胸椎结核治疗的术式选择：81例分析

Surgery option for thoracic spinal tuberculosis: analysis of 81 cases

摘要:

目的 回顾性分析成人胸椎结核的手术方法及疗效，探讨胸椎结核术式选择的适应证。方法 2001年1月至2010年12月采用不同手术方法治疗成年胸椎结核患者112例，81例非跳跃性结核患者获得平均37（17～72）个月的随访。其中有23例合并脊髓功能障碍。根据病灶部位和病变程度采用5种手术方式：A组（18例），胸廓内胸膜外病灶清除、植骨融合内固定术；B组（21例），经胸病灶清除、植骨融合内固定术；C组（10例），胸膜外经肋横突入路病灶清除、植骨融合内固定术；D组（27例），后路固定一期或二期前路经胸或胸膜外病灶清除、植骨融合内固定术；E组（5例），上胸段结核胸骨柄或胸骨劈开入路病灶清除、植骨融合内固定术。结果 （1）手术时间和出血量：手术平均时间A，B，C，D，E组分别为3.5，3.0，3.0，4.5，4.0h；术中平均出血量A，B，C，D，E组分别为350，450，300，640，600ml。（2）脊柱后凸畸形矫正率：A组（47.5±11.8）%，B组（46.9±10.2）%，C组（59.9±17.4）%，D组（61.7±18.6）%，E组（44.1±8.7）%。（3）末次随访时矫正角度丢失率：A组（64.2±19.1）%，B组（63.8±18.1）%，C组（56.9±11.8）%，D组（53.6±15.6）%，E组（63.5±17.1）%。23例伴有脊髓压迫症状的患者中神经功能Frankel分级至少提高了一级。结论 胸椎结核的术式选择应根据病变的部位、范围以及患者的一般状态而定。老龄患者由于体质差，最好采用胸膜外经肋横突入路病灶清除、植骨融合内固定术。后路固定在矫正脊柱后凸畸形及维持矫形方面要优于前路固定。

Abstract:

Objective To investigate the surgical indications by retrospectively analyzing the surgical methods and outcomes in 71 cases with thoracic spinal tuberculosis (TB). Methods Between January 2001 and December 2010, 112 adult patients with thoracic spinal TB were treated with different surgical procedures. We followed up 81 patients (average age 38 years, range 17-68 years), without multiple-level noncontiguous spinal TB, for 17-72 months (mean 37 months), in which 23 patients had neurological deficits. The patients were divided into 5 groups receiving different procedures according to location and extent of the lesion: group A (18 cases) receiving anterior radical debridement and strut grafting with instrumentation by extrapleural approach; group B (21 cases) getting anterior radical debridement and strut grafting with instrumentation by transthoracic approach; group C (10 cases) having posterolateral decompression and strut grafting with posterior instrumentation; group D (27 cases) receiving posterior instrumentation and interlaminar bone grafting with anterior radical debridement and strut grafting in one-stage or two-stage; group E (10 cases) having anterior radical debridement and strut grafting by splitting the manubrium of sternum or the breast bone in the treatment of upper thoracic spinal TB. Results (1) The average operation time and blood loss were 3.5h and 350ml in group A, 3.0h and 350 ml in group B, 3.0h and 300ml in group C, 4.5h and 640ml in group D, and 4.0h and 600ml in group E respectively. (2) The degree of kyphosis was corrected by (47.5±11.8)% in group A, (46.9±10.2)% in group B, (59.9±17.4)% in group C, (61.7±18.6)% in group D, and (44.1±8.7)% in group E respectively. (3) The correction loss at last visit was (64.8±19.3)% in group A, (53.6±15.6)% in group B, (56.9±11.8)% in group C, (54.9±15.4)% in group D, and (44.1±8.7)% in group E respectively. All the 23 cases with neurological deficit were improved at least one grade according to Frankel scoring system. Conclusion These results suggest that all the surgical procedures can obtain good results in correction and maintenance of the deformity, clearance of the foci, decompression of the spinal cord and pain relief in the treatment of thoracic spinal TB, providing that the patients are chosen correctly according to location and extent of the lesions, and patients’ general health status. Posterolateral decompression and strut grafting with posterior instrumentation is recommended for the elderly considering their poor general health condition. Posterior instrumentation may be superior to anterior instrumentation in correction and maintenance of the deformity.