Wiltse入路一期腰椎结核病灶及腰大肌脓肿清除的临床研究

发布时间：2018-03-23 10:56

本文选题：Wiltse入路　切入点：一期手术　出处：《山西医科大学》2017年硕士论文

【摘要】：目的:探讨经Wiltse入路一期行腰椎结核病灶清除及腰大肌脓肿引流的可行性及其临床疗效分析。方法:对2012年11月至2016年5月间在我院诊断为腰椎结核合并腰大肌脓肿且手术采用经Wiltse入路一期行病灶清除、脓肿引流、植骨融合、椎弓根钉矫形内固定的19例患者进行回顾性分析,其中男8例,女11例;年龄(26~64)岁,平均(44±9.9)岁。术前所有患者均规范抗结核化疗2~4周,术后持续正规化疗12~18个月。详细记录患者的手术时间、术中失血量、术后引流量以及引流管拔除时间等数据。术前13例患者合并不同程度神经功能损害,ASIA分级B级3例,C级4例,D级6例。血沉(ESR)63.7±11.8mm/h;C反应蛋白(CRP)16.9±3.54mg/L。脊柱后凸Cobb角为26.9o±2.9o。疼痛视觉模拟评分(VAS)评估术后腰痛改善状况;ASIA分级评估术后1年随访时神经功能恢复程度;监测术前、术后及随访时脊柱后凸Cobb角、红细胞沉降率(ESR)及C反应蛋白(CRP)检测值水平,评价后凸畸形矫正效果和疾病控制情况;X线、CT重建及MRI检查评析内固定有无失效,植骨融合进展,腰大肌脓肿消失时间等。结果:全部患者手术过程顺利,手术时间为(121~260)min,平均(194±40)min,术中失血量为(254~580)ml,平均(410±80)ml;术后引流量为(213~477)ml,平均(340±68)ml;引流管拔除时间为4~10d,平均(6.7±1.8)d。全部患者均获得12~36个月随访,平均(22±7.0)个月。术前合并神经功能损害者获得ASIA1~3级的恢复,未合并神经功能损害者术后无显著加重。VAS评分下降说明术后腰部疼痛症状较术前有明显改善。ESR及CRP在术后6个月内均降至正常水平。术后脊柱后凸Cobb角为(8.7±1.9)o,较术前平均矫正18.2o;后凸畸形矫正在术后1年随访时有(1~3)o丢失。X线、CT重建及MRI检查证实内固定无松脱、断裂及节段塌陷,椎间实现标准骨性融合,融合时间为(4~12)个月,平均(7±2.3)个月,未发现假关节形成。腰大肌脓肿均在术后8个月内彻底消失,平均(7±1.1)个月。术后1例患者出现脑脊液漏,采取有效药物对症治疗,同时要保证引流管一直通畅并适当延长其留置时间,得到良好愈后。1例患者术后两周出现切口不愈合,经再次手术清创、置管引流持续冲洗配合有效抗感染药物对症治疗10天后痊愈。至末次随访时所有病例均未见结核复发。结论:Wiltse入路一期行腰椎结核病灶及腰大肌脓肿清除是一种可行、有效的手术方式,临床疗效确切。
[Abstract]:Objective: to investigate the feasibility and clinical effect of primary lumbar tuberculosis removal and lumbar abscess drainage via Wiltse approach. Methods: from November 2012 to May 2016, we diagnosed lumbar tuberculosis with psoas major muscle in our hospital. Patients with abscess underwent primary debridement via Wiltse approach. 19 patients with abscess drainage, bone graft fusion and pedicle screw internal fixation were retrospectively analyzed, including 8 males and 11 females, aged 26 ~ 64 years (mean 44 卤9. 9) years. All patients were treated with antituberculous chemotherapy for 24 weeks. Postoperative regular chemotherapy lasted 12 ~ 18 months. The time of operation and blood loss during operation were recorded in detail. Before operation, 13 patients were complicated with different degrees of neurologic impairment: Asia grade B, grade B, grade C, grade C, grade D, 6 cases. ESR was 63.7 卤11.8mm / h, the CRP was 16.9 卤3.54mg / L, and the Cobb angle of scoliosis was 26.9o 卤2.9o. Visual analogue score (VASS) was used to evaluate the improvement of postoperative low back pain (LBP). The levels of Cobb angle, erythrocyte sedimentation rate and C-reactive protein (CRP) of kyphosis were monitored before, after operation and at follow-up. The correction effect of kyphosis and disease control were evaluated. X-ray CT reconstruction and MRI were used to evaluate the failure of internal fixation. Progress of bone graft fusion, time of disappearance of abscess of psoas major muscle, etc. Results: all patients underwent successful operation. The operative time was 121U 260min (mean 194 卤40min), the blood loss during operation was 254m 580ml (mean 410 卤80ml), the postoperative drainage volume was 2134477ml (mean 340 卤68ml), the extubation time was 410d (mean 6.7 卤1.8d). All the patients were followed up for 1236 months. The average time was 22 卤7. 0 months. The patients with neurologic impairment received ASIA1~3 grade recovery before operation. There was no significant exacerbation after operation. The decrease of VAS score showed that the symptoms of postoperative lumbar pain were significantly improved. ESR and CRP decreased to normal level within 6 months after operation. The Cobb angle of kyphosis after operation was 8.7 卤1.9 o.Compared with surgery. The average correction of anterior kyphosis was 18.2o.The correction of kyphosis was confirmed by CT reconstruction and MRI examination. Fracture and segmental collapse, standard bone fusion between vertebrae, fusion time was 412 months (mean 7 卤2.3) months, no pseudarthrosis was found. Abscess of psoas major abscess disappeared completely within 8 months after operation. The average time was 7 卤1.1 months. One patient had cerebrospinal fluid leakage after operation and was treated with effective drugs. At the same time, the drainage tube should be kept unobstructed and its retention time should be prolonged properly. The incision nonunion occurred in 1 case after good recovery two weeks after operation. After reoperation, After 10 days of continuous drainage and effective antiseptic therapy, no recurrence of tuberculosis was found in all the patients. Conclusion it is feasible to remove lumbar tuberculosis focus and abscess of psoas major muscle at one stage via the WW Wiltse approach. The effective operation method, the clinical curative effect is definite.
【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.2

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