一期侧前路及后路手术联合治疗胸腰椎结核的临床疗效分析
Clinical study on treatment of thoracolumbar spinal tuberculosis through one-stage anterolateral-posterior approach

摘要：目的 探讨一期侧前路及后路联合病灶清除植骨融合内固定术治疗胸腰椎结核的临床疗效。方法 回顾性分析2010年1月到2014年12月胸腰椎结核56例，其中男31例，女25例，年龄18～72岁，平均43.1岁；术前采用标准四联抗结核方案治疗2～4周；采用一期侧前方结核病灶清除，自体髂骨植骨可吸收螺钉固定术，同期经后方多裂肌间隙入路(Wiltse入路)椎弓根螺钉固定。记录手术时间、出血量、植骨融合情况和术后血沉、Cobb角、VAS评分、美国脊髓损伤协会(American Spinal Injury Association, ASIA)等级变化等情况，评估手术效果。结果 手术时间175～290min，平均(248±42)min；出血量300～900mL，平均(420±68)mL。平均随访(24±5.2)月，植骨融合率100%，融合时间(4.7±0.5)月；末次随访Cobb角(8.2±3.1)°，VAS评分(2.1±0.8)分，血沉(17±4.2)mm/h，ASIA评分除3例为D级外，均为E级，与术前比较差异均有统计学意义。6例患者发生不同程度并发症，无严重并发症发生。结论 一期侧前路病灶清除植骨可吸收螺钉固定及后路Wiltse入路固定治疗胸腰椎结核，可以彻底清除病灶，后凸畸形矫正理想，植骨融合率高，神经减压效果满意；可吸收螺钉可以安全应用于结核病灶清除术后的植骨中。
ABSTRACT: Objective To explore the clinical efficacy of one-stage anterolateral-posterior approach debridement, bone graft and internal fixation in treatment of thoracolumbar spinal tuberculosis. Methods From January 2010 to December 2014, 56 cases of thoracolumbar spinal tuberculosis were retrospectively analyzed, including 31 males and 25 females, aged 18-72 years (mean 43.1 years). All patients were managed by standard courses of chemotherapy with quadruple anti-TB drugs for 2-4 weeks. Patients were treated by anterolateral debridement, autologous iliac bone graft fixed by absorbable screw fixation, and posterior pedicle screw fixation via multi-split muscle gap (Wiltse approach). We recorded the operation time, the amount of bleeding, bone graft fusion, postoperative erythrocyte sedimentation rate (ESR), Cobb angle, VAS score, and American Spinal Injury Association (ASIA) score to evaluate the surgical results. Results The average operation time was 175-290min, with an average of (248±42)min. The bleeding volume was 300-900mL with an average of (420±68)mL. The average follow-up time was (24±5.2) months, bone fusion rate was 100%, and fusion time was (4.7±0.5) months. At the last follow-up, the average Cobb angle was (8.2±3.1)°, VAS was (2.1±0.8), and ESR was (17±4.2)mm/h. The ASIA neurological functions were all classified as Grade E except for 3 cases of Grade D. All these were significantly different from the preoperative ones. Six patients had complications of different degree but without serious complications. Conclusion One-stage anterolateral debridement, autologous iliac bone graft fixed by absorbable screw fixation, and posterior pedicle screw fixation via multi-split muscle gap (Wiltse approach) can completely remove the tuberculosis lesions and achieve ideal kyphosis correction, high bone graft fusion, and satisfactory neurological function recovery. Absorbable screws can be safely applied to the bone graft site after debridement