一期后前联合入路与单纯后路手术治疗下腰椎结核的疗效比较

发布时间：2018-09-02 05:29

【摘要】：目的比较一期后前联合入路与单纯后路手术治疗下腰椎结核的疗效差异,为临床选择恰当术式治疗下腰椎结核提供参考。方法回顾性分析2010年1月—2014年11月手术治疗并获完整随访的48例下腰椎结核患者临床资料,其中采用一期后路固定联合前路病灶清除植骨融合术治疗28例(联合入路组),单纯后路椎弓根钉固定病灶清除植骨融合术治疗20例(单纯后路组)。两组患者性别、年龄、病程、病变节段以及合并症等一般资料比较,差异均无统计学意义(P0.05),具有可比性。记录并比较两组患者手术时间、术中出血量、术后卧床时间及疼痛视觉模拟评分(VAS);根据美国脊柱损伤协会(ASIA)分级标准评估神经功能情况,Bridwell骨融合标准及CT骨融合标准评估植骨融合情况,红细胞沉降率检查结果评价结核控制情况,Oswestry功能障碍指数(ODI)评估腰部功能恢复情况。结果单纯后路组手术时间、术中出血量及术后卧床时间均显著低于联合入路组(P0.05)。联合入路组术中1例发生髂血管损伤,单纯后路组术后2例出现窦道形成;无其他相关并发症发生。两组患者术后均获随访,联合入路组随访时间为13~35个月,平均15.7个月;单纯后路组为15~37个月,平均16.3个月。末次随访时,两组患者结核中毒症状均消失,术前伴有神症状及体征患者其神经功能ASIA分级均恢复至E级。两组患者术前及术后1年、末次随访时VAS评分、红细胞沉降率比较,术前及末次随访时ODI比较,差异均无统计学意义(P0.05);组内术后以上指标均较术前明显改善(P0.05)。影像学复查显示,两组随访期间均未出现内固定物断裂、松动及拔钉等。末次随访时,联合入路组及单纯后路组植骨融合率根据Bridwell骨融合标准分别为89.29%(25/28)、80.00%(16/20),根据CT骨融合标准分别为96.43%(27/28)、90.00%(18/20);组间植骨融合比较差异无统计学意义(P0.05)。结论一期后前联合入路与单纯后路手术治疗下腰椎结核均可获得满意疗效。对于结核病灶位于前柱,骶前或腰大肌脓肿形成,结核累及多个节段的患者,建议选择后前联合入路;结核病灶位于中后柱、前路血管分叉阻挡、不能耐受联合入路手术患者或术前影像学评估经后路能清除病灶时,宜选择单纯后路手术。
[Abstract]:Objective to compare the curative effect of primary anterior combined approach and simple posterior approach in the treatment of lower lumbar tuberculosis, and to provide a reference for clinical treatment of lower lumbar tuberculosis. Methods from January 2010 to November 2014, 48 patients with lower lumbar tuberculosis who received surgical treatment and received complete follow-up were retrospectively analyzed. One stage posterior fixation combined with anterior debridement and fusion was performed in 28 cases (combined approach group) and 20 cases were treated by posterior pedicle screw fixation only (posterior approach group). There was no significant difference in sex, age, course of disease, pathological segment and complications between the two groups (P0.05). The operative time and blood loss were recorded and compared between the two groups. Postoperative bed-rest time and pain visual analogue score (VAS); evaluated neurological function according to the American Spinal injury Association (ASIA) grading criteria and the Bridwell bone fusion criteria and the CT bone fusion criteria for the evaluation of bone graft fusion. The results of erythrocyte sedimentation rate were used to evaluate tuberculosis control. Oswestry dysfunction index (ODI) was used to evaluate the recovery of lumbar function. Results the time of operation, the amount of intraoperative bleeding and the time of bed-rest after operation in simple posterior approach group were significantly lower than those in combined approach group (P0.05). Iliac vascular injury occurred in 1 case in the combined approach group and sinus formation in 2 cases in the simple posterior approach group without other related complications. The follow-up time of the combined approach group was 13 ~ 35 months with an average of 15.7 months, and that of the simple posterior approach group was 15 ~ 37 months with an average of 16.3 months. At the last follow-up, the symptoms of tuberculosis poisoning disappeared in both groups, and the ASIA grade of neurological function recovered to grade E in patients with mental symptoms and signs before operation. There was no significant difference between the two groups in VAS score and erythrocyte sedimentation rate at the last follow-up and ODI before and after the last follow-up (P0.05). The above indexes in the group were significantly improved after operation (P0.05). Imaging examination showed that there were no internal fixation breakage, loosening and nailing in the two groups during the follow-up period. At the last follow-up, the graft fusion rates of the combined approach group and the simple posterior approach group were 89.29% (25 / 28), 80.00% (16 / 20) and 96.43% (27 / 28), 90.00% (18 / 20), respectively, according to the Bridwell bone fusion criteria (P0.05). Conclusion one-stage anterior combined approach and simple posterior approach for the treatment of lumbar tuberculosis can obtain satisfactory results. For patients whose tuberculosis foci are located in anterior column, anterior sacral or psoas abscess, and tuberculosis involving multiple segments, it is recommended to select the posterior anterior combined approach, and the tuberculosis focus is located in the middle and posterior column, and the anterior vascular bifurcation is blocked. Patients who can not tolerate combined approach or preoperative imaging evaluation can clear lesions by posterior approach should choose simple posterior approach.
【作者单位】：西南医科大学附属医院脊柱外科;西南医科大学附属医院病理科;
【分类号】：R687.3

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