检索历史 清除

目的 探讨脊柱结核术后复治的原因及手术治疗策略.方法 收集2010年5月至2014年5月共96例脊柱结核术后复治的患者资料,男51例,女45例;年龄21～59岁,平均39.7岁.根据上次手术入路、脊髓神经受压方向、窦道位置、死骨和脓肿的部位、范围等,采用不同的翻修手术方式进行治疗.收集同期收治的481例未复治脊柱结核患者资料,比较复治组和未复治组间性别、年龄、病程、病灶范围、营养状况、是否耐药结核、病灶清除是否彻底、内固定稳定性、术后是否正规化疗等指标,研究脊柱结核术后复治的危险因素.结果 96例的手术时间为160～280 min,平均210 min;出血量400～1 500 ml,平均600 ml.术前VAS评分平均为7.5分,末次随访平均1.5分,差异有统计学意义;21例伴有脊髓压迫症状的患者神经功能ASIA分级均得到改善;96例术前平均后凸角度18.4°±5.2°,术后平均后凸角度8.9°±2.7°,末次随访时平均矫正角度9.5°±3.6°,平均矫正角度丢失3.5°±1.1°,差异均有统计学意义;Kirkaldy&Willis功能评分优良率88％;35例结核菌培养及药敏试验提示耐药.切口延迟愈合7例;窦道形成24例,13例经换药后愈合,11例再次手术治疗,再手术率11.5％,再手术者中接受一次手术7例,两次手术3例,三次手术1例.结论 脊柱结核术后复治的危险因素包括术中病灶清除不彻底、耐药菌株的出现、术后未行正规化疗、营养状况差、内固定稳定性差,彻底的病灶清除、三面皮质自体髂骨支撑性植骨、坚强的内固定、基于药敏检测的个体化化疗,以及术后适当的灌洗引流是保证复治手术成功的关键.

Objective To investigate the causes of spinal tuberculosis retreatment and its surgical treatment strategy.Methods Between May 2010 and May 2014,96 patients with spinal tuberculosis who had been operated before were retreated.The dates of them were reviewed.There were 51 males and 45 females with mean age of 39.7 years.Deciding upon the revision surgical procedure should be determined by last operation approach,the direction of compression of spinal cord,the position of sinus and extent of foci.The retreated patients were compared with 481 unretreated patients in the following index including sex,age,duration of disease,focus range,nutrition,drug resistant tuberculosis,debridement,stability of instrumentation,postoperative regular chemotherapy,associated tuberculosis.Results The surgery duration time was 160-280 min,average 210 min,and the blood loss was 400-1500 ml,average 600 ml.The VAS score before the operation was 6-9 (average 7.5) and 1-3 (average 1.5) at the last follow-up,the difference was statistically significant.Neurological deficits in 21 patients clinically improved at least one grade according to the ASIA grading system at last follow-up.Kyphosis and scoliosis degrees were corrected significantly postoperatively and the correction was 9.5°±3.6° at the final follow-up.The average angle loss was 3.5°±1.1°.There was significant difference between the kyphosis angles preoperatively,postoperatively and final follow-up.Kirkaldy-Willis function score showed that the total fine rate was 88％.There were 35 patients whose tuberculosis bacterial culture and drug sensitive experiments suggested drug resistance.Wound healing delayed in 7 patients.24 cases had sinus formation,13 cases in which were healed after wound dressing,and 11 cases undertook operation again.Conclusion The causes of spinal tuberculosis retreatment include uncompleted debridement,drug resistant strains of tuberculosis,irregular postoperative anti-tubercular treatment,poor preoperative nutritional status and failure of spinal stability reconstruction.The key of successful revision surgery includes radical debridement,strut grafting with autologous iliac bone block,proper reconstruction of spinal stability,individualized chemotherapy according to the drug-resistance,and the appropriate use of irrigation and drainage postoperatively.