中国修复重建外科杂志

中国修复重建外科杂志

手术时机对胸椎结核伴脊髓损害疗效的影响

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目的探讨后路病灶清除脊髓减压植骨内固定治疗伴脊髓损害的胸椎结核的可行性,比较手术时机对术后疗效的影响。方法回顾分析 2012 年 8 月—2015 年 10 月收治的 26 例胸椎结核伴脊髓损害患者临床资料。所有患者行后方经单侧椎弓根入路病灶清除脊髓减压植骨内固定术,其中 11 例出现脊髓损害症状至手术时间<3 a="" 15="">3 个月(B 组)。两组患者性别、年龄、病变节段及术前红细胞沉降率、C 反应蛋白、病变节段 Cobb 角、美国脊髓损伤协会(ASIA)分级等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。记录并比较两组患者手术时间、术中出血量、住院时间、围术期并发症发生情况及骨融合时间;比较两组术前及末次随访时 Cobb 角并计算矫正度;采用 ASIA 分级评价手术前后脊髓功能。结果两组患者均获随访,随访时间 25~60 个月,平均 41.6 个月。术中、术后均无脑脊液漏发生。A 组住院时间及围术期并发症均显著少于 B 组(P<0.05);两组手术时间、术中出血量及骨融合时间比较差异均无统计学意义(P>0.05)。末次随访时 A、B 组红细胞沉降率和 C 反应蛋白比较差异无统计学意义(P>0.05),但均较术前明显降低(P<0.05)。A 组 1 例 T6、7 结核术后切口出现窦道,经换药等处理后愈合,20 个月骨性融合后取出内固定物,36 个月随访时结核无复发;B 组 1 例 T4、5 结核术后 26 个月时复发并出现胸椎畸形,予以翻修。其余患者均无内固定物相关并发症或结核复发。末次随访时两组患者病变节段 Cobb 角均较术前显著改善(P<0.05),两组间 Cobb 角及矫正度比较差异均无统计学意义(P>0.05)。末次随访时脊髓功能 ASIA 分级,A 组 C 级 1 例、E 级 10 例,B 组 D 级 2 例、E 级 13 例,均较术前显著改善(P<0.05);两组间比较差异无统计学意义(Z=–0.234,P=1.000)。结论对伴有脊髓损害的胸椎结核患者,采用后方经单侧椎弓根入路病灶清除脊髓减压植骨内固定术治疗可以取得满意效果,尽早手术可以缩短患者住院时间、降低围术期并发症发生风险。

ObjectiveTo explore the feasibility of posterior debridement, decompression, bone grafting, and fixation in treatment of thoracic spinal tuberculosis with myelopathy, and investigate the effects of surgical timing on postoperative outcomes.MethodsThe clinical data of 26 patients with thoracic spinal tuberculosis with myelopathy between August 2012 and October 2015 was retrospectively analyzed. All patients underwent posterior unilateral transpedicular debridement, decompression, bone grafting, and fixation and were divided into two groups according to surgical timing. Group A included 11 patients with neurological dysfunction lasting less than 3 months; group B included 15 patients with neurological dysfunction lasting more than 3 months. No significant difference was found between the two groups in gender, age, involved segments, preoperative erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Cobb angle of involved segment, and preoperative American Spinal Injury Association (ASIA) classification (P>0.05). The operation time, intraoperative blood loss, hospitalization stay, perioperative complications, and bone fusion time were recorded and compared between the two groups. The change of pre- and post-operative Cobb angle of involved segments was calculated. Neurological function was assessed according to ASIA classification.ResultsAll patients were followed up 25-60 months (mean, 41.6 months). No cerebrospinal fluid leakage occurred intra- and post-operation. The hospitalization stay and perioperative complications in group A were significantly less than those of group B (P<0.05). There was no significant difference in operation time, intraoperative blood loss, and bone fusion time between the two groups (P>0.05). At last follow-up, there was no significant difference in ESR and CRP between groups A and B (P>0.05), but they were all significantly lower than those before operation (P<0.05). In group A, 1 patient with T6, 7 tuberculosis developed sinus that healed after dressing; the implants were removed at 20 months with bony union and no recurrence was found after 36 months of follow-up. One patient with T4, 5 tuberculosis in group B underwent revision because of recurrence and distal junctional kyphosis of the thoracic spine at 26 months after operation. There was no internal fixation-related complications or tuberculosis recurrence occurred in the remaining patients. At last follow-up, the Cobb angles in the two groups significantly improved compared with those before operation (P<0.05), but there was no significant difference in the Cobb angle and correction degree between the two groups (P>0.05). At last follow-up, the ASIA classification of spinal cord function was grade C in 1 case and grade E in 10 cases in group A, and grade D in 2 cases and grade E in 13 cases in group B; the ASIA classification results in the two groups significantly improved compared with preoperative ones (P<0.05), but no significant difference was found between the two groups (Z=–0.234, P=1.000).ConclusionPosterior unilateral transpedicular debridement, decompression, bone grafting, and fixation is effective in treatment of thoracic spinal tuberculosis with myelopathy. Early surgery can reduce the hospitalization stays and incidence of perioperative complications.

关键词: 手术时机; 胸椎结核; 脊髓损害; 减压

Key words: Surgical timing; thoracic spinal tuberculosis; myelopathy; decompression

引用本文: 彭琪琪, 欧云生, 朱勇, 赵增辉, 罗伟, 杜兴, 李剑箫. 手术时机对胸椎结核伴脊髓损害疗效的影响. 中国修复重建外科杂志, 2019, 33(3): 273-279. doi: 10.7507/1002-1892.201808071 复制

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