| 王 彪,郝定均,郭 华,李 辉,王晓东,朱子奇.颈胸段脊柱结核的手术治疗策略[J].中国脊柱脊髓杂志,2017,(2):97-103. |
| 颈胸段脊柱结核的手术治疗策略 |
| 中文关键词: 脊柱结核 颈胸段脊柱 手术方式 |
| 中文摘要: |
| 【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（P<0.05）。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。 |
Selection of surgical treatment approaches for cervicothoracic spinal tuberculosis |
| 英文关键词:Spinal tuberculosis Cervicothoracic Surgical approach |
| 英文摘要: |
| 【Abstract】 Objectives: To explore the selection of surgical treatment according to the relation between the tuberculosis lesion segments and the suprasternal notch and the clinical outcomes for cervicothoracic spinal tuberculosis. Methods: From January 2003 to January 2013, 45 patients suffering from cervicothoracic spinal tuberculosis were treated surgically, among whom 29 were males and 16 were females, the average age was 35.4±16.7(range, 17 to 62) years. The pathologic change regions were as follows: C7-T1 in 8 cases, T1 in 11 cases, T1-T2 in 7 cases, T2 in 6 cases, T2-T3 in 8 cases and T3 in 5 cases. The presurgical neurological and functional classifications were class A for 2 case, B for 5 cases, C for 9 cases, D for 22 cases and E for 7 cases according to the American Spinal Injury Association(ASIA) system. According to the relation between tuberculosis lesion segments and suprasternal notch on sagittal MRI, 19 patients were treated with a single-stage anterior debridement, fusion and instrumentation approach, that the tuberculosis focus was located higher than the suprasternal notch level. The other 26 patients were treated with a single-stage anterior debridement and fusion, posterior fusion and instrumentation approach, that the tuberculosis focus lied right on the suprasternal notch level or lower than the suprasternal notch level. Quadruple sensitive anti-TB drug treatment was used in all 45 patients preoperatively and postoperatively. The clinical efficacy was evaluated by using statistical analysis based on the cervicothoracic angle of kyphosis, neck disability index(NDI) and Japanese Orthopedic Association(JOA) scoring system, which were 34.7°±6.8°, 39.6±4.6 and 10.7±2.8, preoperatively. Results: The mean surgical duration was 178.0±48.3 minutes. Intraoperative blood loss was averagely 590.0±76.4 milliliters. All patients were followed up for 6.6±3.2(3 to 13) years in average. No instrumentation loosening, migration or breakage was observed during the follow-up. The kyphosis angle, NDI and JOA scores were significantly changed to 10.2°±2.4°, 11.4±3.6 and 17.6±2.4 at last follow-up(P<0.05). One patient received single-stage anterior debridement, intervertebral fusion and internal fixation presented with a sinus of incision at 6-month follow-up. This particular patient then received one-stage anterior instrumentation removal, radical debridement and intervertebral fusion, second-stage posterior fusion and instrumentation. After a follow-up period of 5.5 years, the clinical cure of tuberculosis disease was observed. Bone fusion was achieved in the other 44 patients within 7.2±1.1 months. In 38 cases complicated with neurological disorders, 29(76%) showed 1 to 3 degrees of neurological functional recovery, and the left 9 patients showed no neurological functional changes. Conclusions: On the basis of regular anti-tuberculosis treatment, according to the anatomical relation of suprasternal notch and the cervicothoracic spinal tuberculosis diseased segments revealed on sagittal MRI images, different surgical approachs can achieve completely debridement, fixation and fusion. In that case, good clinical results will be obtained through medium and long term follow-up observation. |
| 投稿时间：2016-11-01 修订日期：2017-01-21 |
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