中国修复重建外科杂志

中国修复重建外科杂志

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

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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(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、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(P<0.05)。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(P>0.05);组内术后以上指标均较术前明显改善(P<0.05)。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(P>0.05)。 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。

Objective To compare the clinical efficacy between one-stage combined posterior and anterior approaches (PA-approach) and simple posterior approach (P-approach) for lower lumbar tuberculosis so as to provide some clinical reference for different surgical procedures of lower lumbar tuberculosis. Methods A retrospective analysis was made on the clinical data of 48 patients with lower lumbar tuberculosis treated between January 2010 and November 2014. Of them, 28 patients underwent debridement, bone graft, and instrumentation by PA-approach (PA-approach group), and 20 patients underwent debridement, interbody fusion, and instrumentation by P-approach (P-approach group). There was no significant difference in gender, age, course of the disease, and destructive segment between 2 groups (P>0.05). The operation time, blood loss, bed rest time, visual analogue scale (VAS) and complication were recorded and compared between 2 groups; American Spinal Injury Association (ASIA) grade was used to evaluate the nerve function, Bridwell classification and CT fusion criteria to assess bone fusion, erythrocyte sedimentation rate (ESR) to evaluate the tuberculosis control, and Oswestry disability index (ODI) to estimate lumbar function. Results The operation time, blood loss, and the bed rest time of the P-approach group were significantly less than those of the PA-approach group (P<0.05). Iliac vessels rupture was observed in 1 case of the PA-approach group and sinus tract formed in 2 cases of the P-approach group. The patients were followed up 13-35 months (mean, 15.7 months) in the PA-approach group and 15-37 months (mean, 16.3 months) in the P-approach group. At last follow-up, common toxic symptom of tuberculosis disappeared and the ASIA scale was improved to grade E. The VAS score and ESR at 1 year after operation and last follow-up, and ODI at last follow-up were significantly improved when compared with preoperative ones in 2 groups (P<0.05), but there was no significant difference between the 2 groups (P>0.05). During follow-up, no internal fixation broken, loosening, or pulling was found. Bridwell bone fusion rates were 89.29% (25/28) and 80.00% (16/20) respectively, and CT fusion rates were 96.43% (27/28) and 90.00% (18/20) respectively, showing no significant difference between the 2 groups (P>0.05). Conclusion Both one-stage PA-approach and simple P-approach could obtain good clinical efficacy. The PA-approach should be selected for patients with anterior-vertebral destroy, presacral or psoas major muscles abscess, and multiple vertebral body destroy, while P-approach should be selected for patient who could gain a good debridement evaluated by imaging before operation, especially for patients with middle-vertebral body destroy, block the iliac blood vessels and old patients.

关键词: 脊柱结核; 下腰椎; 手术入路; 临床疗效

Key words: Spinal tuberculosis; lower lumbar vertebrae; surgery approach; clinical efficacy

引用本文: 廖烨晖, 叶入裴, 李广州, 唐强, 王高举, 钟德君, 王清. 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. 中国修复重建外科杂志, 2017, 31(5): 534-540. doi: 10.7507/1002-1892.201609083 复制

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