脊柱结核死骨范围与抗结核药物治疗效果的相关性

发布时间：2018-06-25 22:44

本文选题：结核病 + 脊柱结核　；参考：《山东医药》2017年43期

【摘要】：目的探讨脊柱结核死骨范围和抗结核药物治疗效果的相关性。方法选择相邻双椎体脊柱结核患者96例,进行前瞻性队列研究。采用东芝Aquillon one 320排螺旋CT对病灶区进行层厚0.5 mm的连续扫描,并进行二维重建,分别选取病灶区横断面、冠状面和矢状面死骨范围最大的层面,用320排螺旋CT的面积测量工具测量该层面死骨面积。横断面的死骨面积与相邻正常椎体横断面积比值的百分数为横断面死骨范围,冠状面的死骨面积与相邻正常椎体最大冠状面积比值的百分数为冠状面死骨范围,矢状面的死骨面积与相邻正常椎体正中矢状面积比值的百分数为矢状面死骨范围;横断面、冠状面和矢状面死骨范围之和的平均值为综合死骨范围。对96例患者采用标准抗结核化疗方案进行治疗,将治疗过程中结核中毒症状减轻、局部疼痛缓解、死骨脓肿范围缩小、血沉和C反应蛋白下降的病例判为治疗有效者,继续保守治疗至疗程满12个月;将治疗过程中死骨、脓肿范围增大,或者达到手术指征,停止保守治疗改为手术治疗的患者判为治疗无效者。对影响抗结核药物治疗效果的危险因素,包括性别、年龄、病程、死骨范围,进行Logistic回归单因素及多因素分析,判断各因素的相对危险性。利用受试者工作特征曲线(ROC)确定合适的死骨范围阳性参考值(即最适合进行抗结核药物治疗的死骨范围),此范围以上就是达到手术指征的死骨范围。结果治疗过程中1例寰枢椎结核患者因无法按照其他部位脊柱结核的测量方法测量死骨范围而被排除出组,4例因耐药排除出组(其中1例脓液穿刺培养显示耐药,1例穿刺活检耐药基因检测显示耐药,2例抗结核治疗、术后病理组织培养显示耐药),2例不具备手术指征但患者强烈要求手术而被排除出组。最终入组的89例患者中,58例抗结核药物治疗有效,31例抗结核治疗失败而采取手术治疗。89例患者年龄15~80岁(平均41.2岁),男57例、女32例,病程0.5~72个月,横断面死骨范围平均值为5.8%,冠状面死骨范围平均值为4.6%,矢状面死骨范围平均值为4.9%,综合死骨范围平均值为5.1%。Logistic逐步回归分析显示横断面死骨范围、综合死骨范围和抗结核药物治疗效果相关(P均0.01)。以横断面死骨范围作为诊断指标,适合抗结核治疗或手术治疗的最佳临界值为1.9%,其预测敏感度和特异度分别达96.77%、65.52%,横断面死骨范围超过1.9%更需要手术治疗。以综合死骨范围作为诊断指标,适合抗结核治疗或手术治疗的最佳临界值为2.6%,其预测敏感度和特异度分别为93.55%、68.97%,综合死骨范围超过2.6%更需要手术治疗。结论脊柱结核死骨范围与抗结核药物治疗效果具有相关性,横断面死骨范围超过1.9%需要手术治疗的可能性大,综合死骨范围超过2.6%需要手术治疗的可能性大。
[Abstract]:Objective to investigate the correlation between the dead bone range of spinal tuberculosis and the effect of anti tuberculosis drug treatment. Methods 96 cases of adjacent double vertebral tuberculosis were selected for prospective cohort study. Using Toshiba Aquillon one 320 row spiral CT, the thickness of the lesion area was continuously scanned with the thickness of 0.5 mm, and two dimensional reconstruction was performed to select the cross section of the lesion area and the crown respectively. The dead bone area was measured by the area measuring tool of 320 rows of spiral CT. The percentage of the ratio of the dead bone area to the adjacent normal vertebral area was the cross section of the dead bone. The percentage of the ratio of the dead bone area to the adjacent normal vertebral area was the crown. The percentage of the ratio between the dead bone area of the sagittal plane and the median sagittal area of the adjacent normal vertebral body was the dead bone range of the sagittal plane; the average value of the cross section, the average dead bone range of the coronal and sagittal plane was the comprehensive dead bone range. 96 patients were treated with the standard anti tuberculosis chemotherapy regimen, and the tuberculosis intoxication in the treatment process was carried out. The symptoms were relieved, local pain relieved, the scope of the dead bone abscess narrowed, the cases of erythrocyte sedimentation and C reaction protein decline were judged to be effective, and continued conservative treatment lasted for 12 months; the dead bone, the abscess range increased, or the surgical indication was reached, and the patients who had stopped conservative treatment to surgical treatment were judged to be ineffective. The risk factors for the effect of anti tuberculosis drugs, including sex, age, course of disease, dead bone range, single factor and multi factor analysis of Logistic regression, were used to determine the relative risk of each factor. The positive reference value of the suitable dead bone range was determined by using the working characteristic curve (ROC) of the subjects (that is, the most suitable for anti tuberculosis drug treatment. " 1 cases of atlantoaxial tuberculosis were excluded because of the failure to measure the range of the dead bone according to the measurement of other parts of the spinal tuberculosis, and 4 cases were excluded from the drug resistance group (1 cases of pus piercing culture showed resistance, 1 cases of drug-resistant biopsies. " 2 cases of anti tuberculosis treatment and postoperative pathological tissue culture showed drug resistance. 2 cases had no indications of surgery but the patients were strongly required to be excluded from the operation. Of the 89 patients, 58 cases of anti tuberculosis drugs were effective, 31 cases of anti tuberculosis treatment failed and.89 patients were aged 15~80 years old (average 41.2 years old). There were 57 men and 32 women, with a course of 0.5~72 months, the average value of the dead bone range was 5.8%, the average of the dead bone range was 4.6%, the average of the dead bone of the sagittal plane was 4.9%. The average dead bone range was 5.1%.Logistic stepwise regression analysis showed the cross section of the dead bone range, and the comprehensive range of dead bone was related to the effect of anti tuberculosis drug treatment (P all 0.01. As a diagnostic index, the optimum critical value for the treatment of anti tuberculosis or surgical treatment is 1.9%, and its predictive sensitivity and specificity are 96.77%, 65.52%, and more than 1.9% of the cross section of the dead bone need surgical treatment. The critical value was 2.6%, its predictive sensitivity and specificity were 93.55%, 68.97%, and the comprehensive range of dead bone was more than 2.6%. Conclusion the dead bone range of spinal tuberculosis was related to the effect of anti tuberculosis drug treatment. The possibility of surgical treatment in the cross section of the cross section of the cross section was greater than 1.9%, and the comprehensive range of dead bone was more than 2.6%. The possibility of surgical treatment is great.
【作者单位】：中国人民解放军第309医院;吉林省长春通源医院北京阜外医院吉林诊疗中心;
【基金】：首都临床特色应用研究项目(Z141107002514055)
【分类号】：R529.2

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