颈胸段脊柱结核的手术治疗策略

发布时间：2018-08-30 09:38

【摘要】：目的:探讨颈胸段脊柱结核病灶部位与胸骨柄上缘切迹位置关系对手术治疗策略选择的影响及临床预后。方法:2003年1月~2013年1月45例颈胸段脊柱结核患者采用手术治疗,其中男29例,女16例;年龄17~62岁(35.4±16.7岁)。病变节段:C7~T1 8例,T1 11例,T1~T2 7例,T2 6例,T2~T3 8例,T3 5例。术前神经功能ASIA分级:A级2例,B级5例,C级9例,D级22例,E级7例。术前颈胸段后凸成角、颈椎残障功能量表(neck disability index,NDI)评分和JOA评分分别为34.7°±6.8°、39.6±4.6及10.7±2.8。根据患者颈胸段MRI矢状位上胸骨柄上缘切线与结核病灶的关系采取不同手术方案,19例椎体结核病灶位于胸骨柄上缘水平切迹线之上的患者采用一期前路病灶清除、植骨融合内固定术,26例病灶平齐于胸骨柄上缘水平切迹线或在之下的患者采用一期前路病灶清除、植骨融合及后路植骨融合内固定术。术前及术后均用四联敏感抗结核药物规律治疗。对患者后凸成角、NDI评分和JOA评分变化情况进行统计学分析来评价疗效。结果:手术时间为178.0±48.3min;术中出血量为590.0±76.4ml。随访6.6±3.2年(3~13年),在随访期内无内固定松动、断裂、失败等情况出现。末次随访时患者颈胸段后凸成角、NDI评分及JOA评分分别为10.2°±2.4°、11.4±3.6及17.6±2.4,与术前比较均有统计学差异(P0.05)。1例单纯行一期前路病灶清除、植骨融合内固定术治疗的患者在术后6个月时手术切口窦道形成,再次行一期前路内固定取出、病灶扩大清除植骨融合和二期后路植骨融合内固定治疗,随访5.5年结核治愈。其余44例患者在术后7.2±1.1个月获得融合。在伴有神经功能减退的38例患者中,29例(76%)末次随访时神经功能ASIA分级提高1~3级,9例分级无变化。结论:颈胸段脊柱结核患者在规律抗结核药物治疗的基础上,根据患者颈胸段MRI矢状位上胸骨柄上缘切线与结核病灶的关系,对不同类型患者采用不同手术方式可完成彻底的病灶清除、固定及融合,中长期随访效果较好。
[Abstract]:Objective: to investigate the relationship between the location of cervical and thoracic spinal tuberculosis and the location of superior margin notch of sternum stalk on the choice of surgical treatment strategy and clinical prognosis. Methods: from January 2003 to January 2013, 45 patients with cervical and thoracic spinal tuberculosis were treated with surgical treatment, including 29 males and 16 females, with an age of 1762 years (35.4 卤16.7 years). There were 8 cases of T 1 with T1T 1 and 7 cases of T 2 T 2 T 2 with T 2 T 3 in 8 cases with T 2 T 3 and T 3 with T 3 in 8 cases. Preoperative neurological function ASIA grade: 2 cases were grade A, 5 cases were grade B, 9 cases were grade C, 22 cases were grade D, 7 cases were grade E. (neck disability index,NDI and JOA scores were 34.7 掳卤6.8 掳and 39.6 卤4.6 and 10.7 卤2.8 respectively. According to the relationship between the superior margin tangent of the superior sternum in the MRI sagittal position of the cervical and thoracic segment and the tuberculosis foci, 19 patients with vertebral tuberculosis foci located above the horizontal notch line of the superior sternum were removed by one stage anterior approach. Bone graft fusion and internal fixation were performed in 26 patients whose lesions were flat at the upper margin of sternum or below the horizontal incisors of sternum by one stage anterior debridement, bone graft fusion and posterior bone graft fusion and internal fixation. All patients were treated with four-drug-sensitive anti-tuberculosis drugs before and after operation. NDI score and JOA score were statistically analyzed to evaluate the curative effect. Results: the operative time was 178.0 卤48.3 min and the intraoperative bleeding was 590.0 卤76.4 ml. Follow-up of 6.6 卤3.2 years (3 ~ 13 years) showed no internal fixation loosening, fracture and failure. At the last follow-up, the scores of NDI and JOA were 10.2 掳卤2.4 掳11.4 卤3.6 and 17.6 卤2.4 respectively, which were significantly different from those before operation (P0.05). The patients treated with bone graft fusion and internal fixation were treated with incision sinus formation at 6 months after operation and were treated with one stage anterior fixation, extensive debridement and bone grafting fusion and secondary posterior bone graft fusion internal fixation. The tuberculosis was cured at a follow-up of 5.5 years. The remaining 44 patients were fused at 7.2 卤1.1 months postoperatively. Of the 38 patients with neurologic dysfunction, 29 (76%) had no change in the ASIA grade at the last follow-up. Conclusion: on the basis of regular antituberculous drug therapy, the relationship between the superior margin of sternum in MRI sagittal position of cervical and thoracic segment and the focus of tuberculosis was found in patients with cervical and thoracic spinal tuberculosis. For different types of patients, different surgical methods can complete focus clearance, fixation and fusion, long-term follow-up results are better.
【作者单位】：西安交通大学附属红会医院脊柱外科;
【分类号】：R687.3

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