复重建外科杂志,2017,31(9):1073-1079.
20吴鹏,欧云生,刘德龙,等.后路经单侧椎弓根病灶清除植骨内固定治疗胸腰椎结核的疗效分析.中国修复重建外科杂志,2015,29(10):1259-1264.
21 Pang X,Shen X,Wu P,et al.Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement,underbody fusion,posterior instrumentation,and postural drainage.Arch Orthop Trauma Surg,2013,133(6):765-772.
22Tofuku K,Koga H,Komiya S.Percutaneous drainage combined with hyperbaric oxygen therapy for pyogenic spondylitis with iliopsoas abscess.Asian Spine J,2014,8(3):253-259.
23 Din?H,Ahmeto?lu A,Baykal S,et al.Image-guided percutaneous drainage of tuberculous iliopsoas and spondylodiskitic abscesses:midterm results.Radiology,2002,225(2):353-358.
24Raviglione M,Marais B,Floyd K,et al.Scaling up interventions to achieve global tuberculosis control:progress and new developments.Lancet,2012,379(9829):1902-1913.
25 甫拉提·买买提,徐韬,买买提艾力·尼亚孜,等.原发性结核性腰大肌脓肿的诊断和治疗.中华医学杂志,2016,96(43):3511-3514.
26Soares Do Brito J,Tirado A,Fernandes P.Surgical treatment of spinal tuberculosis complicated with extensive abscess.Iowa Orthop J,2014,34(4):129-136.
27 Sundararaj GD,Behera S,Ravi V,et al.Role of posterior stabilisation in the management of tuberculosis of the dorsal and lumbar spine.J Bone Joint Surg(Br),2003,85(1):100-106.
28Suh KT,Seong YJ,Lee JS.Simultaneous anterior and posterior surgery in the management of tuberculous spondylitis with psoas abscess in patients with neurological deficits.Asian Spine J,2008,2(2):94-101.
29 Li J,Li XL,Zhou XG,et al.Surgical treatment for spinal tuberculosis with bilateral paraspinal abscess or bilateral psoas abscess:one-stage surgery.J Spinal Disord Tech,2014,27(8):309-314.
30张西峰,王岩,刘郑生,等.经皮穿刺病灶清除灌注冲洗局部化疗治疗脊柱结核脓肿.中国脊柱脊髓杂志,2005,15(9):528-530.
31 Sarathy JP,Zuccotto F,Ho HP,et al.Prediction of drug penetration in tuberculosis lesions.Acs Infect Dis,2016,2(8):552-563.
32Kumar K.The penetration of drugs into the lesions of spinal tuberculosis.Int Orthop,1992,16(1):67-68.
33 Jutte PC,Rutgers SR,Van Altena R,et al.Penetration of isoniazid,rifampicin and pyrazinamide in tuberculous pleural effusion and psoas abscess.Int J Tuberc Lung Dis,2004,8(11):1368-1372.
2 Yacoub Wn,Sohn HJ,Chan S,et al.Psoas abscess rarely requires surgical intervention.Am J Surg,2008,196(2):223-227.
3Büyükbebeci O,Se?kiner I,Karsl?B,et al.Retroperitoneoscopic drainage of complicated psoas abscesses in patients with tuberculous lumbar spondylitis.Eur Spine J,2012,21(3):470-473.
4 Zhang X,Zhang Z,Zhang Y,et al.Minimally invasive retroperitoneoscopic surgery for psoas abscess with thoracolumbar tuberculosis.Surg Endosc,2015,29(8):2451-2455.
5Tuli SM.Historical aspects of Pott’s disease(spinal tuberculosis)management.Eur Spine J,2013,22(Suppl 4):529-538.
6 Kim KT,Lee SH,Lee YH,et al.Clinical outcomes of 3 fusion methods through the posterior approach in the lumbar spine.Spine(Phila Pa 1976),2006,31(12):1351-1358.
7Yin XH,Zhou ZH,Yu HG,et al.Comparison between the anteroposterior and posterior only approaches for treating thoracolumbar tuberculosis(T10-L2)with kyphosis in children:a minimum 3-year follow-up.Childs Nerv Sits,2016,32(1):127-133.
8 王自立.脊柱结核的病灶清除与融合固定问题.中国脊柱脊髓杂志,2006,16(12):888-889.
9张宏其.脊柱结核病灶应清除到何种程度?中国脊柱脊髓杂志,2010,20(10):798-799.
10 Kumar MN,Joseph B,Manur R.Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting.Eur Spine J,2013,22(3):624-632.
11Qian J,Rijiepu A,Zhu B,et al.Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis.Int Orthop,2016,40(10):2081-2088.
12 Garg N,Vohra R.Minimally invasive surgical approaches in the management of tuberculosis of the thoracic and lumbar spine.Clin Orthop Relat Res,2014,472(6):1855-1867.
13Zaveri GR,Mehta SS.Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar underbody fusion(TLIF)and posterior instrumentation.J Spinal Disord Tech,2009,22(4):257-262.
14 Zhang P,Pang W,Wang X,et al.Minimum 5-year follow-up outcomes for single-stage transpedicular debridement,posterior instrumentation and fusion in the management of thoracic and thoracolumbar spinal tuberculosis in adults.Br J Neurosurg,2016,30(6):666-671.
15Jain AK,Jain S.Instrumented stabilization in spinal tuberculosis.Int Orthop,2012,36(2):285-292.
16张宏其,唐明星,王昱翔,等.多枚分网异形钛网技术在单纯一期后路脊柱结核手术中的应用.中国矫形外科杂志,2014,22(15):1353-1358.
17 Jain A,Jain RK,Kiyawat V.Evaluation of outcome of transpedicular decompression and instrumented fusion in thoracic and thoracolumbar tuberculosis.Asian Spine J,2017,11(1):31-36.
18Gao Y,Ou Y,Deng Q,et al.Comparison between titanium mesh and autogenous iliac bone graft to restore vertebral height through posterior approach for the treatment of thoracic and lumbar spinal tuberculosis.PLo S One,2017,12(4):e0175567.
19 赵增辉,朱勇,罗伟,等.一期后路经单侧入路病灶清除植骨内固定治疗多节段胸腰椎结核.中国修复重建外科杂志,2017,31(9):1073-1079.
20吴鹏,欧云生,刘德龙,等.后路经单侧椎弓根病灶清除植骨内固定治疗胸腰椎结核的疗效分析.中国修复重建外科杂志,2015,29(10):1259-1264.
21 Pang X,Shen X,Wu P,et al.Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement,underbody fusion,posterior instrumentation,and postural drainage.Arch Orthop Trauma Surg,2013,133(6):765-772.
22Tofuku K,Koga H,Komiya S.Percutaneous drainage combined with hyperbaric oxygen therapy for pyogenic spondylitis with iliopsoas abscess.Asian Spine J,2014,8(3):253-259.
23 Din?H,Ahmeto?lu A,Baykal S,et al.Image-guided percutaneous drainage of tuberculous iliopsoas and spondylodiskitic abscesses:midterm results.Radiology,2002,225(2):353-358.
24Raviglione M,Marais B,Floyd K,et al.Scaling up interventions to achieve global tuberculosis control:progress and new developments.Lancet,2012,379(9829):1902-1913.
25 甫拉提·买买提,徐韬,买买提艾力·尼亚孜,等.原发性结核性腰大肌脓肿的诊断和治疗.中华医学杂志,2016,96(43):3511-3514.
26Soares Do Brito J,Tirado A,Fernandes P.Surgical treatment of spinal tuberculosis complicated with extensive abscess.Iowa Orthop J,2014,34(4):129-136.
27 Sundararaj GD,Behera S,Ravi V,et al.Role of posterior stabilisation in the management of tuberculosis of the dorsal and lumbar spine.J Bone Joint Surg(Br),2003,85(1):100-106.
28Suh KT,Seong YJ,Lee JS.Simultaneous anterior and posterior surgery in the management of tuberculous spondylitis with psoas abscess in patients with neurological deficits.Asian Spine J,2008,2(2):94-101.
29 Li J,Li XL,Zhou XG,et al.Surgical treatment for spinal tuberculosis with bilateral paraspinal abscess or bilateral psoas abscess:one-stage surgery.J Spinal Disord Tech,2014,27(8):309-314.
30张西峰,王岩,刘郑生,等.经皮穿刺病灶清除灌注冲洗局部化疗治疗脊柱结核脓肿.中国脊柱脊髓杂志,2005,15(9):528-530.
31 Sarathy JP,Zuccotto F,Ho HP,et al.Prediction of drug penetration in tuberculosis lesions.Acs Infect Dis,2016,2(8):552-563.
32Kumar K.The penetration of drugs into the lesions of spinal tuberculosis.Int Orthop,1992,16(1):67-68.
33 Jutte PC,Rutgers SR,Van Altena R,et al.Penetration of isoniazid,rifampicin and pyrazinamide in tuberculous pleural effusion and psoas abscess.Int J Tuberc Lung Dis,2004,8(11):1368-1372.