【摘要】：背景由于耐藥結(jié)核發(fā)病率的不斷上升,全球結(jié)核發(fā)病率呈回升態(tài)勢,中國是結(jié)核病高負(fù)擔(dān)國家,結(jié)核疫情形勢嚴(yán)峻,脊柱結(jié)核的治療面臨著新的挑戰(zhàn)。而歐美等發(fā)達(dá)國家,結(jié)核病發(fā)病率較低,研究報(bào)道的信息較少,可供借鑒學(xué)習(xí)的經(jīng)驗(yàn)不多,對于復(fù)發(fā)復(fù)治脊柱結(jié)核的經(jīng)驗(yàn)就更為匱乏。目前,由于多種原因?qū)е聡鴥?nèi)脊柱結(jié)核復(fù)發(fā)復(fù)治的病例日益增多,脊柱結(jié)核病帶給患者巨大痛苦。盡管國內(nèi)臨床醫(yī)生在抗結(jié)核治療的用藥原則,手術(shù)治療等方面主流意見形成諸多共識,但國內(nèi)學(xué)者對脊柱結(jié)核復(fù)發(fā)原因和再次手術(shù)治療方案的選擇問題上,爭議不斷�；谏鲜霰尘�,本課題圍繞脊柱結(jié)核復(fù)發(fā)再次手術(shù)的原因進(jìn)行分析,對個(gè)體化治療策略展開臨床回顧性研究,以期在脊柱結(jié)核的個(gè)體化治療中減少復(fù)發(fā),使患者達(dá)到更好的預(yù)后,避免二次手術(shù)或多次手術(shù)帶來的痛苦。目的:分析導(dǎo)致脊柱結(jié)核復(fù)發(fā)再次手術(shù)的主要原因,探討再次手術(shù)個(gè)體化治療方案選擇,以提高脊柱結(jié)核治愈率。方法:回顧性分析于2000年1月至2012年12月在我院骨科行手術(shù)治療的脊柱結(jié)核患者861例。通過對醫(yī)院病歷管理系統(tǒng)查找,結(jié)合PACS系統(tǒng)和CIS系統(tǒng)比對患者信息,采用電話、郵件、網(wǎng)絡(luò)、門診等方式進(jìn)行隨訪,篩選出脊柱結(jié)核復(fù)發(fā)后再次手術(shù)治療患者71例,設(shè)為復(fù)發(fā)組,其中男42例,女29例;初次手術(shù)時(shí)年齡5-72歲,平均34.3歲;術(shù)后服藥1周~120個(gè)月,復(fù)發(fā)病程0.5個(gè)月至516個(gè)月。按照性別匹配的原則1:1配比71例設(shè)為未復(fù)發(fā)組。應(yīng)用卡方檢驗(yàn)和Logistic回歸分析的統(tǒng)計(jì)學(xué)方法,對導(dǎo)致脊柱結(jié)核術(shù)后復(fù)發(fā)的多種危險(xiǎn)因素相關(guān)性進(jìn)行分析。71例復(fù)發(fā)患者采取個(gè)體化手術(shù)方式:病灶清除術(shù)、竇道切除術(shù)4例,單純病灶清除術(shù)16例,一期前路病灶清除植骨融合內(nèi)固定術(shù)11例,一期后路病灶清除植骨融合內(nèi)固定術(shù)24例,一期前后路聯(lián)合入路病灶清除植骨融合內(nèi)固定術(shù)4例,二期前后聯(lián)合入路病灶清除植骨融合內(nèi)固定術(shù)5例,CT引導(dǎo)下穿刺置管引流局部化療術(shù)7例。術(shù)后定期復(fù)查血沉、C反應(yīng)蛋白、X線、CT三維重建、MRI,并行個(gè)體化抗結(jié)核藥物治療12~18個(gè)月。結(jié)果:再次手術(shù)中無脊髓神經(jīng)損傷,大血管損傷等嚴(yán)重并發(fā)癥。再次手術(shù)后隨訪時(shí)間24個(gè)月至108個(gè)月,平均29個(gè)月。根據(jù)Bridwell標(biāo)準(zhǔn),62例椎間植骨內(nèi)固定的患者達(dá)到I級骨性融合標(biāo)準(zhǔn),5例椎間骨橋形成,末次隨訪4例仍未治愈。多因素分析結(jié)果提示,導(dǎo)致復(fù)發(fā)再手術(shù)的主要原因是:耐藥脊柱結(jié)核發(fā)病率的逐漸增高,不規(guī)范的抗結(jié)核藥物治療等。結(jié)論:脊柱結(jié)核術(shù)后復(fù)發(fā)原因與結(jié)核耐藥和不規(guī)范的抗結(jié)核治療密切相關(guān),再次手術(shù)治療時(shí)應(yīng)制定個(gè)體化治療方案。在規(guī)范化抗結(jié)核治療的基礎(chǔ)上,根據(jù)患者病情特征,椎體受累情況,個(gè)體化選擇手術(shù)方案,可以有效避免脊柱結(jié)核術(shù)后復(fù)發(fā)。
[Abstract]:Background due to the increasing incidence of drug-resistant tuberculosis, the global TB incidence is rising. China is a high-burden country with TB, the epidemic situation of TB is severe, and the treatment of spinal tuberculosis is facing new challenges. In the developed countries, such as Europe and America, the incidence of tuberculosis is low, the information of research report is less, the experience of learning can be used for reference is not much, and the experience of relapsing and retreating spinal tuberculosis is even less. At present, there are more and more recurrent cases of spinal tuberculosis in China due to various reasons, and spinal tuberculosis brings great pain to patients. Although there is a lot of consensus among domestic clinicians on the principle of antituberculous treatment, surgical treatment and so on, there are many controversies among domestic scholars on the cause of recurrence of spinal tuberculosis and the choice of reoperation treatment. Based on the above background, this paper analyzes the causes of recurrence of spinal tuberculosis and carries out a clinical retrospective study on individualized treatment strategies in order to reduce recurrence in individualized treatment of spinal tuberculosis. To achieve a better prognosis and avoid the pain of secondary or multiple operations. Objective: to analyze the main causes of recurrence of spinal tuberculosis and discuss the choice of individual treatment scheme for reoperation in order to improve the cure rate of spinal tuberculosis. Methods: from January 2000 to December 2012, 861 patients with spinal tuberculosis underwent orthopedic surgery in our hospital. By searching the hospital medical record management system and comparing the patient information with PACS system and CIS system, 71 patients with recurrent spinal tuberculosis were selected by telephone, mail, network, outpatient service and so on. The patients were divided into recurrence group (42 males and 29 females), the age of the first operation was 5-72 years old (mean 34.3 years), the course of recurrence was 0.5 months to 516 months after operation, and the duration of recurrence was 0.5 months to 516 months. According to the principle of gender matching, 71 cases were assigned to no recurrence group at 1:1. By means of chi-square test and Logistic regression analysis, the correlation of multiple risk factors leading to recurrence of spinal tuberculosis after operation was analyzed. 71 patients with recurrent spinal tuberculosis were treated with individualized surgical methods: focal debridement, sinus excision (4 cases), sinus excision (4 cases). There were 16 cases of simple focal debridement, 11 cases of primary anterior debridement and fusion fixation, 24 cases of primary and posterior debridement and internal fixation of bone graft, 4 cases of primary anterior and posterior combined approach, 4 cases of bone graft fusion and internal fixation. Local chemotherapy was performed in 5 cases with CT guided puncture and drainage by combined approach of debridement, bone grafting, fusion and internal fixation. Three dimensional reconstruction of MRI with C reactive protein X ray and CT was performed regularly after operation, and then treated with antituberculous drugs for 12 ~ 18 months. Results: there were no serious complications such as spinal cord nerve injury and major vascular injury. The follow-up time was 24 months to 108 months (mean 29 months). According to the Bridwell standard, 62 patients with intervertebral bone graft and internal fixation met the grade I bone fusion standard. 5 cases had bone bridge formation, and 4 cases had not been cured at the last follow-up. The results of multivariate analysis showed that the main causes of recurrence and reoperation were the increasing incidence of drug-resistant spinal tuberculosis and nonstandard antituberculous drug therapy. Conclusion: the causes of postoperative recurrence of spinal tuberculosis are closely related to drug resistance and nonstandard antituberculous therapy. On the basis of standardized antituberculous therapy, according to the patient's condition, vertebral body involvement and individualized choice of surgical scheme, recurrence of spinal tuberculosis can be effectively avoided.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3

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