手术治疗腰骶椎结核的术式选择

发布时间：2018-07-05 18:55

本文选题：脊柱结核 + 腰骶椎　；参考：《中国脊柱脊髓杂志》2017年02期

【摘要】：目的:回顾性分析一期后路病灶清除内固定椎体间植骨融合术与一期后路内固定联合前路病灶清除、椎体间植骨融合术治疗成人腰骶椎(L5-S1)结核的临床疗效。方法:2010年1月~2014年11月,我院采用手术治疗腰骶椎结核患者21例,男11例,女10例;年龄17~62岁(38.9±14.3岁);病程10~21个月(16.1±2.7个月)。术前抗结核药物治疗2~4周。8例以椎体破坏为主,无脓肿形成/较小椎旁脓肿或椎管内脓肿;前方存在较高血管损伤风险的患者采用一期后路固定病灶清除椎体间植骨融合术(单纯后路手术组)。13例血管分叉高,具有足够的手术操作空间;有流注脓肿形成;前中柱广泛破坏,后方病灶清除困难者采用一期后路固定联合前路病灶清除、椎体间植骨融合术(后前路联合手术组)。术后均继续抗结核药物治疗12~18个月。记录两组患者手术时间、术中失血量、卧床时间、手术前后疼痛视觉模拟评分(visual analogue scale,VAS)及神经功能改善情况,腰椎正侧位X线片或三维CT评估植骨融合情况,监测血沉、C-反应蛋白评价结核控制情况。结果:单纯后路组手术时间161.2±15.6min,失血量695.2±153.2ml,卧床时间8.5±2.5d;后前路联合入路组手术时间233.6±22.7min,失血量862.0±208.5ml,卧床时间16.9±2.0d。两组患者末次随访时VAS评分、血沉、C-反应蛋白较术前明显改善,差异具有统计学意义(P0.05)。单纯后路组术后窦道形成2例;后前路联合手术组患者前路手术术中髂血管损伤1例,男性患者术后出现逆行性射精1例。末次随访时两组患者均获得骨性融合,未出现内固定失败。结论:单纯后路手术治疗以椎体破坏为主,无脓肿形成或较小椎旁脓肿或椎管内脓肿的腰骶椎结核可以获得满意的疗效;伴有较大骶骨前脓肿、病灶位于前柱的患者应采用后前联合入路手术,且需要髂血管分叉高,具有足够的手术操作空间。
[Abstract]:Objective: to retrospectively analyze the clinical effect of one stage posterior debridement and interbody fusion combined with one stage posterior internal fixation combined with anterior debridement and interbody fusion in the treatment of adult lumbosacral tuberculosis (L5-S1). Methods: from January 2010 to November 2014, 21 patients (male 11, female 10) with lumbosacral tuberculosis were treated in our hospital, the age was 1762 (38.9 卤14.3 years), the course of disease was 10 ~ 21 months (16.1 卤2.7 months). 8 cases were treated with antituberculotic drugs for 2 weeks before operation, but no abscess or small paravertebral abscess or intraspinal abscess was found in 8 cases. The patients with high risk of vascular injury were treated with one stage posterior fixed lesion debridement and interbody fusion (simple posterior approach group). 13 patients with high vascular bifurcation had sufficient operation space, and there were effusion abscess formation. The anterior and middle columns were extensively destroyed and the posterior debridement was performed with one stage posterior fixation combined with anterior debridement and interbody bone grafting and fusion (posterior anterior combined operation group). All patients were treated with antituberculous drugs for 12 ~ 18 months. The time of operation, the amount of blood lost during operation, the time of bed rest, the visual analogue score of (visual analogue scale before and after operation and the improvement of nerve function were recorded. ESR C-reactive protein was used to evaluate TB control. Results: the operation time, blood loss and bed rest time were 161.2 卤15.6 min, 695.2 卤153.2 ml and 8.5 卤2.5 days in the simple posterior approach group, and 233.6 卤22.7 min, 862.0 卤208.5 ml and 16.9 卤2.0 days in the posterior combined approach group. At the last follow-up, the scores of VAS and erythrocyte sedimentation rate (ESR) were significantly improved in the two groups (P0.05). There were 2 cases of sinus formation in simple posterior approach group, 1 case of iliac vascular injury in anterior approach group and 1 case of retrograde ejaculation in male group. At the last follow-up, bone fusion was achieved in both groups without failure of internal fixation. Conclusion: lumbar and sacral tuberculosis with no abscess or small paravertebral abscess or intraspinal abscess can be treated with simple posterior approach, with large anterior sacral abscess. Patients with lesions located in anterior column should be operated by posterior anterior combined approach with high iliac artery bifurcation and sufficient operation space.
【作者单位】：西南医科大学附属医院脊柱外科;
【分类号】：R687.3

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