后路交叉肌窗病灶清除治疗超长节段胸、腰椎结核  

Posterior debridement and internal fixation for ultralong segmental tuberculosis in thoracic and lumbar vertebra through cross-window

作　　者：高志朝[1] 王梅[2] 王大勇[3] 祝卫民[5] 陈其昕[4] 孟永俊[1] 傅悦渊 陈四木[1] 

机构地区：[1]杭州师范大学医学院附属余杭医院骨一科 [2]杭州师范大学医学院附属余杭医院ICU [3]杭州师范大学医学院附属余杭医院骨二科 [4]浙江大学附属第二医院骨科 [5]浙江省立同德医院骨科

出　　处：《中华骨科杂志》2014年第2期121-128,共8页Chinese Journal of Orthopaedics

基　　金：浙江省医药卫生科学研究基金（2011KYB093）

摘　　要：目的探讨单纯后正中入路经不同肌窗交叉窗口病灶清除、椎弓根钉一棒系统内固定治疗超长节段胸、腰椎结核的临床疗效。方法自2005年1月至2011年1月采用后路正中切口、最长肌和多裂肌间隙行椎弓根钉一棒系统内固定，骶棘肌外缘设计双侧交叉窗口行侧前方病灶清除及植骨融合术治疗4节段以上的初治胸、腰椎结核患者17例，男10例，女7例；年龄19～68岁，平均39．8岁。病变累及4节段者6例、5节段者7例、6节段及以上者4例，包括2例跳跃病灶。Frankel分级：B级2例、C级3例、D级6例、E级6例。术前均给予营养支持，四联化疗3周以上；术后继续该方案3个月，然后采用三联化疗9～15个月。术后每个月复查尿酸、红细胞沉降率及肝功能。参考马远征脊柱结核病灶治愈标准对疗效进行评估。结果所有病例均获得随访，平均随访时间27．9个月（18～48个月）。植骨融合时间平均6．3个月（4～11个月）。红细胞沉降率恢复正常时间平均为术后3．8个月（2～7．5个月）。Cobb角由术前的平均29．2°（11°-35°）矫正至术后2周时的平均9．6°（5．5°-14．8°）。合并神经损害的11例患者术后12个月随访时神经功能恢复正常9例，另2例恢复至Fran－kelD级。末次随访CT检查示椎旁脓肿消失，无结核复发，均骨性融合。结论单纯后正中入路经不同肌窗交叉窗口病灶清除、内固定术能较好地一次性达到清除病灶、侧前方减压及植骨、病灶外矫形内固定、彻底引流，临床疗效满意。Objective To investigate the clinical efficacy of posterior debridement and internal fixation for ultralong seg- mental tuberculosis in thoracic and lumbar vertebra through cross-window. Methods From January 2005 to January 2011, 17 cases with tuberculosis of more than four segments had undergone posterior internal fixation, debridement and bone graft through bilateral cross-windows in sacrospinalis＇ outer edge. There were 10 males and 7 females, with an average age of 39.8 years （range, 19-68 years）. There were 6 cases with four segments, 7 cases with five segments, and 4 cases with six or more segments, including 2 cases with jump segments. There were 2 cases with Frankel B, 3 with Frankel C, 6 with Frankel D and 6 with Frankel E. Nutri- tional support and quadruple chemotherapy were conducted more than 3 weeks preoperatively and 3 months postoperatively. Then triple chemotherapy of HRE was conducted for 9 to 15 months. Uric acid, ESR and liver function were monitored monthly. The evaluation of efficacy referred to MA Yuanzheng＇ s spinal tuberculosis cure standard. Results All patients were followed up for 27.9 months （range, 18 to 48 months）. The mean time of interbody fusion was 6.3 months （range, 4 to 11 months）. The mean time of ESR returning to normal was 3.8 months postoperatively （range, 2 to 7.5 months）. The mean Cobb angle was corrected from 29.2° （range, 11° to 35°） to 9.6° （range, 5.5° to 14.8°） two weeks postoperatively. 9 of 11 patients with neurological damage returned to normal at the follow-up of 12 months. The other 2 cases recovered to Frankel D. At last follow-up, CT showed paravertebral ab- scess was disappeared and fusion was achieved; no recurrence was found. Conclusion Posterior internal fixation and debride- ment through cross-window may be a good method to achieve lesions clearing, anteriorlateral decompression, interbody fusion, in- ternal fixation, thorough drain and so on. The clinical efficacy could be satisfactory.

关 键 词：胸椎 腰椎 结核 脊柱 脊柱融合术 

分 类 号：R687.3[医药卫生—骨科学]