不同植骨方式在单节段胸腰椎结核手术中的对比研究
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摘要
目的比较自体髂骨植骨、钛网植骨、Cage植骨3种不同植骨方式在单节段胸腰椎结核行后路手术中的临床应用效果。方法回顾性分析2011年2月-2016年7月行后路病灶清除内固定植骨融合手术并获完整随访的97例单节段胸腰椎结核患者的临床资料。依据不同植骨方式分为3组,其中A组(43例)采用自体髂骨植骨,B组(31例)采用钛网植骨,C组(23例)采用Cage植骨。对3组患者的平均手术时间、术中出血量、术中及术后当天血红蛋白、白蛋白丢失情况、疼痛视觉模拟评分(VAS)、神经功能分级(Frankel分级)、Cobb角、椎间高度、植骨融合情况及并发症进行对比。所有患者术前规范抗结核治疗至少2周,术后规范抗结核治疗1年以上。结果97例患者随访15～84月,所有患者结核完全治愈并获得植骨融合,95例患者术后神经功能均较术前有所改善。3组患者在术前、术后的疼痛评分、术中出血量、术中及术后当天血红蛋白丢失程度比较,差别无统计学意义(P>0.05);A组的手术时间长于B,C组(P<0.05);A组的术中、术后当天丢失的白蛋白情况显著高于B,C组(P<0.05);A组的Cobb角矫正度及恢复椎间高度能力小于B,C组(P<0.05)。A组的植骨融合时间与B组比较,差别无统计学意义(P>0.05),但均少于C组(P<0.05)。3组随访期间内固定在位、无松动,结核无复发,A组术后出现10例髂骨取骨区疼痛及2例髂骨取骨区切口感染,B组出现1例手术切口皮下积液。结论在单节段胸腰椎结核治疗中,3种植骨方式均可取得良好的疗效。钛网植骨、Cage植骨在缩短手术时间、减少白蛋白丢失及恢复脊柱矢状位序列及椎间高度具有优势,可避免取骨区并发症,但Cage植骨的骨融合有待提高。
Objective To compare the clinical efficacy of three different bone grafting methods,including autogenous iliac bone grafting,titanium mesh bone grafting and Cage bone grafting,in patients with single-segment thoracic or lumbar spinal tuberculosis through posterior approach. Methods The clinical data of 97 patients with single-segment thoracic or lumbar spinal tuberculosis was retrospectively analyzed. All the participants underwent posterior debridement surgery with internal fixation and bone grafting fusion between February 2011 and July 2016. Participants undergoing different bone grafting methods were divided into three groups,namely group A with 43 cases receiving autogenous iliac bone grafting,group B with 31 cases receiving titanium mesh grafting,and group C with 23 cases obtaining Cage bone grafting. In addition,characteristics among the three groups including mean operative time,blood loss,intraoperative and postoperative hemoglobin,albumin loss,visual analog scale(VAS),neurological function grading(Frankel grading),Cobb angle,intervertebral height,bone graft fusion,and complications were compared. All patients received anti-tuberculosis treatment for at least 2 weeks before surgery and 1 year after surgery. Results The follow-up time of 97 patients ranged from 15 to 84 months. All patients were completely cured and obtained solid bone fusion. Ninety-five postoperative patients obtained improved neurological function. No statistically significant difference was found when comparing the VAS,blood loss,intraoperative and postoperative hemoglobin loss among three groups(P>0.05). A longer operation time as well as more intraoperative and postoperative albumin loss were observed in group A compared with group B or group C(P<0.05). The Cobb correction and restoration of intervertebral height were significantly better improved in group B and group C compared with group A(P<0.05). The bony fusion time showed no significant difference between group A and group B(P>0.05),however it was shorter in group A and group B than that in group C(P<0.05). No loose or rupturing internal fixation,or recurrence of tuberculosis occurred to patients during the follow-up period,except for ten cases suffering chronic pain and 2 cases of incision infection at iliac donor sites in group A and 1 case with subcutaneous hydrops in group B. Conclusion In the treatment of single-segment thoracolumbar spinal tuberculosis,all three different bone grafting methods can achieve good results. Titanium mesh bone grafting or Cage bone grafting may effectively shorten operative time and decrease hemoglobin loss. It can maintain the spinal sagittal plane alignment and avoid the complication of autograft iliac bone fusion. Further research on bone fusion is needed.
Objective To compare the clinical efficacy of three different bone grafting methods,including autogenous iliac bone grafting,titanium mesh bone grafting and Cage bone grafting,in patients with single-segment thoracic or lumbar spinal tuberculosis through posterior approach. Methods The clinical data of 97 patients with single-segment thoracic or lumbar spinal tuberculosis was retrospectively analyzed. All the participants underwent posterior debridement surgery with internal fixation and bone grafting fusion between February 2011 and July 2016. Participants undergoing different bone grafting methods were divided into three groups,namely group A with 43 cases receiving autogenous iliac bone grafting,group B with 31 cases receiving titanium mesh grafting,and group C with 23 cases obtaining Cage bone grafting. In addition,characteristics among the three groups including mean operative time,blood loss,intraoperative and postoperative hemoglobin,albumin loss,visual analog scale(VAS),neurological function grading(Frankel grading),Cobb angle,intervertebral height,bone graft fusion,and complications were compared. All patients received anti-tuberculosis treatment for at least 2 weeks before surgery and 1 year after surgery. Results The follow-up time of 97 patients ranged from 15 to 84 months. All patients were completely cured and obtained solid bone fusion. Ninety-five postoperative patients obtained improved neurological function. No statistically significant difference was found when comparing the VAS,blood loss,intraoperative and postoperative hemoglobin loss among three groups(P>0.05). A longer operation time as well as more intraoperative and postoperative albumin loss were observed in group A compared with group B or group C(P<0.05). The Cobb correction and restoration of intervertebral height were significantly better improved in group B and group C compared with group A(P<0.05). The bony fusion time showed no significant difference between group A and group B(P>0.05),however it was shorter in group A and group B than that in group C(P<0.05). No loose or rupturing internal fixation,or recurrence of tuberculosis occurred to patients during the follow-up period,except for ten cases suffering chronic pain and 2 cases of incision infection at iliac donor sites in group A and 1 case with subcutaneous hydrops in group B. Conclusion In the treatment of single-segment thoracolumbar spinal tuberculosis,all three different bone grafting methods can achieve good results. Titanium mesh bone grafting or Cage bone grafting may effectively shorten operative time and decrease hemoglobin loss. It can maintain the spinal sagittal plane alignment and avoid the complication of autograft iliac bone fusion. Further research on bone fusion is needed.
引文
[1]李新旭,周晓农,王黎霞.结核病空间分布特征及影响因素研究进展[J].中国公共卫生,2014,30(1):102-106.
[2]Ansari S,Amanullah M F,Ahmad K,et al.Pott’s spine:diagnostic imaging modalities and technology advancements[J].N Am J Med Sci,2013,5(7):404-411.
[3]Turgut M.Spinal tuberculosis(Pott's disease):its clinical presentation,surgical management,and outcome.A survey study on 694patients[J].Neurosurg Rev,2001,24(1):8-13.
[4]Wang X,Pang X,Wu P,et al.One-stage anterior debridement,bone grafting and posterior instrumentation vs.single posterior debridement,bone grafting,and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis[J].Eur Spine J,2014,23(4):830-837.
[5]Zeng H,Zhang P,Shen X,et al.One-stage posterior-only approach in surgical treatment of single-segment thoracic spinal tuberculosis with neurological deficits in adults:a retrospective study of 34cases[J].BMC Musculoskelet Disord,2015,16:186.
[6]Briggs M,Closs J S.A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients[J].J Pain Symptom Manage,1999,18(6):438-446.
[7]Frankel H L,Hancock D O,Hyslop G,et al.The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia[J].Paraplegia,1969,7(3):179-192.
[8]Bridwell K H,Lenke L G,McEnery K W,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[J]?Spine(Phila Pa 1976),1995,20(12):1410-1418.
[9]Wang B,LüG,Liu W,et al.Anterior radical debridement and reconstruction using titanium mesh cage for the surgical treatment of thoracic and thoracolumbar spinal tuberculosis:minimium five-year follow-up[J].Turk Neurosurg,2011,21(4):575-581.
[10]Tuli S M.Historical aspects of Pott's disease(spinal tuberculosis)management[J].Eur Spine J,2013,22(Suppl 4):529-538.
[11]杨学军,霍洪军,肖宇龙,等.胸腰椎结核一期病灶清除重建脊柱前中柱功能[J].中国修复重建外科杂志,2010,24(1):37-40.
[12]Jain A K,Dhammi I K.Tuberculosis of the spine:a review[J].Clin Orthop Relat Res,2007,460:39-49.
[13]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[J].中国修复重建外科杂志,2018,32(1):112-117.
[14]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[J].中国脊柱脊髓杂志,2013,23(6):488-492.
[15]Bezer M,Kucukdurmaz F,Aydin N,et al.Tuberculous spondylitis of the lumbosacral region:long-term follow-up of patients treated by chemotherapy,transpedicular drainage,posterior instrumentation,and fusion[J].J Spinal Disord Tech,2005,18(5):425-429.
[16]李仁杰,陈海,罗远健,等.单纯植骨与钛网填充植骨治疗椎体结核的疗效分析[J].山东大学学报(医学版),2011,49(6):115-118,124.
[17]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[J].PLoS One,2017,12(4):0175567.
[18]Upasani V V,Robertson C,Lee D,et al.Biomechanical comparison of kyphoplasty versus a titanium mesh implant with cement for stabilization of vertebral compression fractures[J].Spine(Phila Pa 1976),2010,35(19):1783-1788.
[19]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[J].中华创伤骨科杂志,2008,10(3):260-265.
[20]Faraj A A,Webb J K.Spinal instrumentation for primary pyogenic infection report of 31patients[J].Acta Orthop Belg,2000,66(3):242-247.
[21]Oga M,Arizono T,Takasita M,et al.Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis.Clinical and biologic study[J].Spine(Phila Pa1976),1993,18(13):1890-1894.
[22]李玉伟,王海蛟,崔巍,等.单纯前路或后路病灶清除植骨融合内固定术治疗腰椎结核的疗效对比[J].中国脊柱脊髓杂志,2017,27(12):1081-1086.
[2]Ansari S,Amanullah M F,Ahmad K,et al.Pott’s spine:diagnostic imaging modalities and technology advancements[J].N Am J Med Sci,2013,5(7):404-411.
[3]Turgut M.Spinal tuberculosis(Pott's disease):its clinical presentation,surgical management,and outcome.A survey study on 694patients[J].Neurosurg Rev,2001,24(1):8-13.
[4]Wang X,Pang X,Wu P,et al.One-stage anterior debridement,bone grafting and posterior instrumentation vs.single posterior debridement,bone grafting,and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis[J].Eur Spine J,2014,23(4):830-837.
[5]Zeng H,Zhang P,Shen X,et al.One-stage posterior-only approach in surgical treatment of single-segment thoracic spinal tuberculosis with neurological deficits in adults:a retrospective study of 34cases[J].BMC Musculoskelet Disord,2015,16:186.
[6]Briggs M,Closs J S.A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients[J].J Pain Symptom Manage,1999,18(6):438-446.
[7]Frankel H L,Hancock D O,Hyslop G,et al.The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia[J].Paraplegia,1969,7(3):179-192.
[8]Bridwell K H,Lenke L G,McEnery K W,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[J]?Spine(Phila Pa 1976),1995,20(12):1410-1418.
[9]Wang B,LüG,Liu W,et al.Anterior radical debridement and reconstruction using titanium mesh cage for the surgical treatment of thoracic and thoracolumbar spinal tuberculosis:minimium five-year follow-up[J].Turk Neurosurg,2011,21(4):575-581.
[10]Tuli S M.Historical aspects of Pott's disease(spinal tuberculosis)management[J].Eur Spine J,2013,22(Suppl 4):529-538.
[11]杨学军,霍洪军,肖宇龙,等.胸腰椎结核一期病灶清除重建脊柱前中柱功能[J].中国修复重建外科杂志,2010,24(1):37-40.
[12]Jain A K,Dhammi I K.Tuberculosis of the spine:a review[J].Clin Orthop Relat Res,2007,460:39-49.
[13]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[J].中国修复重建外科杂志,2018,32(1):112-117.
[14]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[J].中国脊柱脊髓杂志,2013,23(6):488-492.
[15]Bezer M,Kucukdurmaz F,Aydin N,et al.Tuberculous spondylitis of the lumbosacral region:long-term follow-up of patients treated by chemotherapy,transpedicular drainage,posterior instrumentation,and fusion[J].J Spinal Disord Tech,2005,18(5):425-429.
[16]李仁杰,陈海,罗远健,等.单纯植骨与钛网填充植骨治疗椎体结核的疗效分析[J].山东大学学报(医学版),2011,49(6):115-118,124.
[17]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[J].PLoS One,2017,12(4):0175567.
[18]Upasani V V,Robertson C,Lee D,et al.Biomechanical comparison of kyphoplasty versus a titanium mesh implant with cement for stabilization of vertebral compression fractures[J].Spine(Phila Pa 1976),2010,35(19):1783-1788.
[19]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[J].中华创伤骨科杂志,2008,10(3):260-265.
[20]Faraj A A,Webb J K.Spinal instrumentation for primary pyogenic infection report of 31patients[J].Acta Orthop Belg,2000,66(3):242-247.
[21]Oga M,Arizono T,Takasita M,et al.Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis.Clinical and biologic study[J].Spine(Phila Pa1976),1993,18(13):1890-1894.
[22]李玉伟,王海蛟,崔巍,等.单纯前路或后路病灶清除植骨融合内固定术治疗腰椎结核的疗效对比[J].中国脊柱脊髓杂志,2017,27(12):1081-1086.