上颈椎结核的微创治疗
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摘要
目的探讨微创方法治疗上颈椎结核的临床疗效。方法回顾性分析2005年11月至2012年1月解放军总医院第一医学中心院收治的上颈椎结核患者9例,其中男6例,女3例,年龄17～68岁,平均(40.0±14.6)岁。累及相邻双节段8例(C1/27例,C2/3 1例),累及相邻3节段(C1-3)1例,其中3例合并其他部位结核。治疗前红细胞沉降率(erythrocyte sedimentation rate,ESR)为(52.2±6.7)mm/h,视觉模拟评分法(visual analogue scale,VAS)评分7～10分,平均为(8.6±1.0)分。1例合并侧方脱位畸形。所有患者均无脊髓压迫症状;均口服四联抗结核治疗3个月,三联抗结核治疗12个月。所有患者均采用CT引导下穿刺置管,局部注入异烟肼0.1mg,1～2次/d;治疗过程中佩戴围领保护。结果本组病例随访28～108个月,平均(60.0±24.8)个月,所有患者临床症状消失,复查ESR(8.0±3.5)mm/h,VAS评分(2.3±1.0)分;术后1例出现管路脱落、1例出现管路堵塞,均给予更换导管。2例微创治疗过程中仍伴有颈部疼痛、骨质破坏及寰枢椎不稳和脱位,分别于治疗后的8周、11周行颈后路椎弓根钉固定+自体髂骨植骨术。无颈椎结核复发,无窦道及假关节形成;手术患者植骨均获得融合。结论正规抗结核治疗是上颈椎结核最基本的治疗方法。大多数上颈椎结核可通过仅实施局部化疗获得治愈。对于微创治疗过程中合并寰枢椎不稳、脱位的患者,给予后路固定融合术可获得较好的临床疗效。
Objective To investigate the methods and clinical efficacy of stepped care for upper cervical tuberculosis.Method Clinical date of 9 patients(male 7,female 2) diagnosed as upper cervical tuberculosis from November 2005 to January 2012 were reviewed retrospectively.The average age of these patients was 40±14.6 years(range,17-68).8 cases were involved in the adjacent two levels(C1/2 7 cases,C2/3 1 case),1 involved in the adjacent three levels(C1-3),3 cases were involved in other organ tuberculosis.Before treatment,the mean VAS score was(8.6±1.0),and the mean ESR was(52.2±6.7) mm/h.One case occurred lateral dislocation deformity.None cases occurred symptoms of spinal cord compression.All cases underwent tetragenous anti-TB treatment for first 3 months,and triple anti-TB treatment in the succeeded 12 months.9 patients with retropharyngeal abscess were treated with CT guidance puncture and placed catheter,local chemotherapy with isoniazid 0.1 mg qd or bid and protected with Philadelphia collar.Result Mean follow-up duration of was(60.0±24.8) months(range,28-108 months).It was found that clinical symptoms completely disappeared,and ESR was(8.0±3.5)mm/h.At last follow-up,the mean VAS score was(2.3±1.2).2 cases were treated with change catheter for catheter fall off and blockage.No tuberculosis recurrence,sinus tract occurred and pseudo articulation formation.During minimally invasive treatment,2 patients were treated with open fixation and fusion operation respectively in 8 and 11 weeks for upper cervical vertebrae destruct,atlantoaxial instability or subluxation,and neck pain without relief.Conclusion Regularity anti-TB treatment is the most basic treatment for upper cervical tuberculosis.Most of the upper cervical tuberculosis can only local chemotherapy for cure.For cases with atlantoaxial instability or dislocation,anterior approach minimally invasive treatment and open internal fixation and bone grafting can obtain good clinical curative effect.
Objective To investigate the methods and clinical efficacy of stepped care for upper cervical tuberculosis.Method Clinical date of 9 patients(male 7,female 2) diagnosed as upper cervical tuberculosis from November 2005 to January 2012 were reviewed retrospectively.The average age of these patients was 40±14.6 years(range,17-68).8 cases were involved in the adjacent two levels(C1/2 7 cases,C2/3 1 case),1 involved in the adjacent three levels(C1-3),3 cases were involved in other organ tuberculosis.Before treatment,the mean VAS score was(8.6±1.0),and the mean ESR was(52.2±6.7) mm/h.One case occurred lateral dislocation deformity.None cases occurred symptoms of spinal cord compression.All cases underwent tetragenous anti-TB treatment for first 3 months,and triple anti-TB treatment in the succeeded 12 months.9 patients with retropharyngeal abscess were treated with CT guidance puncture and placed catheter,local chemotherapy with isoniazid 0.1 mg qd or bid and protected with Philadelphia collar.Result Mean follow-up duration of was(60.0±24.8) months(range,28-108 months).It was found that clinical symptoms completely disappeared,and ESR was(8.0±3.5)mm/h.At last follow-up,the mean VAS score was(2.3±1.2).2 cases were treated with change catheter for catheter fall off and blockage.No tuberculosis recurrence,sinus tract occurred and pseudo articulation formation.During minimally invasive treatment,2 patients were treated with open fixation and fusion operation respectively in 8 and 11 weeks for upper cervical vertebrae destruct,atlantoaxial instability or subluxation,and neck pain without relief.Conclusion Regularity anti-TB treatment is the most basic treatment for upper cervical tuberculosis.Most of the upper cervical tuberculosis can only local chemotherapy for cure.For cases with atlantoaxial instability or dislocation,anterior approach minimally invasive treatment and open internal fixation and bone grafting can obtain good clinical curative effect.
引文
[1]Ferrer MF,Torres LG,Ramirez OA,et al.Tuberculosis of the spine.A systematicreview of case series[J].Int Orthop,2012,36(2):221-231.
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[7]Mak KC,Cheung KM.Surgical treatment of acute TB spondylitis:indications and outcomes[J].Eur Spine J,2013,22(Suppl 4):603-611.
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[9]张西峰,肖嵩华,刘郑生,等.局部化疗治疗颈椎结核的临床研究[J].脊柱外科杂志,2012,10(1):29-31.
[10]张西峰,王岩,肖嵩华,等.活动期脊柱结核的微创治疗:提高病灶内药物浓度的探讨[J].中华外科杂志,2008,46(9):700-702.
[11]Bhojraj SY,Shetty N,Shah PJ.Tuberculosis of the craniocervical junction[J].J Bone Joint Surg Br,2001,83(2):222-225.
[2]Rajasekaran S.The problem of deformity in spinal tuberculosis[J].Clin Orthop Relat Res,2002,(398):85-92.
[3]Wang L,Liu L,Song Y,et al.Cervical tuberculosis associated with cervical pain and neurologic deficit:a case report and literature review[J].Spine J,2014,14(5):13-18.
[4]Tuli SM.Tuberculosis of the craniovertebral region[J].Clin Orthop,1974,(104):209-212.
[5]Khoo LT,Mikawa K,Fessler RG.A surgical revisitation of Pott distemper of the spine[J].Spine J,2003,3(2):130-145.
[6]Ge Z,Wang Z,Wei M.Measurement of the concentration of three antituberculosis drugs in the focus of spinal tuberculosis[J].Eur Spine J,2008,17(11):1482-1487.
[7]Mak KC,Cheung KM.Surgical treatment of acute TB spondylitis:indications and outcomes[J].Eur Spine J,2013,22(Suppl 4):603-611.
[8]Hodgson AR,Stock FE.Anterior spinal fusion.The operative approach and pathological findings in 412 patients with Pott’s disease of the spine[J].Br J Surg,1960,48:172-178.
[9]张西峰,肖嵩华,刘郑生,等.局部化疗治疗颈椎结核的临床研究[J].脊柱外科杂志,2012,10(1):29-31.
[10]张西峰,王岩,肖嵩华,等.活动期脊柱结核的微创治疗:提高病灶内药物浓度的探讨[J].中华外科杂志,2008,46(9):700-702.
[11]Bhojraj SY,Shetty N,Shah PJ.Tuberculosis of the craniocervical junction[J].J Bone Joint Surg Br,2001,83(2):222-225.