發(fā)布時(shí)間：2018-03-23 10:56

  本文選題：Wiltse入路　切入點(diǎn)：一期手術(shù)　出處：《山西醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:探討經(jīng)Wiltse入路一期行腰椎結(jié)核病灶清除及腰大肌膿腫引流的可行性及其臨床療效分析。方法:對2012年11月至2016年5月間在我院診斷為腰椎結(jié)核合并腰大肌膿腫且手術(shù)采用經(jīng)Wiltse入路一期行病灶清除、膿腫引流、植骨融合、椎弓根釘矯形內(nèi)固定的19例患者進(jìn)行回顧性分析,其中男8例,女11例;年齡(26~64)歲,平均(44±9.9)歲。術(shù)前所有患者均規(guī)范抗結(jié)核化療2~4周,術(shù)后持續(xù)正規(guī)化療12~18個(gè)月。詳細(xì)記錄患者的手術(shù)時(shí)間、術(shù)中失血量、術(shù)后引流量以及引流管拔除時(shí)間等數(shù)據(jù)。術(shù)前13例患者合并不同程度神經(jīng)功能損害,ASIA分級(jí)B級(jí)3例,C級(jí)4例,D級(jí)6例。血沉(ESR)63.7±11.8mm/h;C反應(yīng)蛋白(CRP)16.9±3.54mg/L。脊柱后凸Cobb角為26.9o±2.9o。疼痛視覺模擬評(píng)分(VAS)評(píng)估術(shù)后腰痛改善狀況;ASIA分級(jí)評(píng)估術(shù)后1年隨訪時(shí)神經(jīng)功能恢復(fù)程度;監(jiān)測術(shù)前、術(shù)后及隨訪時(shí)脊柱后凸Cobb角、紅細(xì)胞沉降率(ESR)及C反應(yīng)蛋白(CRP)檢測值水平,評(píng)價(jià)后凸畸形矯正效果和疾病控制情況;X線、CT重建及MRI檢查評(píng)析內(nèi)固定有無失效,植骨融合進(jìn)展,腰大肌膿腫消失時(shí)間等。結(jié)果:全部患者手術(shù)過程順利,手術(shù)時(shí)間為(121~260)min,平均(194±40)min,術(shù)中失血量為(254~580)ml,平均(410±80)ml;術(shù)后引流量為(213~477)ml,平均(340±68)ml;引流管拔除時(shí)間為4~10d,平均(6.7±1.8)d。全部患者均獲得12~36個(gè)月隨訪,平均(22±7.0)個(gè)月。術(shù)前合并神經(jīng)功能損害者獲得ASIA1~3級(jí)的恢復(fù),未合并神經(jīng)功能損害者術(shù)后無顯著加重。VAS評(píng)分下降說明術(shù)后腰部疼痛癥狀較術(shù)前有明顯改善。ESR及CRP在術(shù)后6個(gè)月內(nèi)均降至正常水平。術(shù)后脊柱后凸Cobb角為(8.7±1.9)o,較術(shù)前平均矯正18.2o;后凸畸形矯正在術(shù)后1年隨訪時(shí)有(1~3)o丟失。X線、CT重建及MRI檢查證實(shí)內(nèi)固定無松脫、斷裂及節(jié)段塌陷,椎間實(shí)現(xiàn)標(biāo)準(zhǔn)骨性融合,融合時(shí)間為(4~12)個(gè)月,平均(7±2.3)個(gè)月,未發(fā)現(xiàn)假關(guān)節(jié)形成。腰大肌膿腫均在術(shù)后8個(gè)月內(nèi)徹底消失,平均(7±1.1)個(gè)月。術(shù)后1例患者出現(xiàn)腦脊液漏,采取有效藥物對癥治療,同時(shí)要保證引流管一直通暢并適當(dāng)延長其留置時(shí)間,得到良好愈后。1例患者術(shù)后兩周出現(xiàn)切口不愈合,經(jīng)再次手術(shù)清創(chuàng)、置管引流持續(xù)沖洗配合有效抗感染藥物對癥治療10天后痊愈。至末次隨訪時(shí)所有病例均未見結(jié)核復(fù)發(fā)。結(jié)論:Wiltse入路一期行腰椎結(jié)核病灶及腰大肌膿腫清除是一種可行、有效的手術(shù)方式,臨床療效確切。
[Abstract]:Objective: to investigate the feasibility and clinical effect of primary lumbar tuberculosis removal and lumbar abscess drainage via Wiltse approach. Methods: from November 2012 to May 2016, we diagnosed lumbar tuberculosis with psoas major muscle in our hospital. Patients with abscess underwent primary debridement via Wiltse approach. 19 patients with abscess drainage, bone graft fusion and pedicle screw internal fixation were retrospectively analyzed, including 8 males and 11 females, aged 26 ~ 64 years (mean 44 鹵9. 9) years. All patients were treated with antituberculous chemotherapy for 24 weeks. Postoperative regular chemotherapy lasted 12 ~ 18 months. The time of operation and blood loss during operation were recorded in detail. Before operation, 13 patients were complicated with different degrees of neurologic impairment: Asia grade B, grade B, grade C, grade C, grade D, 6 cases. ESR was 63.7 鹵11.8mm / h, the CRP was 16.9 鹵3.54mg / L, and the Cobb angle of scoliosis was 26.9o 鹵2.9o. Visual analogue score (VASS) was used to evaluate the improvement of postoperative low back pain (LBP). The levels of Cobb angle, erythrocyte sedimentation rate and C-reactive protein (CRP) of kyphosis were monitored before, after operation and at follow-up. The correction effect of kyphosis and disease control were evaluated. X-ray CT reconstruction and MRI were used to evaluate the failure of internal fixation. Progress of bone graft fusion, time of disappearance of abscess of psoas major muscle, etc. Results: all patients underwent successful operation. The operative time was 121U 260min (mean 194 鹵40min), the blood loss during operation was 254m 580ml (mean 410 鹵80ml), the postoperative drainage volume was 2134477ml (mean 340 鹵68ml), the extubation time was 410d (mean 6.7 鹵1.8d). All the patients were followed up for 1236 months. The average time was 22 鹵7. 0 months. The patients with neurologic impairment received ASIA1~3 grade recovery before operation. There was no significant exacerbation after operation. The decrease of VAS score showed that the symptoms of postoperative lumbar pain were significantly improved. ESR and CRP decreased to normal level within 6 months after operation. The Cobb angle of kyphosis after operation was 8.7 鹵1.9 o.Compared with surgery. The average correction of anterior kyphosis was 18.2o.The correction of kyphosis was confirmed by CT reconstruction and MRI examination. Fracture and segmental collapse, standard bone fusion between vertebrae, fusion time was 412 months (mean 7 鹵2.3) months, no pseudarthrosis was found. Abscess of psoas major abscess disappeared completely within 8 months after operation. The average time was 7 鹵1.1 months. One patient had cerebrospinal fluid leakage after operation and was treated with effective drugs. At the same time, the drainage tube should be kept unobstructed and its retention time should be prolonged properly. The incision nonunion occurred in 1 case after good recovery two weeks after operation. After reoperation, After 10 days of continuous drainage and effective antiseptic therapy, no recurrence of tuberculosis was found in all the patients. Conclusion it is feasible to remove lumbar tuberculosis focus and abscess of psoas major muscle at one stage via the WW Wiltse approach. The effective operation method, the clinical curative effect is definite.
【學(xué)位授予單位】：山西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.2

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