脊柱结核再次手术原因分析及治疗方案选择的临床回顾性研究

发布时间：2018-09-08 12:05

【摘要】：背景由于耐药结核发病率的不断上升,全球结核发病率呈回升态势,中国是结核病高负担国家,结核疫情形势严峻,脊柱结核的治疗面临着新的挑战。而欧美等发达国家,结核病发病率较低,研究报道的信息较少,可供借鉴学习的经验不多,对于复发复治脊柱结核的经验就更为匮乏。目前,由于多种原因导致国内脊柱结核复发复治的病例日益增多,脊柱结核病带给患者巨大痛苦。尽管国内临床医生在抗结核治疗的用药原则,手术治疗等方面主流意见形成诸多共识,但国内学者对脊柱结核复发原因和再次手术治疗方案的选择问题上,争议不断。基于上述背景,本课题围绕脊柱结核复发再次手术的原因进行分析,对个体化治疗策略展开临床回顾性研究,以期在脊柱结核的个体化治疗中减少复发,使患者达到更好的预后,避免二次手术或多次手术带来的痛苦。目的:分析导致脊柱结核复发再次手术的主要原因,探讨再次手术个体化治疗方案选择,以提高脊柱结核治愈率。方法:回顾性分析于2000年1月至2012年12月在我院骨科行手术治疗的脊柱结核患者861例。通过对医院病历管理系统查找,结合PACS系统和CIS系统比对患者信息,采用电话、邮件、网络、门诊等方式进行随访,筛选出脊柱结核复发后再次手术治疗患者71例,设为复发组,其中男42例,女29例;初次手术时年龄5-72岁,平均34.3岁;术后服药1周~120个月,复发病程0.5个月至516个月。按照性别匹配的原则1:1配比71例设为未复发组。应用卡方检验和Logistic回归分析的统计学方法,对导致脊柱结核术后复发的多种危险因素相关性进行分析。71例复发患者采取个体化手术方式:病灶清除术、窦道切除术4例,单纯病灶清除术16例,一期前路病灶清除植骨融合内固定术11例,一期后路病灶清除植骨融合内固定术24例,一期前后路联合入路病灶清除植骨融合内固定术4例,二期前后联合入路病灶清除植骨融合内固定术5例,CT引导下穿刺置管引流局部化疗术7例。术后定期复查血沉、C反应蛋白、X线、CT三维重建、MRI,并行个体化抗结核药物治疗12~18个月。结果:再次手术中无脊髓神经损伤,大血管损伤等严重并发症。再次手术后随访时间24个月至108个月,平均29个月。根据Bridwell标准,62例椎间植骨内固定的患者达到I级骨性融合标准,5例椎间骨桥形成,末次随访4例仍未治愈。多因素分析结果提示,导致复发再手术的主要原因是:耐药脊柱结核发病率的逐渐增高,不规范的抗结核药物治疗等。结论:脊柱结核术后复发原因与结核耐药和不规范的抗结核治疗密切相关,再次手术治疗时应制定个体化治疗方案。在规范化抗结核治疗的基础上,根据患者病情特征,椎体受累情况,个体化选择手术方案,可以有效避免脊柱结核术后复发。
[Abstract]:Background due to the increasing incidence of drug-resistant tuberculosis, the global TB incidence is rising. China is a high-burden country with TB, the epidemic situation of TB is severe, and the treatment of spinal tuberculosis is facing new challenges. In the developed countries, such as Europe and America, the incidence of tuberculosis is low, the information of research report is less, the experience of learning can be used for reference is not much, and the experience of relapsing and retreating spinal tuberculosis is even less. At present, there are more and more recurrent cases of spinal tuberculosis in China due to various reasons, and spinal tuberculosis brings great pain to patients. Although there is a lot of consensus among domestic clinicians on the principle of antituberculous treatment, surgical treatment and so on, there are many controversies among domestic scholars on the cause of recurrence of spinal tuberculosis and the choice of reoperation treatment. Based on the above background, this paper analyzes the causes of recurrence of spinal tuberculosis and carries out a clinical retrospective study on individualized treatment strategies in order to reduce recurrence in individualized treatment of spinal tuberculosis. To achieve a better prognosis and avoid the pain of secondary or multiple operations. Objective: to analyze the main causes of recurrence of spinal tuberculosis and discuss the choice of individual treatment scheme for reoperation in order to improve the cure rate of spinal tuberculosis. Methods: from January 2000 to December 2012, 861 patients with spinal tuberculosis underwent orthopedic surgery in our hospital. By searching the hospital medical record management system and comparing the patient information with PACS system and CIS system, 71 patients with recurrent spinal tuberculosis were selected by telephone, mail, network, outpatient service and so on. The patients were divided into recurrence group (42 males and 29 females), the age of the first operation was 5-72 years old (mean 34.3 years), the course of recurrence was 0.5 months to 516 months after operation, and the duration of recurrence was 0.5 months to 516 months. According to the principle of gender matching, 71 cases were assigned to no recurrence group at 1:1. By means of chi-square test and Logistic regression analysis, the correlation of multiple risk factors leading to recurrence of spinal tuberculosis after operation was analyzed. 71 patients with recurrent spinal tuberculosis were treated with individualized surgical methods: focal debridement, sinus excision (4 cases), sinus excision (4 cases). There were 16 cases of simple focal debridement, 11 cases of primary anterior debridement and fusion fixation, 24 cases of primary and posterior debridement and internal fixation of bone graft, 4 cases of primary anterior and posterior combined approach, 4 cases of bone graft fusion and internal fixation. Local chemotherapy was performed in 5 cases with CT guided puncture and drainage by combined approach of debridement, bone grafting, fusion and internal fixation. Three dimensional reconstruction of MRI with C reactive protein X ray and CT was performed regularly after operation, and then treated with antituberculous drugs for 12 ~ 18 months. Results: there were no serious complications such as spinal cord nerve injury and major vascular injury. The follow-up time was 24 months to 108 months (mean 29 months). According to the Bridwell standard, 62 patients with intervertebral bone graft and internal fixation met the grade I bone fusion standard. 5 cases had bone bridge formation, and 4 cases had not been cured at the last follow-up. The results of multivariate analysis showed that the main causes of recurrence and reoperation were the increasing incidence of drug-resistant spinal tuberculosis and nonstandard antituberculous drug therapy. Conclusion: the causes of postoperative recurrence of spinal tuberculosis are closely related to drug resistance and nonstandard antituberculous therapy. On the basis of standardized antituberculous therapy, according to the patient's condition, vertebral body involvement and individualized choice of surgical scheme, recurrence of spinal tuberculosis can be effectively avoided.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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