结构性与非结构性植骨融合治疗单节段胸椎结核的近期疗效
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摘要
目的比较一期后路病灶清除非结构性与结构性植骨治疗单节段胸椎结核的近期疗效。方法回顾性分析2011年6月—2015年8月接受一期后路病灶清除、植骨融合内固定治疗的61例患者临床资料,其中采用结构性植骨26例(A组)、非结构性植骨35例(B组)。两组患者性别、年龄、病程、合并症、病变节段、合并椎旁脓肿者以及术前美国脊柱损伤协会(ASIA)分级、C反应蛋白(C reactive protein,CRP)、疼痛视觉模拟评分(VAS)、病变节段Cobb角等比较,差异均无统计学意义(P>0.05);但B组术前红细胞沉降率(erythrocyte sedimentation rate,ESR)明显低于A组(t=3.128,P=0.003)。记录并比较两组手术时间、术中出血量、住院时间、VAS评分、ESR、CRP、ASIA分级、并发症、病变节段Cobb角及其矫正率、丢失率以及植骨融合时间。结果 B组手术时间、术中出血量显著少于A组,但患者住院时间长于A组,差异均有统计学意义(P<0.05)。A组随访时间为(36.3±10.0)个月,明显长于B组的(18.4±4.2)个月(t=10.722,P=0.000)。末次随访时,两组患者VAS评分、ESR及CRP均较术前明显改善(P<0.05);B组CRP显著高于A组(t=–2.947,P=0.005),ESR及VAS评分比较差异无统计学意义(P>0.05)。末次随访时,两组患者ASIA分级均较术前明显改善,组间比较差异无统计学意义(Z=–1.104,P=0.270)。A、B组术后分别有9、10例发生并发症,差异无统计学意义(χ2=0.254,P=0.614)。术后3 d时B组Cobb角明显大于A组(t=–2.861,P=0.006);末次随访时两组Cobb角差异无统计学意义(t=–1.212,P=0.230)。术后A组Cobb角矫正率及丢失率均大于B组,其中Cobb角丢失率比较差异有统计学意义(t=2.261,P=0.031)。两组植骨均融合,B组植骨融合时间明显短于A组,差异有统计学意义(t=4.824,P=0.000)。结论非结构性植骨与结构性植骨治疗单节段胸椎结核均能取得良好临床疗效,但前者具有手术创伤小、植骨融合时间短等优势。
Objective To compare the short-term effectiveness of one-stage posterior debridement with nonstructural bone graft and structural bone graft in the treatment of single segment thoracic tuberculosis. Methods The data of 61 patients with single segment thoracic tuberculosis, who were treated by one-stage posterior debridement, bone graft fusion, and internal fixation between June 2011 and August 2015, was retrospectively analyzed. All of them, 26 cases were treated with structural bone graft(group A) and 35 cases with non-structural bone graft(group B). No significant difference was found between the two groups in gender, age, disease duration, comorbidity, involved segments,paravertebral abscess, and preoperative American Spinal Injury Association(ASIA) grade, C reactive protein(CRP), visual analogue scale(VAS) score, and Cobb angle of involved segments(P>0.05). But the preoperative erythrocyte sedimentation rate(ESR) in group B was significantly lower than that in group A(t=3.128, P=0.003). The operation time,intraoperative blood loss, hospitalization stay, VAS score, ESR, CRP, ASIA grade, postoperative complications, Cobb angle of involved segments and its correction rate and loss rate, and bone fusion time were recorded and compared between the two groups. Results Compared with group A, group B had shorter operation time, less intraoperative blood loss, and longer hospitalization stay, showing significant differences(P<0.05). The follow-up time of group A was(36.3±10.0)months, which was significantly longer than that of group B [(18.4±4.2) months](t=10.722, P=0.000). At last follow-up,the VAS score, ESR, and CRP in the two groups all significantly improved when compared with those before operation(P<0.05); the CRP of group B was significantly higher than that of group A(t=–2.947, P=0.005); but there was no significant difference in ESR and VAS score between the two groups(P>0.05). At last follow-up, the ASIA grade of the two groups significantly improved when compared with those before operation, and there was no significant difference between the two groups(Z=–1.104, P=0.270). There were 9 cases and 10 cases of complications in groups A and B,respectively, and there was no significant difference(χ2=0.254, P=0.614). The Cobb angle in group B was significantly higher than that in group A at 3 days after operation(t=–2.861, P=0.006), but there was no significant difference in Cobb angle between the two groups at last follow-up(t=–1.212, P=0.230). The postoperative correction rate and loss rate of Cobb angle in group A were higher than those in group B, and there was a significant difference in the loss rate between the two groups(t=2.261, P=0.031). All patients got bone graft fusion and the bone fusion time of group B was significantly shorter than that of group A(t=4.824, P=0.000). Conclusion Non-structural and structural bone graft can both achieve good effectiveness in the treatment of single segment thoracic tuberculosis, but the former has the advantages of less surgical trauma and shorter fusion time.
Objective To compare the short-term effectiveness of one-stage posterior debridement with nonstructural bone graft and structural bone graft in the treatment of single segment thoracic tuberculosis. Methods The data of 61 patients with single segment thoracic tuberculosis, who were treated by one-stage posterior debridement, bone graft fusion, and internal fixation between June 2011 and August 2015, was retrospectively analyzed. All of them, 26 cases were treated with structural bone graft(group A) and 35 cases with non-structural bone graft(group B). No significant difference was found between the two groups in gender, age, disease duration, comorbidity, involved segments,paravertebral abscess, and preoperative American Spinal Injury Association(ASIA) grade, C reactive protein(CRP), visual analogue scale(VAS) score, and Cobb angle of involved segments(P>0.05). But the preoperative erythrocyte sedimentation rate(ESR) in group B was significantly lower than that in group A(t=3.128, P=0.003). The operation time,intraoperative blood loss, hospitalization stay, VAS score, ESR, CRP, ASIA grade, postoperative complications, Cobb angle of involved segments and its correction rate and loss rate, and bone fusion time were recorded and compared between the two groups. Results Compared with group A, group B had shorter operation time, less intraoperative blood loss, and longer hospitalization stay, showing significant differences(P<0.05). The follow-up time of group A was(36.3±10.0)months, which was significantly longer than that of group B [(18.4±4.2) months](t=10.722, P=0.000). At last follow-up,the VAS score, ESR, and CRP in the two groups all significantly improved when compared with those before operation(P<0.05); the CRP of group B was significantly higher than that of group A(t=–2.947, P=0.005); but there was no significant difference in ESR and VAS score between the two groups(P>0.05). At last follow-up, the ASIA grade of the two groups significantly improved when compared with those before operation, and there was no significant difference between the two groups(Z=–1.104, P=0.270). There were 9 cases and 10 cases of complications in groups A and B,respectively, and there was no significant difference(χ2=0.254, P=0.614). The Cobb angle in group B was significantly higher than that in group A at 3 days after operation(t=–2.861, P=0.006), but there was no significant difference in Cobb angle between the two groups at last follow-up(t=–1.212, P=0.230). The postoperative correction rate and loss rate of Cobb angle in group A were higher than those in group B, and there was a significant difference in the loss rate between the two groups(t=2.261, P=0.031). All patients got bone graft fusion and the bone fusion time of group B was significantly shorter than that of group A(t=4.824, P=0.000). Conclusion Non-structural and structural bone graft can both achieve good effectiveness in the treatment of single segment thoracic tuberculosis, but the former has the advantages of less surgical trauma and shorter fusion time.
引文
1 Jain AK, Kumar J. Tuberculosis of spine:neurological deficit. Eur Spine J, 2013,22(Suppl 4):624-633.
2金大地.化疗和外科干预并重,进一步提高脊柱结核治疗水平.中华骨科杂志,2005, 25(2):65-67.
3罗卓荆.脊柱结核为什么要彻底清除病灶.中国脊柱脊髓杂志,2010,20(10):797-798.
4高永建,欧云生,权正学,等.胸腰椎脊柱结核外科治疗的研究进展.中国修复重建外科杂志,2018, 32(1):112-117.
5 Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects. Spine(Phila Pa1976), 1995, 20(12):1410-1418.
6杨智贤,彭小忠,武振国,等.脊柱结核外科治疗骨缺损的修复.中国组织工程研究与临床康复,2011,15(30):5665-5668,
7 Yin XH, Liu ZK, He BR, et al. Single posterior surgical management for lumbosacral tuberculosis:titanium mesh versus iliac bone graft:A retrospective case-control study. Medicine(Baltimore), 2017,96(51):e9449.
8 Wang YX, Zhang HQ, Li M, et al. Debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion in the surgical treatment of multilevel noncontiguous spinal tuberculosis in elderly patients via a posterior-only. Injury, 2017,48(2):378-383.
9 Kanayama M, Cunningham BW, Haggerty CJ, et al. In vitro biomechanical investigation of the stability and stress-shielding effect of lumbar interbody fusion devices. J Neurosurg, 2000, 93(2Suppl):259-265.
10 Gao 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. PLoS One, 2017,12(4):e0175567.
11邹沙沙,陈婷婷,田汝辉,等.自体髂骨植骨供骨区并发症的Meta分析.中国组织工程研究,2013,17(5):931-937.
12 Harris WH. Management of the deficient acetabulum using cementless fixation without bone grafting. Orthop Clin North Am,1993, 24(4):663-665.
13周磊,李明,刘培来,等.一期前路病灶清除钛网植骨融合内固定治疗胸腰椎结核.中国矫形外科杂志,2007,15(7):487-490.
14 Soares do Brito J, Batista N, Tirado A. Surgical treatment of spinal tuberculosis:an orthopedic service experience. Acta Med Port,2013, 26(4):349-356.
15王丛,陈根元,杨成业,等.改良后路病灶清除打压植骨内固定治疗胸腰椎结核.中国脊柱脊髓杂志,2011,21(10):835-838.
16 Liu JM, Zhou Y, Peng AF, et al. One-stage posterior surgical management of lumbosacral spinal tuberculosis with nonstructural autograft. Clin Neurol Neurosurg, 2017,153:67-72.
17 Xu Z, Wang X, Wu P, et al. Surgical treatment for mono-segmental lumbar tuberculosis by single-stage posterior debridement,compact bone grafting and posterior single-segment fixation.Injury, 2015, 46(7):1311-1316.
18 Hu MW, Liu ZL, Zhou Y, et al. Posterior lumbar intebody fusion using spinous process and laminae. J Bone Joint Surg(Br), 2012,94(3):373-377.
19官众,许勇,任磊,等.三种不同植骨方式在胸、腰椎结核手术治疗中的观察.中国脊柱脊髓杂志,2013,23(6):488-492.
20 Liu JM, Chen XY, Zhou Y, et al. Is nonstructural bone graft useful in surgical treatment of lumbar spinal tuberculosis?:A retrospective case-control study. Medicine(Baltimore), 2016,95(35):e4677.
21 Rajasekaran S. Kyphotic deformity in spinal tuberculosis and its management. Int Orthop, 2012, 36(2):359-365.
22 Tosun B, Erdemir C, Yonga O, et al. Surgical treatment of thoracolumbar tuberculosis:a retrospective analysis of autogenous grafting versus expandable cages. Eur Spine J, 2014, 23(11):2299-2306.
23王新涛,闫景龙,杨显声,等.微小颗粒骨移植骨细胞活性的实验研究.中华创伤骨科杂志,2008,10(3):260-265.
24夏景君,阎景龙,张志鹏,等.颗粒骨和块状骨对骨髓基质细胞作用的实验研究.哈尔滨医科大学学报,2002, 36(2):141-143.
25 Li H, Zou X, Xue Q, et al. Effects of autogenous bone graft impaction and tricalcium phosphate on anterior interbody fusion in the porcine lumbar spine. Acta Orhop Scand, 2004, 75(4):456-463.
26 Yao Y, Zhang H, Liu M, et al. Prognostic factors for recovery of patients after surgery for thoracic spinal tuberculosis. World Neurosurg, 2017, 105:327-331.
27孙天胜,沈建雄,刘忠军,等.中国脊柱手术加速康复——围术期管理策略专家共识.中华骨与关节外科杂志,2017, 10(4):271-279.
28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.
2金大地.化疗和外科干预并重,进一步提高脊柱结核治疗水平.中华骨科杂志,2005, 25(2):65-67.
3罗卓荆.脊柱结核为什么要彻底清除病灶.中国脊柱脊髓杂志,2010,20(10):797-798.
4高永建,欧云生,权正学,等.胸腰椎脊柱结核外科治疗的研究进展.中国修复重建外科杂志,2018, 32(1):112-117.
5 Bridwell KH, Lenke LG, McEnery KW, et al. Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects. Spine(Phila Pa1976), 1995, 20(12):1410-1418.
6杨智贤,彭小忠,武振国,等.脊柱结核外科治疗骨缺损的修复.中国组织工程研究与临床康复,2011,15(30):5665-5668,
7 Yin XH, Liu ZK, He BR, et al. Single posterior surgical management for lumbosacral tuberculosis:titanium mesh versus iliac bone graft:A retrospective case-control study. Medicine(Baltimore), 2017,96(51):e9449.
8 Wang YX, Zhang HQ, Li M, et al. Debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion in the surgical treatment of multilevel noncontiguous spinal tuberculosis in elderly patients via a posterior-only. Injury, 2017,48(2):378-383.
9 Kanayama M, Cunningham BW, Haggerty CJ, et al. In vitro biomechanical investigation of the stability and stress-shielding effect of lumbar interbody fusion devices. J Neurosurg, 2000, 93(2Suppl):259-265.
10 Gao 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. PLoS One, 2017,12(4):e0175567.
11邹沙沙,陈婷婷,田汝辉,等.自体髂骨植骨供骨区并发症的Meta分析.中国组织工程研究,2013,17(5):931-937.
12 Harris WH. Management of the deficient acetabulum using cementless fixation without bone grafting. Orthop Clin North Am,1993, 24(4):663-665.
13周磊,李明,刘培来,等.一期前路病灶清除钛网植骨融合内固定治疗胸腰椎结核.中国矫形外科杂志,2007,15(7):487-490.
14 Soares do Brito J, Batista N, Tirado A. Surgical treatment of spinal tuberculosis:an orthopedic service experience. Acta Med Port,2013, 26(4):349-356.
15王丛,陈根元,杨成业,等.改良后路病灶清除打压植骨内固定治疗胸腰椎结核.中国脊柱脊髓杂志,2011,21(10):835-838.
16 Liu JM, Zhou Y, Peng AF, et al. One-stage posterior surgical management of lumbosacral spinal tuberculosis with nonstructural autograft. Clin Neurol Neurosurg, 2017,153:67-72.
17 Xu Z, Wang X, Wu P, et al. Surgical treatment for mono-segmental lumbar tuberculosis by single-stage posterior debridement,compact bone grafting and posterior single-segment fixation.Injury, 2015, 46(7):1311-1316.
18 Hu MW, Liu ZL, Zhou Y, et al. Posterior lumbar intebody fusion using spinous process and laminae. J Bone Joint Surg(Br), 2012,94(3):373-377.
19官众,许勇,任磊,等.三种不同植骨方式在胸、腰椎结核手术治疗中的观察.中国脊柱脊髓杂志,2013,23(6):488-492.
20 Liu JM, Chen XY, Zhou Y, et al. Is nonstructural bone graft useful in surgical treatment of lumbar spinal tuberculosis?:A retrospective case-control study. Medicine(Baltimore), 2016,95(35):e4677.
21 Rajasekaran S. Kyphotic deformity in spinal tuberculosis and its management. Int Orthop, 2012, 36(2):359-365.
22 Tosun B, Erdemir C, Yonga O, et al. Surgical treatment of thoracolumbar tuberculosis:a retrospective analysis of autogenous grafting versus expandable cages. Eur Spine J, 2014, 23(11):2299-2306.
23王新涛,闫景龙,杨显声,等.微小颗粒骨移植骨细胞活性的实验研究.中华创伤骨科杂志,2008,10(3):260-265.
24夏景君,阎景龙,张志鹏,等.颗粒骨和块状骨对骨髓基质细胞作用的实验研究.哈尔滨医科大学学报,2002, 36(2):141-143.
25 Li H, Zou X, Xue Q, et al. Effects of autogenous bone graft impaction and tricalcium phosphate on anterior interbody fusion in the porcine lumbar spine. Acta Orhop Scand, 2004, 75(4):456-463.
26 Yao Y, Zhang H, Liu M, et al. Prognostic factors for recovery of patients after surgery for thoracic spinal tuberculosis. World Neurosurg, 2017, 105:327-331.
27孙天胜,沈建雄,刘忠军,等.中国脊柱手术加速康复——围术期管理策略专家共识.中华骨与关节外科杂志,2017, 10(4):271-279.
28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.