發(fā)布時(shí)間：2018-09-02 05:29

【摘要】：目的比較一期后前聯(lián)合入路與單純后路手術(shù)治療下腰椎結(jié)核的療效差異,為臨床選擇恰當(dāng)術(shù)式治療下腰椎結(jié)核提供參考。方法回顧性分析2010年1月—2014年11月手術(shù)治療并獲完整隨訪的48例下腰椎結(jié)核患者臨床資料,其中采用一期后路固定聯(lián)合前路病灶清除植骨融合術(shù)治療28例(聯(lián)合入路組),單純后路椎弓根釘固定病灶清除植骨融合術(shù)治療20例(單純后路組)。兩組患者性別、年齡、病程、病變節(jié)段以及合并癥等一般資料比較,差異均無統(tǒng)計(jì)學(xué)意義(P0.05),具有可比性。記錄并比較兩組患者手術(shù)時(shí)間、術(shù)中出血量、術(shù)后臥床時(shí)間及疼痛視覺模擬評分(VAS);根據(jù)美國脊柱損傷協(xié)會(ASIA)分級標(biāo)準(zhǔn)評估神經(jīng)功能情況,Bridwell骨融合標(biāo)準(zhǔn)及CT骨融合標(biāo)準(zhǔn)評估植骨融合情況,紅細(xì)胞沉降率檢查結(jié)果評價(jià)結(jié)核控制情況,Oswestry功能障礙指數(shù)(ODI)評估腰部功能恢復(fù)情況。結(jié)果單純后路組手術(shù)時(shí)間、術(shù)中出血量及術(shù)后臥床時(shí)間均顯著低于聯(lián)合入路組(P0.05)。聯(lián)合入路組術(shù)中1例發(fā)生髂血管損傷,單純后路組術(shù)后2例出現(xiàn)竇道形成;無其他相關(guān)并發(fā)癥發(fā)生。兩組患者術(shù)后均獲隨訪,聯(lián)合入路組隨訪時(shí)間為13~35個(gè)月,平均15.7個(gè)月;單純后路組為15~37個(gè)月,平均16.3個(gè)月。末次隨訪時(shí),兩組患者結(jié)核中毒癥狀均消失,術(shù)前伴有神癥狀及體征患者其神經(jīng)功能ASIA分級均恢復(fù)至E級。兩組患者術(shù)前及術(shù)后1年、末次隨訪時(shí)VAS評分、紅細(xì)胞沉降率比較,術(shù)前及末次隨訪時(shí)ODI比較,差異均無統(tǒng)計(jì)學(xué)意義(P0.05);組內(nèi)術(shù)后以上指標(biāo)均較術(shù)前明顯改善(P0.05)。影像學(xué)復(fù)查顯示,兩組隨訪期間均未出現(xiàn)內(nèi)固定物斷裂、松動(dòng)及拔釘?shù)�。末次隨訪時(shí),聯(lián)合入路組及單純后路組植骨融合率根據(jù)Bridwell骨融合標(biāo)準(zhǔn)分別為89.29%(25/28)、80.00%(16/20),根據(jù)CT骨融合標(biāo)準(zhǔn)分別為96.43%(27/28)、90.00%(18/20);組間植骨融合比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論一期后前聯(lián)合入路與單純后路手術(shù)治療下腰椎結(jié)核均可獲得滿意療效。對于結(jié)核病灶位于前柱,骶前或腰大肌膿腫形成,結(jié)核累及多個(gè)節(jié)段的患者,建議選擇后前聯(lián)合入路;結(jié)核病灶位于中后柱、前路血管分叉阻擋、不能耐受聯(lián)合入路手術(shù)患者或術(shù)前影像學(xué)評估經(jīng)后路能清除病灶時(shí),宜選擇單純后路手術(shù)。
[Abstract]:Objective to compare the curative effect of primary anterior combined approach and simple posterior approach in the treatment of lower lumbar tuberculosis, and to provide a reference for clinical treatment of lower lumbar tuberculosis. Methods from January 2010 to November 2014, 48 patients with lower lumbar tuberculosis who received surgical treatment and received complete follow-up were retrospectively analyzed. One stage posterior fixation combined with anterior debridement and fusion was performed in 28 cases (combined approach group) and 20 cases were treated by posterior pedicle screw fixation only (posterior approach group). There was no significant difference in sex, age, course of disease, pathological segment and complications between the two groups (P0.05). The operative time and blood loss were recorded and compared between the two groups. Postoperative bed-rest time and pain visual analogue score (VAS); evaluated neurological function according to the American Spinal injury Association (ASIA) grading criteria and the Bridwell bone fusion criteria and the CT bone fusion criteria for the evaluation of bone graft fusion. The results of erythrocyte sedimentation rate were used to evaluate tuberculosis control. Oswestry dysfunction index (ODI) was used to evaluate the recovery of lumbar function. Results the time of operation, the amount of intraoperative bleeding and the time of bed-rest after operation in simple posterior approach group were significantly lower than those in combined approach group (P0.05). Iliac vascular injury occurred in 1 case in the combined approach group and sinus formation in 2 cases in the simple posterior approach group without other related complications. The follow-up time of the combined approach group was 13 ~ 35 months with an average of 15.7 months, and that of the simple posterior approach group was 15 ~ 37 months with an average of 16.3 months. At the last follow-up, the symptoms of tuberculosis poisoning disappeared in both groups, and the ASIA grade of neurological function recovered to grade E in patients with mental symptoms and signs before operation. There was no significant difference between the two groups in VAS score and erythrocyte sedimentation rate at the last follow-up and ODI before and after the last follow-up (P0.05). The above indexes in the group were significantly improved after operation (P0.05). Imaging examination showed that there were no internal fixation breakage, loosening and nailing in the two groups during the follow-up period. At the last follow-up, the graft fusion rates of the combined approach group and the simple posterior approach group were 89.29% (25 / 28), 80.00% (16 / 20) and 96.43% (27 / 28), 90.00% (18 / 20), respectively, according to the Bridwell bone fusion criteria (P0.05). Conclusion one-stage anterior combined approach and simple posterior approach for the treatment of lumbar tuberculosis can obtain satisfactory results. For patients whose tuberculosis foci are located in anterior column, anterior sacral or psoas abscess, and tuberculosis involving multiple segments, it is recommended to select the posterior anterior combined approach, and the tuberculosis focus is located in the middle and posterior column, and the anterior vascular bifurcation is blocked. Patients who can not tolerate combined approach or preoperative imaging evaluation can clear lesions by posterior approach should choose simple posterior approach.
【作者單位】： 西南醫(yī)科大學(xué)附屬醫(yī)院脊柱外科;西南醫(yī)科大學(xué)附屬醫(yī)院病理科;
【分類號】：R687.3

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